Medicare isn’t doing its own ‘truth checking.’ Why?

Kudos to ProPublica for "Examining Medicare," but there's more to this story than the bad apples

In April, the Department of Health and Human Services released its great Medicare data dump unlocking a treasure chest of reporting opportunities. The government revealed details about the $77 billion in payments Medicare made to 800,000 doctors who treat patients for Part B services, which include doctor visits, outpatient treatments, and lab services. News organizations and others had long pushed to make these numbers public, and once they were—thanks to a lawsuit filed by Dow Jones—the data did not disappoint. Not unexpectedly, ProPublica, expert in data slicing and dicing, pounced on the numbers. For its resulting series, called “Examining Medicare,” ProPublica deserves a shout-out.

On April 16, ProPublica kicked off the series with a piece, co-published with NPR, reporting that Medicare continued to pay doctors even if they had been suspended from Medicaid, indicted or charged with fraud, or had settled civil allegations of submitting false claims to Medicare. Subsequent stories looked at ambulance companies in New Jersey billing Medicare for unusually large numbers of non-emergency ambulance rides in 2012, and docs who billed at Medicare’s top level at least 90 percent of the time. A mid-June piece noted that doctors with unusual billing patterns—such as charging only for the most complicated and high-priced office visits—also had been “disciplined by their state medical boards or faced accusations against their licenses.” The story nods to similar reporting done (sometimes in collaboration with ProPublica) by Bloomberg, The Wall Street Journal, the Dallas Morning News, KQED in California, and the Chicago Tribune, which tailored the focus for their audiences and reached similar conclusions. The Dallas Morning News, for instance, found 10 of the 77 Texas providers who almost exclusively billed for the most expensive office visits in 2012 “have been fined or otherwise sanctioned by the Texas Medical Board.”

Surely patients would want to know if their doctors were overbilling, and ProPublica’s Treatment Tracker, which lets consumers compare their doctors to others, and its Patient Guide, which suggests good questions for patients to ask, are useful components of the package. Charles Ornstein, ProPublica’s lead writer on the series, says the consumer features of the project “give people an opportunity to make the data personal to them.”

And yet: Should consumers, a.k.a patients, have to police their doctors because the federal and state government health policemen have taken a hike, as ProPublica’s reporting suggests they have? Ornstein says Medicare may have wanted reporters to help document fraud and abuse when it released its data. “CMS is giving a response it intends to put data out there that allows you to truth check,” he told me. But the real question is why isn’t Medicare doing its own truth checking? It’s not surprising high billers often had other disciplinary problems; If a provider is willing to stretch the law in one area, why not another? What is it about Medicare’s oversight of the nation’s doctors that allows these outliers to continue business as usual despite a sanction now and then? The US healthcare system has evolved from a cottage industry to a profit-driven marketplace—what is it, politically, that has made this transition possible and allowed these doctors to continue flourishing? Fred Schulte, a senior reporter for the Center for Public Integrity, raised this point with me a couple weeks ago discussing his series detailing hypocrisy and regulatory neglect in the Medicare Advantage program. “Medicare managed care was a complete disaster, and then they opened the flood gates [to big money],” Schulte told me. “It’s annoying that you don’t see government learning from previous mistakes.” Does Medicare really want to? Or are the pressures from the regulated to look the other way simply too great?

Ornstein’s series does suggest that Medicare may not be doing enough policing, but doesn’t really get into the whys. In the series opener he wrote: “ProPublica’s analysis shows Medicare could and should be doing far more to use its own data to sniff out cost-inflating errors and fraud.” In a May 29 piece, he reported the inspector general for the Department of Health and Human Services found Medicare was spending some $7 billion more than it should have for physician office visits and patient evaluations in 2010. Yet Medicare, in its reply to the IG’s findings, says it has no plans to review the billings of doctors who almost always charge for the most expensive visits because it’s not cost effective to do so. A regional inspector general, Dwayne Grant, who oversaw the new report told ProPublica, “We don’t want to pay them too much but we don’t want to pay them too little either.” Last week, I highlighted six times Medicare has caved to pressure to go easy on an industry it’s supposed to police; could this be a seventh?

The policing and enforcement problems plaguing Medicare go deeper than the handful of outliers that ProPublica plucked out of the data. It’s always been easier to report on the rotten apples than to examine the whole barrel. ProPublica’s effort and those of other news organizations should be considered a strong first leg of a longer journalistic journey using data to explore the health system’s ongoing failures, including policing and enforcement. Data, no matter how illuminating, can take us only so far. What the data mean and don’t mean is what the public needs to know.

Related content:

The promise and peril of new Medicare data

Six times Medicare caved

Investigating a $150 billion ‘black box’

Has America ever needed a media watchdog more than now? Help us by joining CJR today.

Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman. Tags: , , , ,