Are Maryland and The Wall Street Journal showing federal health-care cops how to do their job? Kind of looks that way.
On a computer network based in Woodlawn, on huge encrypted hard drives, are patient records containing evidence of the estimated $50 billion that fraudsters and abusers drain from the federal Medicare program every year. But pressure from doctors has kept the data under guard for three decades.
The Journal and the Maryland Health Services Cost Review Commission are mining the information in long-overdue attempts to shed light on abuse.
As previously reported in The Baltimore Sun, the commission screened billing data last year to try to identify hospitals and doctors who were installing unusually high numbers of coronary artery stents. The analysis came in the wake of allegations that Dr. Mark Midei implanted hundreds of unnecessary stents at St. Joseph Medical Center.
The commission gets health-care payment data by virtue of the state's unique ability to set hospital prices. The Journal is prying out the information the old-fashioned way: through freedom-of-information requests, lawsuits and nagging.
In a series beginning last year, the newspaper used Medicare databases to anchor reports on a New York doctor who made $2 million a year by ordering numerous expensive tests; how doctors help set their own Medicare reimbursement; and how a New York urology practice reaped $27 million by sending prostate-cancer patients to its own radiology center.
The latest dispatch last week recounted the tale of Dr. Vishal James Makker, a Portland, Ore., neurosurgeon with the highest rate in the nation of repeat surgeries for a particular spinal procedure. Makker told the paper his cases were more difficult than those of other surgeons.
Health care is the main component of America's fiscal time bomb. Medicare, the federal program headquartered in Baltimore County for those over 65, accounts for about a fourth of health-care spending. The thievery and gaming associated with Medicare are legendary.
Saving the system from obese morbidity will partly involve combing claims data to expose and deter wrongdoing. Yet since the 1970s the Centers for Medicare and Medicaid Services, as the Woodlawn-based agency is formally known, has guarded the information like crown jewels.
The American Medical Association, the biggest doctor trade group, won a court order on privacy grounds that stopped the government from showing how much money doctors get and what procedures they order. That makes the data largely useless for patients or news organizations trying to draw conclusions not only about billings but about quality of care.
"Americans spend like $2 trillion a year on health care," Mike Williams, the Journal's Page One editor, said in an interview. "The single richest and most telling source of data on the entire health care system is this Medicare claims data. It exists because taxpayers pay for it, and yet it's not open to the public."
Along with the Center for Public Integrity, the Journal filed a public information request for a portion of the database and then spent months negotiating the cost, getting Medicare to furnish an encryption key and trying to understand the information. While the agency "substantially reduced" the original $100,000 fee, the Journal reported, it forbade the paper from naming doctors identified in the database without their permission.
In January, the newspaper sued to remove Medicare's ban on showing which doctors get paid what, emphasizing that it's not seeking information on patients. A few weeks ago, Iowa Republican Sen. Charles Grassley introduced legislation to end the secrecy. Oregon Democratic Sen. Ron Wyden also supports opening Medicare's trove, according to news reports.
For their part, Maryland authorities screened Medicare and other billing records to see if other hospitals and doctors showed the same high rates of stent implantation displayed by St. Joseph. Data obtained by The Sun from the cost review commission show that Washington Adventist and Union Memorial hospitals appeared to have higher-than-typical stent placement rates. Both hospitals have said the procedures were justified.
(Investigations based on that screen "are under way and ongoing," says David Paulson, spokesman for the Maryland Department of Health and Mental Hygiene.)
The federal government's own data mining for fraud and abuse sounds recent and less than full-blown.
"We've been developing that over the last couple of years," Nicholas DiGiulio, special agent in charge with the Department of Health and Human Services' inspector general, said in an interview. "Our agents even have access to billing data."
HHS is Medicare's parent agency. DiGiulio declined to discuss specific investigations or to say whether his office is looking at stents.