October 2, 2014

Now You See It, Now You Don’t


In its continued effort to force transparency on everyone but itself, the government, through the Centers for Medicare & Medicaid Services (CMS), has released another data dump that is supposed to shed light on the financial relationships between vendors and healthcare providers.

In reality, what it does shed is just more noise and confusion on an already noisy and confusing issue. In fact, this release makes the April 9 dump of procedures and services reported by provider, which in and of itself was a mess, look like a perfectly thought-out work of excellence. And since this is designed to “help” the average consumer figure out something of value about their healthcare provider, the release of these data makes absolutely no sense to me.

So, what do we have here, besides more sleight-of-hand by CMS? Well, it is a database that contains nearly four and a half million payment records reporting just shy of $3.5 billion in payments to mostly physicians and teaching hospitals. Does that help anyone so far? I was just wondering how many average consumers are already titillated by this little bit of really important and transparent information.

The database contains five months’ worth of data, which begs an important question: why?  I mean, was there some really urgent need to release data in a format that is, at least from my perspective, total junk? Was there a lawsuit? Were people’s lives at stake? There must have been some very important reason to get CMS to publish a database of poorly formatted, poorly thought-out, and poorly identified information in order to help consumers make educated decisions about their healthcare. Or, just maybe, this is opposite day!

From what I could gather from my initial review, about 40 percent of the records within the database fail to disclose the person or entity to whom the payment was made. CMS said that about a third of the data would not be released because of inconsistencies and other problems. That means that, in total, nearly two-thirds (64 percent) of spending could not be attributed to a given named entity. That’s just crazy. If you think only a third your data are representative, even at this low a level, then maybe you should wait until you figure out a way to present all the data accurately. Research payments accounted for nearly $1.4 billion in payments, yet 90 percent of that could not be attributed to a particular entity. Raise your hands if you think the remaining 10 percent is of value. No hands? Okay.  Moving on.

General payments to physicians and hospitals, which accounted for just over a quarter of all payments, totalled around $1 billion and of those, nearly a third (31 percent) could not be attributed to a given entity. Around a third of that went for royalty and licensing payments and another 20 percent went for promotional speaking engagements. At the bottom was 0.02 percent paid out for entertainment. But who can believe the data? Not me. The data themselves were a mess. Drug and medical equipment companies reported payments under dozens of different subsidiary companies and it will be difficult to reconcile accurate estimates back to the parent organization as a result. According to Charles Ornstein of ProPublica[1] (www.propublica.org), Johnson & Johnson “submitted payments under at least 15 subsidiaries” while Medtronic reported payments under “at least six subsidiaries.” In many instances, there were fields that contained pure gibberish and in other cases, there was text where there should have been numbers and numbers where there should have been text. CMS stated that they withheld a third of the data because of problems, but how did they miss all the others that I found in just a cursory review?  The answer is easy for me: I don’t believe them.

As stated, research payments consumed the lion’s share of the total, at around 42 percent of payment data that was released. I am not sure if CMS is saying that this is a bad thing or not. Maybe I am a bit biased, but I love to see lots of money spent in research. I recently went through complex spinal surgery and I selected the doctor based on his involvement in researching areas that included the type of surgery he performed on me. But the data were not found within this database so, as a consumer, it wouldn’t have done me any good. And the data are totally unclear here. For example, I looked at a payment of several million dollars that went to a single physician. But when I researched it further, I found out that this physician was the head of the board of trustees for a well-known teaching facility and the payments were not to him, but to the organization as a whole for research being conducted by lots of providers in several departments. These are types of mistakes that create misunderstandings and instead of clearing things up, just make them muddier.

If CMS really wants to promote transparency, then give me the algorithms that their top-secret RAC contractors use to identify claims that fail medical necessity tests. Give me the methodology used by CMS auditors to identify potential fraud and abuse so we can address those issues a priori. CMS doesn’t want transparency, they want confusion, and the truth is, I just can’t figure out why.

This data dump is even more useless than the April 9 dump of the PUF files. Now, don’t be confused. I am not anti-government, anti-transparency or anti-data. I am anti-junk, and as an analyst, statistician, and researcher, I believe that you should not tell a story until you have all of the facts. You don’t release half-truths and then tell the public that it is for their own good.

Take a look at the files yourself. They are posted on the CMS website at http://www.cms.gov/openpayments/index.html. Then tell me that you think the “average consumer” is going to get any benefit out of it. In fact, CMS has this posted on the Open Payments website:

“Some datasets, particularly the general payments dataset included in the zip file containing identifying information, are extremely large and may be burdensome to download and/or cause computer performance issues.” 

Really? Well, that won’t stop my mom or dad from researching payments made to their doctors (NOT). Kudos to Charles Ornstein and his team at ProPublica for doing a bang-up job on publishing details of the release. If you want to get into the weeds, go to www.propublica.org as they have done a great job in defining the issues.

So what if my doctor made money from big pharma by presenting at one of their conferences? Do you really think I care if some medical device manufacturer buys my physician and her staff lunch during a presentation of a new product? The CEO of United Healthcare made $106 million last year. Anyone screaming about that? I have been in this industry for a very long time and it would seem that we have much bigger fish to fry than this. I am not saying that these types of data dumps aren’t important, and I am all for transparency. I’m just saying that CMS has their priorities all messed up. If they really wanted to help improve quality and access to care, then they would figure out a way to put the RAC contractors on a leash and help solve the two-year moratorium on ALJ appeals hearings. 

In summary, this is not transparency, this is noise, and what noise does is conceal the signal. Nate Silver said this in his book, The Signal and the Noise: Why So Many Predictions Fail—but Some Don’t: “The signal is the truth. The noise is what distracts us from the truth.” So, from my perspective, what CMS has done is create a distraction from the truth.

And that’s the world according to Frank.

About the Author

Frank Cohen is the director of analytics and business Intelligence for DoctorsManagement. He is a healthcare consultant who specializes in data mining, applied statistics, practice analytics, decision support, and process improvement. Mr. Cohen is also a member of the National Society of Certified Healthcare Business Consultants.

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[1] Our First Dive Into the New Open Payments System; Charles Ornstein, PoPublia, Sep. 30, 2014, www.propublica.org/article/our-first-dive-into-the-new-open-payments-system

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