May, 2014

Data Way to Go

By Michael J. Katin, MD

Over the past several years, it has been rare for practitioners of radiation oncology, let alone physicians in general, to have an interval of time free of disruptive forces, and April was no exception.

This event was caused by the sudden availability of previously-restricted government information. Unlike previous examples, this occurred without the intervention of persons such as Daniel Ellsberg or Julian Assange. On April 9, CMS voluntarily (sort of ) released to the press the 2012 Medicare payments to physicians and other non-institutional health care providers, creating the opportunity for anyone to search out the goods on his or her favorite (or least favorite) practitioner. Not only can the total amount received for Medicare be learned, but the number of procedures of each type are listed as well. It was probable that misinterpretation of these data could occur on at least two levels. First, the amount of money received from Medicare was likely assumed to be profit. For radiation oncologists in freestanding units, these could include pens, gowns, tongue depressors, telephone bills, malpractice insurance and, oh, yes, linear accelerators, simulators, physicists, dosimetrists, therapists, nurses, billing personnel, receptionists, and compliance officers. The estimate is that approximately 82% of income goes for operating expenses. The second problem is that there is no way to know (short of publishing everyone's tax return---which I'm certain will be coming!) how much income was received by a physician other than through Medicare, and how many procedures were done to non-Medicare clients. Deciding on an orthopedist, for example, based on the number of his or her procedures, could be all right for hip replacements but not for ulnar collateral ligament reconstructions. One could conclude that pediatricians and obstetricians have very little to do all day.

But it is what it is, and no government bureaucrat seemed to care enough to emphasize the nuances of this information. Several professional organizations were preparing to intervene to start damage control, but this turned out not to be necessary It was on April 25 that Donald Sterling's private but recorded rants were released, providing sustenance for the public's appetite for controversy and resulting in nearly everyone's totally forgetting about the CMS release. ASCO, ASTRO, ACRO, and AFROC should all be eternally grateful....at least until the 2013 numbers come out.

In the interim, we have the opportunity to remind the public in as many ways possible that there enormous expenses, responsibilities, and pressures that go along with these payments.

In addition, it needs to be emphasized that there are other entities in the country that consume resources and provide a lot less benefit than does the medical care system? Solyndra consumed $1.6 billion, including a $535 million government loan guarantee, and so far the only energy it's saved is the electricity not being used in the unoccupied headquarters building. Comment should probably be withheld regarding the amount / spent in wars in Iraq and Afghanistan -- but only since the cost in mortality and morbidity is more relevant and since the total hasn't yet been reached.

Ironically, now that Mr. Sterling and V have temporarily saved us from public antipathy, the Los Angeles Clippers franchise will be sold and will bring the owners, primarily Mr. Sterling, between $1 and 2 billion dollars. According to the CMS data for 2012, that could cover the total Medicare charges for radiation oncology from that year!!! Of course, could you get 18,118 people to fill seats and buy beer and nachos while watching patients receiving radiation therapy treatments? Well, maybe some treatment devices are more interesting than others. But then there's that privacy thing.

Another comparison would be between federal salaries for bureaucrats, judges and members of Congress, starting with base salaries and then adding in expenses and other benefits. There never seems to be a question of return on investment in most of these cases (because they're worth it!!!! Of course!!!).

The way things work, it probably will continue that the average person will assume that physicians keep all the money that Medicare pays. This would be the same as assuming that the money paid for an airline ticket goes entirely to the pilot or that the salary of an NFL player is kept entirely by him rather than shared with his entourage. It may be necessary to totally change the system to get past this. Alternatives could include having expenses could be put onto a Medicare expense account or credit card to be paid directly to the vendors and bypassing the physician. This has the potential for abuse, but probably much less so than for other government programs. As always, there is the prospect of having everyone put on salary, which can work to eliminate contamination of the treatment decision process by the profit motive, resulting in a much more pure and efficient system. Possibly this could be modified by a "pay-for-performance " method, although there is always controversy as to which performances deserve to be rewarded. When it finally gets down to it, though, there is probably only one method by which a physician can be compensated that will truly reflect the value and appreciation of the patient for what has been done.