Medicare reimbursement data offers trove of consumer info

Among the weapons to treat the "wet" form of macular degeneration in 2012 were two potent drugs that are injected into the eye. Studies have found the two to be equally effective, yet Medicare pays doctors less than $50 to administer one and about $320 to inject the other.

Which do you think doctors used more often?

The costlier one, by far.

Local ophthalmologists say that money isn't a factor in their decisions and that there are medical reasons to use the more expensive Lucentis for some patients. Consumer advocates say otherwise.

One thing is clear. With the release Wednesday of a vast new trove of Medicare data, we are going to be engaging in more debates like this.

The Obama administration posted the numbers of outpatient procedures performed by more than 880,000 health-care providers, along with the amount of money they were reimbursed under the Medicare Part B program - $77 billion in all. The raw data would be tricky for most patients to navigate, but Medicare expects consumer groups to create user-friendly tools for the public to look up doctors by name. The New York Times already has, at http://nyti.ms/1n32Xde.

A key way the data are useful to patients is by listing the numbers of procedures done by each provider, said Mark Pauly, a health economist at the University of Pennsylvania's Wharton School.

"The general rule of thumb is go to someone who is doing a lot of them rather than a few of them," Pauly said.

The data also will be used by analysts who study cost. High-volume physicians might be very good at their trade, for example, but some of those procedures could be medically unnecessary.

Drew Harris, director of the health-policy program at the Jefferson University School of Population Health, warned that drawing such conclusions requires careful analysis. A doctor who does a lot of a given procedure may simply have a specific area of focus, while others in the same practice develop other areas of expertise.

Also, in some cases, multiple doctors are reimbursed through the ID number of one doctor in their practice, making it appear as if that physician is unusually prolific.

Pathologist Michael McGinnis, based in Wrightstown, Burlington County, was reimbursed $12,577,017 by Medicare in 2012 - third highest in the nation.

He said his provider code was used for about 27 doctors at Plus Diagnostics in Union, N.J., where he is medical director. "I don't really work directly at the facility," he told Bloomberg News. "I'm doing administrative work."

The data were released after decades of litigation and over the strenuous objections of the American Medical Association.

The federal Centers for Medicare and Medicaid Services urged the public, media, and academics to use the data to identify excess costs. "We want the public to help us," Jonathan Blum, CMS's principal deputy administrator, told reporters. "We want the press to identify outliers in spending."

Ophthalmologists are among the specialists with the highest rates of reimbursement, and injections of Lucentis are a big reason why.

In 2012, Pennsylvania eye doctors performed these injections more than 220,000 times on Medicare patients, receiving reimbursements of $71 million; New Jersey doctors did more than 160,000 of the injections, receiving $52 million.

The less expensive Avastin, a cousin of Lucentis, was injected 44,000 times in Pennsylvania and 29,000 times in New Jersey, for less than $3.5 million in the two states.

Lucentis is approved by the Food and Drug Administration for wet macular degeneration, whereas Avastin is FDA-approved for cancer. Physicians are allowed to inject Avastin in the eye, but this use is considered "off-label."

Both drugs work on macular degeneration by thwarting the growth of abnormal blood vessels. Both drugs also can be found elsewhere in the bloodstream of patients, so researchers have been careful to monitor whether there are any adverse cardiovascular effects.

There is evidence that Avastin "penetrates" the circulatory system more than Lucentis, said Julia Haller, ophthalmologist-in-chief at Wills Eye Hospital.

So a cautious physician might opt instead for Lucentis in a patient with complications such as diabetes or a risk of heart problems, Haller said.

"The decision isn't based on how much the drug costs," Haller said. "The decision is based on what's best for the patient."

Stuart Fine, one of the researchers involved in the initial comparison study between Lucentis and Avastin, countered that the rates of adverse effects associated with the two drugs are similar.

"The bottom line is the drugs are equivalent with regard to visual outcome and equivalent with regard to side effects," said Fine, a former Penn physician now at the University of Colorado School of Medicine in Denver.

John Rother, president of the National Coalition on Health Care, said Lucentis would be cheaper if Medicare could negotiate with drugmakers, as governments do in other countries. Asked about physician claims that money does not affect their decisions, Rother said: "I think claims like that should be viewed with extreme suspicion, given the dollar incentives."

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