AMA Gives 9 Reasons for Caution on Using Medicare Physician Data

Errors Errors

Data being released may contain errors because there is currently no mechanism for physicians and other providers to review and correct their information.

Quality Quality

The data does not include explicit information on quality of care provided or quality measurement. It solely focuses on payment and utilization of services so it cannot be used to evaluate the value of care provided. 

Number of Services Number of Services

Residents, physician assistants, nurse practitioners and others under a physician's supervision can all file claims under that physician's National Provider Identifier (NPI); the data may not properly detail the services performed and who performed them. Additionally, there are several instances in which it can appear that two surgical procedures were done when in fact there was only one. For example, when there are co-surgeons or an assistant at surgery, the procedure should be counted as only one surgery, not two. 

Charges vs. Payment Charges vs. Payment

Medicare and other payers pay fixed prices for services based on fee schedules; therefore the amount paid to physicians is generally far less than what was charged and is not an accurate portrayal of payment.

Patient Population Patient Population

The data being released is an incomplete representation of the services physicians provide, as it is not risk adjusted. Additionally, it does not include care for private insurance patients or Medicaid beneficiaries, making it a limited view of the patients a physician cares for. 

Site of Service Site of Service

Payment amounts vary based on where the service was provided. To reflect a difference in practice costs, Medicare pays physicians less for services provided in a hospital outpatient department than for services in the physician's office.  However, for services in the outpatient department, another payment is made to the facility to cover its practice costs so that, in reality, the total costs to Medicare and to the patient may be higher when a service is provided in a facility setting.

Provider Comparisons Provider Comparisons

There is a lack of specificity in specialty descriptions and practice types in the data, which could be misleading when making comparisons between physicians. In some cases, physicians who appear to have the same specialty can serve very different types of patients, thus impacting the mix of services provided.

Missing Information Missing Information

The data does not account for patient mix and demographics or drug and supply costs.

Coding and Billing Changes Coding and Billing Changes

Any analysis using the data should take into account changes in Medicare's coding and billing rules that may be different over time and across regions of the country (e.g., local coverage determinations). 

Medicare has publicly posted 2012 Part B payment information on more than 880,000 physicians and other billable professionals in all 50 states. The government says the data makes possible analyses to compare 6,000 types of services and procedures along with payments received by individual providers. The American Medical Association counters that the data has significant shortcomings regarding the accuracy and value of services rendered by physicians, and gives nine examples.


Already a subscriber? Log in here
Please note you must now log in with your email address and password.