The United States began releasing the Medicare payments it made to individual doctors on April 9, a move that sparked sensational headlines and debates about privacy. The data offer insights into the $77 billion paid by Medicare’s fee-for-service program to more than 880,000 health care professionals in 2012.
Should Canadian provinces follow the U.S.’s lead and publicly release information on how much every doctor receives from the government?
Why the U.S. changed its policy
Doctor payments had been kept private in America after a 1979 federal ruling that stated revealing physicians’ Medicare revenue violated the Privacy Act. The rules changed last May, after a judge decided the ban should be lifted.
The motion to make the information public was brought forward by Dow Jones in 2011, which publishes The Wall Street Journal, after the paper began a series on Medicare abuse. “The privacy interests of physicians no longer clearly outweigh the compelling public interest in monitoring a program that now consumes one out of every eight federal dollars,” Dow Jones said in its court filing.
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The American Medical Association, concerned that physicians’ right to privacy would be violated by the release and that the information could be misinterpreted, was against the ruling. “The manner in which CMS is broadly releasing physician claims data, without context, can lead to inaccuracies, misinterpretations and false conclusions,” it said in a statement.
When the data were released in April, more than 150,000 users downloaded it within the first week. The media simultaneously published pieces about highly paid doctors and specialties, as well as payments by state.
A new online tool now lets the public look up providers by name or location. It shows the services they provided, their average submitted charge, and their average Medicare payment.
‘I think you swallow hard and you do it’
Some believe Canadian provinces should also release this information. In the wake the 2012 scandal in Ontario concerning the payments to air ambulance service executives, Michael Decter, former Ontario deputy minister of health and founder of the Health Council of Canada, argued in favour of disclosing pay to doctors in Ontario and other entities funded almost entirely by the government.
There are two arguments in favour of revealing payments, he says: first, taxpayers are funding doctors, so they should have transparency, as they do through the Ontario Sunshine Lists, which release salary information for those who make over $100,000 and are paid by the government. The second is that sometimes technological advances or other changes mean there’s a rapid grown in income for specialties, and transparency might serve as an “early warning system” against that.
But reports tha the Sunshine List may be contributing to increasing salaries for executives have moderated his views. “My feelings have gotten a little more mixed on it,” he says. “On balance, I think it would probably be a good thing. But it certainly was not a good thing in the case of managers of health care.”
Peter Cram, a general internist at UHN who moved here from the States last December, supports the U.S’s information release. “I believe in transparency. I think that you swallow hard and you do it,” he says. “If you have a publicly funded health care system, the people paying the bill have a reasonable right to ask who is getting paid by the system and how much.” He thinks it’s the right thing to do in Ontario as well.
The downsides, like the fact that interpreting the data isn’t easy, or the chance that it will get taken out of context, aren’t enough of a reason to not release the information, he says. Plus, the U.S. data didn’t cause much of a stir among his American colleagues. “I’m not sure how many physicians other than people who got called out in The New York Times actually even noticed,” he says.
B.C.’s Blue Books
In British Columbia, payments to individual practitioners are already released through the Blue Book, which includes fee-for-service payments.
“There’s not a lot of debate in British Columbia about the existence of the Blue Book,” says Bill Cavers, president of the Doctors of B.C. “It’s generally considered that since it is a public purse… transparency is a good thing, and taxpayers do have a right to know where their taxpayer dollars are going.”
That said, he is concerned about clarity, adding that the numbers can be misconstrued as salaries, when in fact overhead must be taken into account.
Other B.C. doctors agree they don’t think much about it. “It’s been like that for so long here that I actually don’t know another way,” says Adeera Levin, head of the division of nephrology at the University of British Columbia, adding “Do I think that with public money there should be some accountability to the public? Yeah, I do.” However, she believes patients are more likely to look at ratemds.com than they are the Blue Book.
The Sunshine Lists
In Ontario, salaried doctors who make more than $100,000 annually have their payments made public through the so-called Sunshine Lists. Created by the 1996 Public Sector Salary Disclosure Act, the lists reveal the names and salaries of those paid more than $100,000 a year by the government. It includes teachers, police officers and government employees – as well as staff at hospitals and public health boards.
Decter thinks the system is uneven, since it discloses the pay for salaried hospital-based physicians but not fee-for-services based doctors. (He also thinks the minimum salary for disclosure is outdated, and should be raised above $100,000.)
Alberta recently started releasing their own sunshine lists, but they don’t include hospital CEOs or physicians, focusing instead on government and ministerial staff.
Finding clarity on income
One issue with releasing information about payments is that the public can misinterpret them as income.
“I’m not really clear on how publishing individual payments to physicians is going to help us with our goal [of providing high-quality, accessible care to people in Ontario],” says Ved Tandan, president of the OMA. “In some ways, I think it might even be a little irresponsible, because the information can be misleading, and it would be taken out of context because it’s almost impossible to provide the context required to understand it.”
The overhead costs of doctors do need to be taken into account. A recent paper for the Institute for Clinical Evaluative Sciences estimated net income from public payments for physicians for 2009/2010. It found self-reported overhead varied from 42.5% for ophthalmologists to 12.5% for those in emergency medicine. The mean self-reported physician overhead in Canada is 28%.
This can make a large difference: the researchers found ophthalmologists received the second-largest public payments, but due to high overhead, only had the eighth-highest take-home salaries. It’s even more pronounced in the U.S., as doctors there have higher billing, administration and malpractice costs.
The numbers could also be low, since they only include clinical billings, and physicians often have other sources of income from things like consulting and sitting on advisory boards.
In addition, doctors lack benefits many employees have, such as extended health, life insurance and pensions. And many doctors work more than 40 hours a week, with the average physician in Canada putting in 54 hours a week.
The missing metric: value
Another potential problem is the idea that, lacking a clear metric for quality, the public would assume all doctors have equal worth, and those paid more are simply more costly.
“If a very skilled ophthalmologist running a very efficient practice is being paid $900,000 a year, but has got high overhead and really low complication rates, the public might consider that good value for money. But that person could be vilified because they’re being paid a lot of money,” says David Henry, a professor at the University of Toronto who co-authored the ICES paper.
It’s particularly difficult to judge value in medicine. Doctors who perform more procedures can seem more productive, but they may actually be doing unnecessary tests or surgeries.
“I’m not against disclosure generally,” Henry says. “I’m just less convinced that disclosing public payment to individuals is worthwhile when you don’t know what the value is provided by that individual.”
Releasing payments in the U.S. was an attempt to reduce waste and help cut costs. But a 2010 study by University of Toronto researchers suggests it may have the opposite effect. It found that for university-sector salaries, “there is no evidence suggesting that salary disclosure has much of an influence in off-setting other factors affecting salary growth.”
“The rise of executive pay in the health sector has been accelerated by transparency rather than moderated by it,” says Decter. While he’s still in favour of releasing individual payments, he’s disheartened by the idea of them being used as a bargaining chip. “I think forces like competitive behaviour tend to outweigh the public interest considerations.”