Group getting Medicare claims data

Washington -- Physicians practicing in four states and Washington, D.C., could start seeing some of their Medicare claims data posted online after a consumer group successfully sued the government for the information.

The U.S. District Court for the District of Columbia ruled Aug. 22 that Health and Human Services must release Medicare physician claims data for the District of Columbia, Illinois, Maryland, Virginia and Washington state to Consumers' Checkbook/Center for the Study of Services. The nonprofit group had sued HHS after the department rejected its initial Freedom of Information Act request.

Under the decision, HHS must hand over by Sept. 21 select information from all Medicare claims filed in 2004 by physicians in those states. Consumers' Checkbook/CSS did not request any data that contain identifiable information about patients.

Physician-specific data, on the other hand, are fair game. After it receives the claims information, the consumer group as a first step plans to create a free online public resource that lists the number of certain major procedures that each physician performed in 2004 on Medicare patients. The organization says seniors will be able to make more informed decisions about which physician to use for a procedure if they know how many times he or she typically provides the service in a given year.

"A consumer selecting a physician for a knee replacement or prostate surgery or other major procedure will be able easily to check that a physician has an appropriate level of experience," said Robert Krughoff, president of Checkbook/CSS.

Some physicians whose treatment patterns will be on display said Medicare would be forced to sacrifice something of far greater importance in the name of information transparency.

"It's very disheartening to hear that the promises of [physician] privacy and confidentiality that have long been guaranteed in our health care system have been so easily overturned by a single lawsuit," said W. Hugh Maloney, MD, president of the Washington State Medical Assn.

HHS defended in court its rejection of the FOIA request by arguing that the release would constitute an unwarranted invasion of physician privacy. By looking at the number of times an individual physician performed Medicare procedures and then consulting the fee schedule for each service, a person could determine how much the program paid that doctor in a year, HHS said.

But the public's interest in obtaining the information for the purpose of choosing the right doctors outweighs the minimal privacy intrusion that might occur, U.S. District Judge Emmet G. Sullivan wrote in his decision. "The information the plaintiff requests to be disclosed concerns only the business income of the physicians involved and not intimate facts about their personal lives."

Sullivan noted that the public interest exception to privacy law is more difficult to obtain when the information is destined for commercial use. Although Checkbook/CSS has charged fees in the past for its reports, the fact that it is a nonprofit organization means that the public interest still takes precedence, he said.

But some doctors worry that just because the court has deemed the information useful to patients does not necessarily mean it is accurate.

When the first reports show up on the group's Web site, physicians whose names appear should make sure their listed procedure counts are correct, said Martin P. Wasserman, MD, executive director of MedChi, the Maryland State Medical Society.

Checkbook/CSS said it would invite doctors to attest to their procedure data but did not say what would occur in the event of a challenge.

Next steps

HHS officials are reviewing the latest development and will decide whether the department will appeal the court's decision, a spokeswoman said. The American Medical Association and the medical societies for Illinois and Virginia also are reviewing the matter before weighing in. A spokesman for the Medical Society of the District of Columbia could not be reached for comment by press time.

Consumers' Checkbook/CSS isn't waiting for the outcome of any potential HHS appeal before moving forward. The organization already has a similar freedom of information request for 2005 Medicare claims data for all 50 states, and it expects the request to go through now that the court has ruled in its favor.

The group will encourage private insurers to pool physician claims information with the Medicare reports to create more accurate snapshots of individual doctors' experience levels. Krughoff noted that the Bush administration already has started a transparency campaign involving the public release of claims-based data so patients can make more informed health care decisions.

Checkbook/CSS doesn't plan to stop at simply listing procedure counts for individual physicians. The data eventually could be used by the group to determine more complex measures of health care quality, such as how well doctors provide care according to clinical guidelines.

But more complex public reports may take years to put together if they are going to provide any meaningful information, MedChi's Dr. Wasserman said. Compiling procedure counts for four states and the District of Columbia alone will require wrangling a massive amount of data to give only a minuscule insight into physicians' quality of care.

"At the end of the day, this is probably going to be worthless for patients," Dr. Wasserman said.