The recent release by the Centers for Medicare and Medicaid Services (CMS) of physician reimbursement data for doctors who billed Medicare Part B has angered many physicians. Ophthalmologists in particular have reason to be upset: of the 344 doctors identified by CMS as receiving more than $3 million each in compensation, 151 were ophthalmologists. The lay media's interpretation of this data, and its subsequent coverage of the debate about cost-effective treatment for age-related macular degeneration (AMD) as it relates to ranibizumab (Lucentis, Genentech) and bevacizumab (Avastin, Genentech), depicted ophthalmologists as incredibly high-income physicians (when in reality they are not in the top 7 in terms of total revenue), providers whose lack of concern for cost-effective treatment drains the public coffers, or, worse, as providers who knowingly prescribe a more expensive treatment because of the supposed economic benefit.

Ophthalmologists have a right to be upset with the manner in which all of this came to light, especially considering the fact that the CMS has never included Part B drugs in its yearly publication of specialty revenue and neglected to release any context for the payment data, opting instead to provide the public with raw data that did more to confuse than inform. At a minimum, providing overhead costs for each specialty, or distinguishing between doctors who bill only for themselves versus those who bill for all physicians working in their practice, would have helped the public understand the massive tome of data.

By exploring the history of and reasons for this recent data release, ophthalmologists can prepare for any future releases of Medicare Part B payment data and can have a more nuanced understanding of exactly how and why this release affects them.

BACKGROUND

Several news outlets, including The New York Times and The Wall Street Journal, have been petitioning for the release of Medicare Part B data for several years. These media outlets ostensibly wanted to scrutinize the data to identify outliers and expose providers who illegally billed for services that were never rendered or for drugs that were never delivered.

The media's efforts to get hold of this information were ignored until, in April 2014, the CMS released data showing how much it paid individual physicians via Medicare Part B. Physicians should ask why Medicare Part B reimbursement data were released and why the data were released with no context.

HEALTH POLICY

Public health policy is a volatile mix of policy, economics, and politics; the CMS data release was a result of dysfunctional policy, miscalculated economics, and misleading politics.

Policy

There is a twofold rationale for releasing Medicare Part B reimbursement data to the public: It adds greater transparency and allows taxpayers to understand how much the CMS is paying, and to whom; in addition, the data may help patients identify which doctors more frequently bill for—and therefore likely have more experience with—certain procedures, which can inform their decisions when trying to choose a physician. The latter reason is certainly justifiable; however, the confusion that arose immediately following the data release undermines the claim of greater transparency. In reality, the release of raw numbers without any context or information that patients could use to fully assess and understand the data creates a system more opaque than transparent. The release of payment data contributes little to patients' understanding of a particular physician's history with a procedure—perhaps that physician is billing for several employees at his or her practice, for example— and in no way meaningfully informs patients' decisions about selecting a provider.

Economics

The widespread use of Medicare Part B drugs by ophthalmologists is a relatively new practice. Since 2006, the year the US Food and Drug Administration approved ranibizumab for treating wet AMD, the use of ranibizumab, bevacizumab, and aflibercept (Eylea, Regeneron) has become commonplace for a number of eye diseases. Additionally, because an overwhelming majority of their patients are beneficiaries of Medicare Part B, ophthalmologists bill Medicare at a much higher rate than ever before, and more so than other medical subspecialties.

Meanwhile, although the frequency of use of such agents has risen, reimbursement has followed a downward trend. Prior to the approval of ranibizumab for treating wet AMD, the CMS reimbursed billers the average wholesale price (AWP) of a drug plus 16%. By 2006, the reimbursement price was AWP plus 6%. Following the federal government's budget sequestration of 2013, the reimbursement rate fell to AWP plus 4%.

At the beginning of 2013, CMS expressed some concern about the increased billing of Medicare Part B drugs and theorized that physicians were prescribing drugs such as ranibizumab and aflibercept because, given that their AWP is higher than bevacizumab, the add-on percentage of more expensive drugs meant more gross reimbursement to physicians. This, however, is simply not the case. Prior to the government's mishandling of the compounding issue, roughly 70% of ophthalmologists used bevacizumab off-label at a time when they would have received reimbursement at a rate of AWP plus 6%. After access to compounded bevacizumab was restricted, which coincided with the budget sequestration of 2013 and thus lower reimbursement rates for physicians who bill Medicare Part B, only about 30% of ophthalmologists used it to treat wet AMD.

Claims that doctors currently prescribe ranibizumab in order to receive greater compensation are weakened by the fact ophthalmologists did not seize upon the opportunity to do so when that very practice would have been most profitable. Rather, it seems clear that the restricted access to bevacizumab—a restriction created by federal regulation—is responsible for ophthalmologists' increased use of more expensive anti-VEGF agents, thus partially explaining their appearance among the most highly reimbursed individuals by Medicare Part B.

Politics

With these facts, it is obvious that the use of more expensive agents—as evidenced in the CMS data—was more likely a function of faulty federal policy (as illustrated by the restricted access to bevacizumab following federal regulation of compounding pharmacies) than of physicians overprescribing to milk the system. By not couching the released data in a context that could help the public synthesize and understand the numbers' importance, the CMS data unfairly portrayed ophthalmologists as greedy opportunists who drain the healthcare system. When one considers preexisting policy, it appears that ophthalmologists have little choice when treating a patient with an anti-VEGF agent: They can either offer immediate, expensive, but on-label treatment with a particular anti-VEGF agent or deferred, less expensive, but off-label treatment with a different anti-VEGF agent.

It is impossible to know the circumstances and motivations behind the release of this data. Perhaps it was an effort to pass the buck and blame doctors for the rising cost of health care. Perhaps the massive machine that is the CMS was unable to properly contextualize the data under a certain time constraint. Regardless, one thing is clear: The reaction to the CMS data release, especially by the press, makes sense when one considers the fact that the CMS published raw data without the tools to explain their meaning. The media's ostensible goal—to identify individual outliers for scrutiny—is impossible to achieve without accompanying information from the CMS that explains why some doctors' high reimbursement rates may be misleading. The reaction by data consumers—to look at the top of the list to identify the highest grossing doctors—is as natural as it is logical, but leads, as many ophthalmologists have seen, to confusion, anger, and a sense of betrayal by the federal government. It falls on the CMS, the agency tasked with releasing this data, to responsibly disseminate information so that physicians practicing in good faith are not placed under unnecessary scrutiny by the media.

NEXT STEPS

Many physicians have no problem with releasing information about Medicare Part B data so long as it is done in a forthright, meaningful, and productive fashion that provides the consumer this information alongside the tools to understand it. What can physicians do to make sure that future data releases contain the proper context and information to best inform patients' decisions about their doctors? For one, medical societies will likely make an organized effort to address their issues with the current data format with the administration in charge of releasing this data. These societies will have to work closely with the CMS to ensure that any future data releases are not disingenuous and offer a fair, coherent report that is actually of value to consumers.

William L. Rich III, MD, is the medical director of health policy for the American Academy Ophthalmology and a senior partner at Northern Virginia Ophthalmology Associates in Falls Church. Dr. Rich may be reached at hyasxa@gmail.com.