Medicare Data Could Cut Health Care Costs
Health Care Explainer (4:3)
Economists say one reason the health care system wastes so much money is a simple lack of information. It's nearly impossible to know which physicians are doing an efficient job, or which ones are ordering too many tests or the wrong tests. What's needed, economists say, is a huge database of information.
It turns out, that database exists, but no one is allowed to use it to evaluate doctors. The fight over what can and can't be done with this data stretches back many years.
Arnold Milstein, who advises the White House on health care economics, has been at the center of the debate. He says he noticed a lot of unnecessary spending in his early days as a physician — much of it stemming from one unlikely tool.
"It's often said that the single most powerful influence in quality and spending is the physician's pen," he says. "Over time, I began to realize the wisdom of that insight."
Milstein diagnosed the problem as one of relative ignorance: Physicians don't have a clue how they compare with their colleagues. They don't know if they're spending more than another doctor to treat the same condition. There just wasn't any place for them to see comparative statistics.
Then Milstein had an idea: tapping Medicare data. Every time someone covered by Medicare goes to the doctor or gets a test done or buys some medication, the government gets a record, because the government pays the bill.
"Sitting there like a diamond on the desert floor was the Medicare database, essentially the nation's biggest source of information on whether or not doctors are or are not adhering to what are called scientific clinical guidelines," he says. "It's the only source of information on the total amount of health insurance fuel that they burn on solving a given clinical problem."
Milstein figures the data could be used by patients to find good doctors, by insurance companies who might want to reward doctors who practice efficiently, and by doctors themselves, who want to know how they compare.
Today the Medicare database is widely used by researchers for all kinds of studies — but not to publish information about individual doctors. That's not allowed. "I want the fact that this got across the goal line, on my tombstone," Milstein says.
A Visit To The Database
It's easy to see why physicians might not like the idea of getting graded. Their life-and-death work is inherently hard to quantify.
Visit the database itself, and you start to see the enormous scale of what's at stake. Medicare officials agreed to give an NPR reporter a tour of it, in Baltimore, under strict security. Half a dozen staff tagged along.
"I have to ask everyone to travel as a group," said Bob Vaccaro, director of the database center, as we lined up.
The data center looks kind of like a library. Instead of books, the shelves contain rows and rows of computer data cassettes. On those tapes is medical information about millions and millions of people, from past presidents and aging rock stars to ordinary Americans. Some of the 500,000 cassettes sit on circular bookshelves. A robot orbits the shelves and plucks the cassettes as research demands.
Vaccaro says there are petabytes of data here (a petabyte is a 1 with 15 zeros after it). Every day, Medicare gets bills for over $1 billion in care.
But analyzing the information about people on these tapes can be a tricky business. That's one reason physicians are wary about anyone using the data in this room to evaluate them.
A Question Of Privacy — For Doctors
The American Medical Association recently fought a lawsuit from the group Consumers' Checkbook, which tried to get some of the data for individual physicians released.
Psychiatrist Jeremy Lazarus, who serves on the AMA's board of trustees, says he's not convinced the data would be useful. Consider the example of a doctor working as part of a team, he says. How would you know whose performance the data reflected?
Privacy also becomes an issue. Medicare officials are careful not to release data on individual patients. Lazarus says the same rule should apply to physicians. If people learned how many procedures a doctor filed for through Medicare, they could figure out something about how much money the doctor makes. "And that is personal information," Lazarus says.
That argument holds no sway with Joseph Califano, the secretary of health, education and welfare under President Jimmy Carter. Califano says the Medicare database is paid for by the taxpayers.
"There is no free federal lunch, OK?" he says. "When you get federal dollars, there is a price."
When he was in office, Califano wanted to release the data on individual physicians. He ran into resistance from Congress and eventually gave up. "Every member of Congress has their favorite doctor, their favorite hospital in their district," he says. "And those guys come to them and say, 'You can't let this happen!' "
Today the battle has finally landed in court. Consumers' Checkbook asked the courts in 2006 to release information about individual physicians under the Freedom of Information Act. The government argued against handing over the data, and the AMA eventually joined in.
In 2007, a judge ruled in favor of releasing the data. Early this year, a panel of judges overturned that decision. Consumers' Checkbook is now weighing whether to appeal the case, this time to the U.S. Supreme Court.
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From NPR News, this is ALL THINGS CONSIDERED. I'm Robert Siegel.
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And I'm Melissa Block.
Economists say one reason the health care system wastes so much money is a simple lack of information. Take doctors: Which ones managed to keep costs down? Which ones don't by, for example, ordering too many tests? What we need, economists say, is a huge database of information. And it turns out, that database exists, but as NPR's David Kestenbaum explains, no one is allowed to use it to evaluate doctors.
DAVID KESTENBAUM: The fights over this data go back many years. And often you can find the fingerprints of one man: Arnold Milstein.
Dr. ARNOLD MILSTEIN (Medical Director, Pacific Business Group on Health): Yes, I've been at it for quite a while.
KESTENBAUM: Milstein is now part of a group advising the White House on health care economics, but he started out as a physician where he saw a lot of unnecessary spending. And he realized a lot of that spending started in one place with one tool.
Dr. MILSTEIN: It's often said that the single most powerful influence in American health care quality and spending is the physician's pen. Over time, I began to realize the wisdom of that insight.
KESTENBAUM: The problem as he saw it: physicians don't have a clue how they compare with their colleagues. They don't know if they're spending way more than another doctor to treat the same condition. There just wasn't any good data. And then Milstein had a thought, a single, simple idea: What about the freaking Medicare database? Those are his words. It turns out that every time someone covered by Medicare goes to the doctor or gets a test done or buys some medication, any time anything medical happens, the government gets a record, because of course Medicare is paying the bill.
Dr. MILSTEIN: Sitting there like a diamond on the desert floor was the Medicare database, which is essentially the nation's biggest source of information on whether or not doctors are or are not adhering to what are called scientific clinical guidelines, which is our best measure of quality today.
KESTENBAUM: Milstein figures the data could be used by patients to find good doctors, by insurance companies, who might want to reward doctors who practice efficiently, and by doctors themselves, who might want to know how they compare. Today, the Medicare database is widely used by researchers for all kinds of studies, but that one thing Milstein wanted to do with it - publish information about individual physicians that has not been allowed, so far.
Dr. MILSTEIN: I want the fact that this got across the goal line, on my tombstone.
KESTENBAUM: You can understand why physicians might not like the idea. Who wants to get graded, especially if you think what you do - something as complicated as medicine, life or death stuff - is pretty hard to grade. And you get a sense for the magnitude of what's at stake and what might be unleashed by visiting the database itself. I asked for a tour and the Medicare folks said fine, come to this facility in Baltimore, but no cameras.
(Soundbite of steps)
KESTENBAUM: A half a dozen staff tagged along.
Mr. BOB VACCARO (Director, Medicare Database Center): I have to ask everyone to travel as a group. Mark's(ph) being kind enough to take us through our security. Pay no attention to the guys with the guns behind us and so...
(Soundbite of laughter)
KESTENBAUM: This is Bob Vaccaro, who runs the data center. Why is there so much security?
Mr. VACCARO: This information is highly confidential. It is the data that supports the American public and Medicare.
KESTENBAUM: The data center is kind of like a library. But instead of books, rows and rows of computer data cassettes. On those tapes, medical information about - who knows - past presidents, aging rock stars, millions and millions of people.
Mr. VACCARO: This would have your grandmother's medical records, your parents medical records and if you happen to be a wager in Medicare status, we have your records.
KESTENBAUM: On one of these many, many, many, many, many, many tapes here.
Mr. VACCARO: (unintelligible) about 500,000 cartridges and of the 500,000, 300,000 are in the robotic systems.
KESTENBAUM: Some of the cassettes sit on circular bookshelves and a robot orbits and grabs them when they're needed.
Mr. VACCARO: What we are doing is we're looking at a robotic system…
KESTENBAUM: Oh…
Mr. VACCARO: …and actually you can see it's scanning the robot…
KESTENBAUM: Oh, it's just ran by - it just ran by the window. Vaccaro says there are petabytes of data here, that's a one with 15 zeros after it. Every day, Medicare gets bills for over a billion dollars worth of medical care. Older people, let's face it, they tend to go to the doctor a lot. But the people on these tapes are very complicated. And that's one reason physicians are wary about the idea of using the data to evaluate individual doctors.
Dr. JEREMY LAZARUS (Speaker, The House of Delegates of the American Medical Association): My name is Dr. Jeremy Lazarus. I am speaker of the House of Delegates of the American Medical Association and a member of the board of trustees.
KESTENBAUM: He's also a psychiatrist. The American Medical Association recently fought a lawsuit that tried to get some of the data for individual physicians released. Lazarus says, frankly, he's just not sure the data would be useful.
Dr. LAZARUS: For example, you might have an individual physician that's working with a team of other physicians taking care of a particular patient and that data about one physician during the process of a patient's illness might not incorporate all the other physicians or the part of the system that that patient is being treated in. So, you only get a slice of what might be going on and a very complex treatment situation.
KESTENBAUM: I guess they say, it's true there are complications. There are always complications, but let's have the data out there and we can least begin to work with it.
Dr. LAZARUS: From our point of view, the complications about releasing information that would not benefit patients in terms of actually making informed decisions is more harmful than releasing that information.
KESTENBAUM: There's also a privacy issue. The Medicare folks are careful not to release data on individual patients. And Lazarus says the same rule should apply to physicians. If people learned how many procedures a doctor filed for through Medicare, they could figure out something about how much money the doctor makes.
Dr. LAZARUS: That is personal information.
Mr. JOSEPH CALIFANO (Former Secretary of Health, Education and Welfare,): That argument holds no water with me. There's no free federal lunch, okay? When you get federal dollars, there's a price.
KESTENBAUM: This is Joe Califano. He was the secretary of health, education and welfare under President Carter. He points out this is a database paid for by the taxpayers. Califano himself wanted to release the data on individual physicians, but he ran into resistance from Congress and eventually gave up.
Mr. CALIFANO: The thing about health care and about this is, you know, every member of Congress has their favorite doctors, their favorite hospital right in their district. And those guys come to them and say, you can't let this happen.
KESTENBAUM: Today, the battle has finally landed in court. In 2006, a consumer group, Consumers' Checkbook, sued to get information about individual physicians released under the Freedom of Information Act. They wanted patients to be able to see how many times a doctor had, say, done a particular surgery. The government took up the other side and the American Medical Association eventually joined in. A judge listened to the arguments and in 2007, ruled in favor of releasing the data. Then, early this year, a panel of judges overturned the decision. Consumers' Checkbook is now weighing whether to appeal the case, this time to the U.S. Supreme Court.
David Kestenbaum, NPR News. Transcript provided by NPR, Copyright National Public Radio.
