CMS One Way Data Transparency


1-23-2014 8-42-19 PMAccording to an article on the CMS Blog, in 60 days the government plans to begin disclosing information regarding payments it has made to individual physicians. In order to receive the information, there has to be a FOIA request and each request will be evaluated on a “case by case basis” which means it is unlikely that they plan to just give their entire payment database over to the first person who makes an inquiry. However, the CMS blog states that the government is planning to publicly disseminate aggregate information regarding payment information.

The AMA, all of the State Medical Societies, and a few dozen specialty societies all oppose the idea (.pdf file), alleging that privacy rights of the physicians would be violated, that releasing raw data would result in “inaccurate and misleading information,” and that releasing information such as a physician’s National Provider Identifier would subject the physicians to identity fraud.
On the other hand, watchdog groups such as the “Council for Affordable Health Coverage” believe that all of the data regarding physician payments should be on a publicly accessible database rather than being disseminated on a case-by-case basis.

CMS responded to the medical establishment’s concerns by stating that before releasing individual data, it will consider the “importance of protecting physicians’ privacy and ensuring the accuracy of any data released as well as appropriate protections to limit potential misuse of the information.”

To me, this should be a no-brainer. If any entity does business with the government – not just physicians – disclosure of what services are being performed and what payments are being made should be a right to every citizen.  Remember that whole bit about establishing a constitution on behalf of “We the People”? Remember Abraham Lincoln’s dream of a government of the people, by the people, and for the people? People are the government. If We the People are paying for services through taxes then there is always an overwhelming public interest in seeing how much We the People are paying. If those providing services to the government don’t like it, then do business somewhere else.

With very few exceptions, We the People should be able to see a full and detailed accounting of all government income and expenditures – not just aggregate physician payments.

That’s where CMS’ whole “we’re disclosing physician payments to prevent fraud and abuse” argument falls apart.

Payments to individual doctors are going to be disclosed. Also, any payments or “transfers of value” physicians receive from pharmaceutical companies or medical device manufacturers is also on a government database.

What isn’t going to be disclosed?

  • It isn’t clear whether CMS will release payments to physicians per individual procedure or per individual office visit. My guess is that it won’t. So you won’t know whether your doctor works 4 hours a day twice a week or 12 hours a day for seven days a week to get the payments that CMS is disclosing. You won’t know the overhead in the doctor’s office or the amount of the payments on the doctor’s student loans or the thousands of dollars each month that the doctor pays in malpractice premiums. CMS won’t tell you to divide their “payment” by at least one third to account for taxes that the doctor pays. CMS will just provide you with a number so that everyone can shake their heads at how unfair it is that medical providers are being paid so much
  • It also isn’t clear whether CMS will break down payments to hospitals by specific ICD-9 or CPT codes. To be fair, CMS has published aggregate data for payments to hospitals for the top 100 DRGs, but those payments are several years out of date, in the aggregate, and only involve “average covered charges” and “average total payments” but do not itemize what CMS pays the hospitals for specific services. The aggregate payments include intangible variables such as “teaching,  disproportionate share, capital, and outlier payments” so it is impossible to compare “apples with apples” using the data.
  • And CMS definitely won’t divulge information about patients. The Federal Register Notice (.pdf file) signed by CMS administrator Marilyn Tavenner and approved by Kathleen Sebelius, the Secretary of the Department of Health and Human Services specifically states that “in all cases, we are committed to protecting the privacy of Medicare beneficiaries.” Those superusers and drug seekers who run up the health care tab on the public dime are protected from scrutiny.

On one hand, CMS alleges that it wants to create transparency to avoid fraud, but on the other hand it releases only select data.

Where is the data on how often CMS has denied payments to physicians or to healthcare organizations for services that were provided?
Where is the data showing why those payments were denied?
Where is the data showing how often the denials were reversed and how much extra time that CMS was able to avoid paying for legitimate services by inappropriately denying payments?
Where is the data on the average length of a phone call it takes to contact CMS regarding an inappropriate denial?
The fact is that we don’t get the “transparency” when we look back at CMS.
It’s a one-way mirror.

If we’re really interested in combating fraud, why can’t we get FOIA requests for aggregate payments made on behalf of patients? We don’t need to know what the payments are for and public agencies delivering social security or welfare benefits are not covered by HIPAA privacy rules, so don’t even go there.
Shouldn’t it be my right to see how much of my tax dollars are being paid to the guy on disability down the road with the souped-up Escalade who goes on vacation more than I do and who is out on the golf course all day? Or is it that fraud only of “public interest” when it is committed by medical providers?

CMS is taking this approach for one reason – to vilify medical providers.

With 37% unemployment in this country, medical providers are an easy target. Publish data that inflame a large proportion of the population, allege that medical providers are being “greedy” for not accepting pay cuts, then use that negative public opinion as a means to justify cutting payments and creating even more laws and regulations that make the practice of medicine even less appealing. When you’ve driven enough providers out of health care so that there isn’t sufficient access to all the aging baby boomers and newly-minted Medicaid patients, you can blame that on the medical providers, too. How dare we not provide care to our fellow citizens.

I’m all for transparency, but there needs to be global transparency, not a bunch of smoke and mirrors labeled as “transparency” and used as a means to an end.
You want to publish the data? Publish all of the data.

Come to think of it, maybe we can create public databases of all the payments and perks to all government officials. How much in “transfer of value” has Kathleen Sebelius received since she entered office? Business trips? Meals? Office supplies? Travel?

Betcha those numbers would put payments provided to most medical providers to shame.


  1. Regarding the privacy/fraud issue by releasing NPI numbers… You can google the name of any physician and find their NPI number (as well as their address). Don’t know why that’s the case, but that info is already available.

  2. Wow! I didnt know they had the ability to figure out how much they paid. When we submit a claim over a third get denied so we have to resubmit them. If we do get paid we have to triple check to be sure it is the right amount. When things are messed up you call CMS and they have no idea why the claim was rejected or how much they paid. they them send you to a subcontractor who sends you back to CMS. Of course you can only call CMS from 9:00 to 11:00 and 1:30 to 3:30 if you hope to get someone.

  3. It’s a huge disappointment upon the realization that this matter is heavily cloaked (I guess like most government actions). In nursing school, I was taught about the inevitability of ideal meeting real once I began my job.
    I’ve said it before, if affordability of health care is going to be mandated successfully,for the love of Pete, give the people the power… in every market, we have the power to choose Target, or Walmart, generics or brands.
    This controlled release of payments is great, however I agree the motives behind it are setting the stage for a bigger play. What a shame.
    For ObamaCare to work (and be economically feasible) costs control at every level (MFGs, Hospital, HCP, Insurer, Client) is imperative. Oh, and don’t forget those resources… at some point, rationing needs to be defined and explained to everyone.
    Thanks for a great contribution to the blogosphere Doc. 🙂

  4. Pingback: Healthcare Update — 02-13-2014 | Dr. WhiteCoat

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