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Covering Medicare Spending, Part 1: Tips from The Wall Street Journal's Secrets of the System

Covering Medicare Spending, Part 1: Tips from The Wall Street Journal's Secrets of the System

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The Wall Street Journal's , , ,   and have been dismantling Medicare's claims database piece by piece for months in a series of blockbuster stories under the umbrella "."

There are tons of great lessons to be found here for health writers. And, on top of that, the Journal is performing an incredible service for writers and the rest of the public by . In the , I am going to outline some of tips gleaned from the series and talk about how health writers – and readers – could benefit from an open claims database.

Here are the first five tips:

1. Cut deals, if you must. It took a lawsuit by the to even allow the Journal a glimpse of the data. Tamman request, which ended up as part of a legal tangle that also drew in the Florida Medical Association. To settle the lawsuit, the Department of Health and Human Services, which runs Medicare, gave the Journal and the center 5% of the claims data for a fee.

, they "later obtained a decryption key to identify individual providers but signed a contract agreeing not to publish such identities in most cases." This makes for some convoluted writing in some of the stories. The lead for their kickoff piece is about an unnamed doctor, for one. But the deal also allowed the Journal to provide readers personalized examples with hard data that previously had been hidden.

2. Work with experts to identify patterns. Schoofs and Tamman had a tough task. They had to take what they learned from the database and then report it out without revealing the names of the individual doctors. They clearly knew that the dollar figures alone – no matter how staggering – weren't going to tell the whole story. That's why they wrote:  

Somewhere in the New York City area there is a family-practice doctor who, government records suggest, pocketed more than $2 million in 2008 from Medicare, the federal insurance program for the elderly. That made her one of the best-paid family-medicine physicians in the Medicare system. But more noteworthy than the sum is her pattern of billing, which strongly suggests abuse or even outright fraud, according to experts who have examined her records. This doctor didn't do typical family medicine. Instead, she administered a wide array of sophisticated tests, including polysomnography sleep analyses, nerve conduction probes and needle electromyography procedures-some of which have been flagged by federal antifraud authorities for special scrutiny. As a doctor of osteopathy, she has certifications for family practice and a hands-on treatment called "manipulative therapy," but none in neurology. She denies wrongdoing.

3. Show who built the barriers to public access. Unless you have spent a lot of time covering health care financing stories, you may not know one of the main oddities about the claims database.  Hospitals and other health care institutions have to be transparent with their claims. This is why reporters, including me, have been able to write detailed stories about what different hospitals charge for the same procedures. For doctors, though, the claims are kept secret. :

The reason is that the American Medical Association, the doctors' trade group, successfully sued the government more than three decades ago to keep secret how much money individual physicians receive from Medicare. The AMA has continued to defend this ruling, including in two cases in which federal appeals courts issued decisions last year.

Throughout the series, Schoofs and Tamman make it clear how these barriers were created and who is fighting to keep them in place.

4. Explain why transparency matters. The series itself is exhibit A for why reporters and the public should be granted access to the claims data. Schoofs and Tamman have exposed some deep flaws in the way claims are paid, tracked and vetted. As they explain:

If it were fully available, with doctors clearly identified, the public could expose countless ways in which some health-care providers misuse or waste taxpayer dollars, health-care advocates say. The database could even provide some information on physician quality. Especially in the digital age, the database could be a powerful tool for holding the $500 billion Medicare program accountable.

5. Also explain how transparency can have unintended side effects. The Journal does not oversimplify and present the AMA as a nefarious cabal bent on keeping the public in the dark. It gives the AMA's arguments their due and allows readers to decide whether the risks – or instances of human error – are :

In March 1977, amid a national debate over the cost of health care, the Carter administration released a list of all doctors who received Medicare reimbursements of $100,000 or more during 1975. The media covered it, publishing the names of highly paid doctors. The AMA responded by saying the list was riddled with errors-a charge later upheld by the Comptroller General. A Michigan doctor was listed as earning $115,000 from Medicare, when he actually earned only $15,000. "My wife must think I have an apartment on the side and a mistress as well," he quipped at the time.

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[...] Reporters have mined the Medicare claims database for all kinds of interesting stories, as outlined here, by the University of Southern California’s Reporting on Health [...]

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