Fact Sheets Apr 09, 2014

HHS Releases Physician-Level Medicare Data

Billing & payments
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HHS Releases Physician-Level Medicare Data

Today the Department of Health and Human Services (HHS) released a new privacy-protected data set that has information on the number and type of health care services that individual physicians and certain other health care providers furnished in 2012 under the Medicare Part B fee-for-service (FFS) program, as well as information on the amount that Medicare paid them for those services. The new data set has information for over 880,000 distinct health care providers in all 50 states, DC and Puerto Rico who collectively received $77 billion in Medicare payments in 2012. The new data are posted on the website of the Centers for Medicare & Medicaid Services (CMS).

CMS created the new data set using information from the Physician/Supplier Part B Claims File, also known as the Carrier File, which has final action FFS claims that are submitted by physicians and other non-institutional health care providers, such as non-physician practitioners, ambulatory surgical centers, clinical laboratories, and ambulance providers. The new data set does not have information for institutional health care providers, such as hospitals or nursing homes, or for suppliers of durable medical equipment; some data on these types of providers is already publicly available: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/.

The new data set identifies individual providers using their National Provider Identifier (NPI) and the specific services that they furnished using Healthcare Common Procedure Coding System (HCPCS) codes. For each provider and service, the new data set has the total number of services that were furnished, the provider’s average charge, the average Medicare payment, and the average Medicare-allowed amount, which is the sum of Medicare’s payment and any deductible or coinsurance owed by the beneficiary. The new data set also has the standard deviation for each payment metric, so that users of the data can better understand how much the payment amounts varied, even for a specific service. CMS did not include information in cases where a provider furnished 10 or fewer units of a particular service to ensure the confidentiality of patient-specific information.

When health care providers obtain an NPI, they indicate whether the NPI will be used by an individual or an organization and the specialty that best describes the type of health care services that they furnish. The chart below shows the ten specialties with the highest aggregate Medicare payments in the new data set; together, those provider specialties accounted for 57 percent ($44 billion) of the total Medicare payments included in the new data set.

Provider Specialties with the Highest Medicare Payments

 

This bar chart shows the provider types with the highest aggregate Medicare payments. At the top is internal medicine NPIs, which accounted for approximately 8.5 billion in spending, followed by ophthalmology, cardiology, ambulance service supplier, clinical laboratory, family practice, diagnostic radiology, hematology/oncology, ambulatory surgical center, and dermatology. The chart also shows that certain of these providers have organizational NPIs, specifically ambulance services supplier, clinical laboratory, and ambulatory surgical center.

The new data set will make it possible to conduct a wide range of analyses that compare the services provided and payments received by individual health care providers. For example, the table below shows the ten physician specialties that had the highest Medicare-allowed amount per individual physician, on average. (We did not include figures for any specialty that had fewer than 500 providers.) It is worth noting that the top four specialties – hematology/oncology, radiation oncology, ophthalmology, and medical oncology – often use Part B-covered prescription drugs, which are usually administered by a physician. In those cases, Medicare’s payment to the physician also includes payments for the drugs themselves.

Specialties with the Highest Medicare-Allowed Amount per Individual Physician

 

Table 1 – Specialties with the Highest Medicare-Allowed Amount per Individual Physician: This table shows the ten specialties that had the highest Medicare allowed amount, per physician on average. Hematology/oncology is at the top with an average Medicare allowed charge of $463,844. In total there are 7,373 hematology/oncology NPIs and on average these providers bill 24 services. The remaining specialties in the top 10 were radiation oncology (with an average Medicare allowed charge of $458,222), ophthalmology ($429,657), medical oncology ($390,992), rheumatology ($333,016), cardiology ($290,279), nephrology ($286,751), dermatology ($281,206), interventional pain management ($252,907), and cardiac electrophysiology ($237,904).

The new data set can also be used to examine how patterns of service use vary across physicians and specialities. For example, Medicare has five different HCPCS codes (99211-99215) for routine office visits, based on the length of the visit. The Medicare-allowed amount for those codes in 2012 ranged from $20 for 99211, a 5-minute visit, to $140 for 99215, a 40-minute visit.

The chart below shows how often the physicians in four specialties used those codes; the red dots represent the national averages. Neurologists were more likely to use one of the higher-valued codes (99214 or 99215), while dermatologists are more likely to bill 99212 or 99213.

Office Visit Codes by Specialty

 

Chart 2 – Office visit Codes by Specialty: This bar chart shows how often the physicians in four specialties used the codes 99211, 99212, 99213, 99214, and 99215 – which all represent different lengths of time for a routine office visit – and the national average across specialties. Internal medicine specialties mirrored the national average utilization for these codes – internal medicine doctors used codes 99211, 99212, and 99215 less than 10% of the time, but used 99213 approximately 45% of the time and 99214 slightly less than 40% of the time. Dermatology NPIs used codes 99212 and 99213 more frequently, cardiology NPIs used codes 99211 and 99214 more frequently, and neurology NPIs used codes 99214 and 99215 more frequently.

The new data set can also be used to examine the variation across individual physicians in how often they provided a particular service. For example, there were 55,000 internal medicine physicians who provided one of the longer office visits (the 99214 code) at least 11 times in 2012. The average internal medicine physician provided this service 377 times over the course of the year, but there was wide variation around this average. About 26 percent of internal medicine physicians furnished this service less than 100 times, while another 16 percent provided this service at least 700 times.

Delivery of Longer Office Visits (HCPCS Code 99214) by Internal Medicine Physicians

 

Chart 3 – Delivery of Longer Office Visits by Internal Medicine Physicians: This bar chart shows the count of HCPCS code 99214 delivered by internal medicine physicians. About 26% of physician furnished this service less than 100 times, but 16% provided this service over 700 times.

The new data set also suggests the most physicians provide a relatively limited number of distinct health care services. For example, cardiologists as a group submitted claims for 1,346 different HCPCS codes, but individual cardiologists only submitted claims for 23 codes, on average. We also found that a single HCPCS code often accounted for a substantial share of the Medicare payments for a particular specialty. The chart below shows ten different specialties, the individual code that accounted for the most Medicare payments for that specialty, and the payments for that top code as a percentage of the overall total. 

Top Code by Specialty

 

Chart 4 – Top Code by Specialty: This bar chart shows for ten different specialties, the individual top HCPCS code than accounted for the most Medicare payments for that specialty and the payments for that code as a percentage of overall payments for that specialty. While for clinical laboratory NPIs the top code, 88305, only accounts for approximately 8% of payments, for ambulatory surgical center NPIs the top code, 6984, accounts for nearly 40% of payments.

The following graph examines the relationship between total Medicare payment, total services, and number of providers for selected procedures and healthcare services within a provider specialty. The 99214 code, which appears for internal medicine, family practice, and cardiology, has a large payment amount driven by a large number of services. Other codes, such as A0427 (ALS1-emergency), have high total payments due to a high per-service payment amount.

Medicare Payment, Total Services, and Number of Providers for Selected HCPCS Codes

 

 

Chart 5 – Medicare Payment, Total Services, and Number of Provider for Selected HCPCS Codes: This bubble chart demonstrates the relationship between total Medicare payment, total services, and number of providers for selected services. The chart shows that for certain services few providers delivered the services, total payments were low, and the number of services was low – this applies to codes such as 77418 and 66984. On the other hand, other codes have a high number of providers delivering the service, high total payments, and a high number of services – this applies to codes such as 99214.

To view the new physician data set, please go to: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html

To read the press release, please visit: http://www.cms.gov/newsroom/newsroom-center.html

For additional information on how Medicare pays for physician services, please see: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareClaimSubmissionGuidelines-ICN906764.pdf

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