For about the past week, there has been a lot of reporting regarding the CMS release of medicare payments to providers in 2012. In an early responsive move, AMA provided a release entitled 9 ways CMS’ claim data release could mislead patients, reporters. APTA’s response-not exactly bold or informative was simply a referred link to AMA (am sure Membership Matters Week was simply a priority). It is unclear to me why CMS is being exempt from criticism on this-although clearly the best defense might simply be an offense.
CMS’ working theory is that by providing public access to payment data, transparency is upheld and providers will be on guard or compelled to curb utilization, fraud and abuse sensitive to overbilling of our senior citizens. Unfortunately for CMS, even prior to this gimmick meant in part to demonize, providers needed little incentive to stop seeing medicare patients and prior reports confirm that about 50% of MD’s are already limiting or eliminating medicare patients from their practice. While the the data tells us little that we didn’t already know, the interpretation of the data, including many of our colleagues who see running queries on their PT buddies as their “Angry Bird” internet addiction, needs to be viewed with great suspicion.
Let’s provide some general context. From the data and Wall Street Journal report, we know:
- 1% of doctors accounted for 14% of medicare billings. This amount of $77 billion is more than 15x all outpatient rehab including PT
- the 1000 highest paid doctors received $3.05 billion in payments. This is roughly 75% of outpatient PT payments for about 37,000 physical therapists in the data
- one-third top earning doctors are ophthalmologists, and one of ten is a radiation oncologist (already well known)
The medicare data tell us the obvious-cancer, heart disease, eye conditions and imaging account for the largest bolus of money spent. Primary care spending accounts for minimal and rehab is roughly 1%.
In no particular order, here is what medicare #physicaltherapy data doesn’t tell you:
1. The burden that CMS places on #physicaltherapy providers. These include the mandated plan of care, extensive documentation requirements which take time from patients, PQRS, G codes, multiple group therapy interpretations, out of line conclusions and implementation by Medpac, superimposed rules that fall outside of state practice acts, stringent technical filing requirements, and the antiquated exceptions process (here is even a more extensive list and for more fun, the “are you smarter than a PT regulator quiz” ).
2. Nothing about the episode of care. Was the patients’ referral (oh yeah, yet again another medicare requirement despite most states allowance of direct access) after a failed back surgery? What money was spent upstream or downstream from the physical therapy event? Since PT is a referred service, any data reporting of it in a single silo approach doesn’t tell us anything discerning.
3. The outcomes. The data is presented neutrally without any regard to the functional status of the patient at discharge. There is no relevance to “good” or “bad” care. A PT with low medicare payments with heavy weighting toward passive modalities might be construed as better than a PT with higher manual therapy and exercise interventions.
4. Patient demograpics, comorbidities, or rehab setting. All of these make huge differences in payment data. There is no way to discern between a chiro clinic that bills PT under a PT numbers vs. a physician office vs. a corporate practice of PT vs. an independent PT provider.
5. Whether PTA’s were involved in the care or not. Some practices-particularly in states like Florida have a much higher percent of medicare patients and likely have more PTA involvement which would create an illusion that 100% of the medicare payment is tied to the PT.
6. Accuracy of the data. Every medical provider has gotten requests for refunds for patients they have never seen and has has billed patients whose care has crossed over to different PT’s. Unless this data has been reviewed extensively by outside parties that can be trusted (e.g. public accounting and audit firms), any payment data should be viewed with scrutiny. What about the mandated delays around the end of the fiscal year and the growth in private medicare-wouldn’t that throw things off a bit?
7. Cost of providing #physicaltherapy. Medicare patients are the highest cost patients to treat. Coupled with rules that in essence reduce PT’s to underpaid hourly technical assistants, the medicare data by implication suggests payments are earnings-or at least imply it in a relative basis. This
“The Math” post demonstrates by taking cost data including overhead that the max earnings of a medicare PT to $57k-and that was in 2006! Additional rules (e.g. MPPR), compliance, and constraints have actually reduced since then. Oh, and educational costs and time to get a DPT have only skyrocketed thus creating unprecedented student debt.
8. Instruction by the regional medicare carriers or fiscal intermediaries. They are given broad powers by CMS including the ability to
kill codes like group therapy. Every private practice provider has been at the mercy of them on instructions such as bill all the PT under group ID vs. NPI vs. owner.
9. Timeliness of payments. Were payments in early 2012 based on 2011 regulations? What about appeals and subsequent payment? How many times were the charges submitted and re-submitted? What about CMS notorious wholesale claims rejections (G codes) and system errors? The bottom line is the data doesn’t tell us anything new or meaningful. I understand the suspicion of results
like this that suggest names that are hard to pronounce notably in the Brooklyn area have some clear issues but if there is malicious fraud and abuse at play (and I refuse to suggest this), wouldn’t that be more a failure of CMS
RAC program which is currently on hold or their 17 year old Health Care Fraud and Abuse Program? Why is CMS in publishing this data getting such a free pass in all of this?
Thoughts?
@physicaltherapy
