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Feds indict doc whose abuses were detailed in 2010 WSJ series

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In The Wall Street Journal, John Carreyrou reports that a physician the paper spotlighted in a data-driven series on Medicare abuses has now been “indicted by a federal grand jury … for allegedly submitting more than $13 million of false claims.”

The article marks the first time the Journal has been able to print the physician’s name (Emma Poroger), even though they’ve been aware of it for more than a year.

The Journal identified Dr. Poroger, a doctor of osteopathy, as having suspicious billing patterns by mining the Medicare claims database, a computerized record of every bill submitted to the program. But her name was withheld in the October 2010 front-page article because Medicare keeps information pertaining to individual doctors confidential under a three-decade-old court injunction.

That injunction stems from a 1979 lawsuit filed by the American Medical Association, the doctors’ trade group, to keep secret how much money physicians receive from Medicare. At the time, the court said doctors’ privacy trumped the public’s interest in knowing how tax dollars are spent.

The Journal’s publisher, Dow Jones & Co., filed court papers this year seeking to overturn the injunction. In September, a federal judge in Florida ruled that Dow Jones’s case could proceed.

Carreyrou also called out a few other physicians featured anonymously in the series whose names had also been made public in various official proceedings.

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Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

WSJ exposes flaws of Medicare’s pay now, investigate later culture

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In the latest story to take advantage of their paper’s Medicare data trove, The Wall Street Journal‘s Mark Schoofs and Maurice Tamman use egregious cases of physicians abusing Medicare’s physical therapy reimbursements to demonstrate the weakness of Medicare’s “pay first, look into fraud later” approach.

They show that, given the data the federal government has access to, detecting fraud should be a speedier, more effective process. CMS has its reasons for slow fraud detection, but Schoofs and Tamman clearly aren’t buying them all.

There are plenty of reasons why Medicare often fails to stop questionable payments up front. To protect law-abiding doctors and hospitals — the vast majority — Medicare is required to pay nearly everybody within 30 days. Medicare says it is reluctant to suspend payments to providers who may have made honest mistakes, out of concern that beneficiaries might go without needed treatment.

The reporters identify what they say is “a central problem” – Medicare isn’t taking advantage of its claims database, a computerized record of every claim submitted and every dollar paid out.

The Wall Street Journal originally identified Dr. Wayne and the other medical providers discussed in this article through a Medicare database that is much more limited than the one available to fraud investigators. The database, obtained in conjunction with the nonprofit Center for Public Integrity, contains records only through 2008, and includes the claims of just 5% of randomly selected Medicare beneficiaries.

Peter Budetti, the head of the new Center for Program Integrity at the Centers for Medicare & Medicaid Services, says the system is working toward fraud prevention and that “he’d like to emulate the credit-card industry, which has developed software to flag suspicious charges before paying them.”

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

WSJ details conflicts that drive spine fusion surgery

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The Wall Street Journal‘s John Carreyou and Tom McGinty have taken advantage of their paper’s Medicare data stockpile to look at the conflicts of interest and piles of royalty money that drive the popularity of spine fusion treatments whose effectiveness has been disputed. Their work centers on Medtronic, which the Milwaukee Journal Sentinel‘s John Fauber also has written about.

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Photo by planetc1 via Flickr

For surgeons, the financial incentives to perform spine fusions can be strong. Though hospitals often lose money on the procedure when it’s performed on Medicare patients due to the high cost of the implants, the surgeons themselves can get paid as much as $12,000 per surgery.

Complex fusions … are reimbursed by Medicare at a sharply higher rate than decompressions, to account for the elaborate spinal devices used and the longer length of surgery. Complex fusions increased 15-fold among Medicare beneficiaries with spinal stenosis from 2002 to 2007, according to the JAMA study.

A big part of many surgeons’ income lies in their consulting and royalty arrangements with device makers, although disclosure of these arrangements remains piecemeal for now. Medtronic began releasing information about its payments to surgeons on its website in June, after coming under intense scrutiny from Sen. Charles Grassley (R., Iowa).

They’re required to keep some details under wraps, but the WSJ duo still manages to unleash anecdotes, including one about a surgeon who received “between $400,000 and $1.3 million in royalty, consulting and other payments from three spine-device makers.”

For reporters looking to understand the medical issues surrounding these procedures and why these conflicts can be detrimental to patients, see Janet Moore’s work in the Star Tribune.

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

WSJ explains why Medicare data is hidden

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In The Wall Street Journal, reporters Mark Schoofs and Maurice Tamman have pulled off an impressive feat, weaving a tale of freedom of information and databases so compelling that it’s already attracted hundreds of comments and attention from all over. At its heart, it’s the tale of why public Medicare payment data does not identify the doctors and individual providers who receive about an eighth of its annual disbursements. If the practitioners were identified, the authors argue, the public and press would be better equipped to expose and deter fraud.

The Medicare claims database, partially available for around $18,300 a year, is one of the most powerful health data resources in the world. It’s also hamstrung:

While the services and earnings of hospitals and other institutional providers can be publicly identified, such information is kept strictly confidential for doctors and other individual providers. 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.

This time around, The Wall Street Journal and the Center for Public Integrity took the AMA on. For health journalists, their description of what followed is really the crux of the story:

The Wall Street Journal, in conjunction with the nonprofit Center for Public Integrity, attempted for nearly a year to obtain the database. As part of the effort, the CPI filed a lawsuit against the Department of Health and Human Services, which houses the Medicare program. The Journal and CPI wanted the data at no cost; the government wanted $100,000 for eight years of data. In a settlement, The Journal and CPI obtained the requested data at a substantially reduced fee. They later obtained a decryption key to identify individual providers but signed a contract agreeing not to publish such identities in most cases.

The database, technically known as the Carrier Standard Analytic File, focuses on doctors and others paid on a fee-for-service basis. It contains 5% of all beneficiaries, and includes all doctor claims that Medicare paid directly in association with their care.

There’s far more to the story including information about the Consumers’ Checkbook lawsuit and the penultimate paragraphs on just how clear-cut fraud cases can be, once you know what to look for. An article on the Center for Public Integrity’s website promises more reporting, presumably based on the database, of “some of the questionable spending that occurs in the Medicare program.”

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Physician Panel Prescribes the Fees Paid by Medicare

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

$95 million to figure out proper doses for kids

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On The Wall Street Journal’s Health Blog, Katherine Hobson profiles the Pediatric Trials Network, a seven-year, NIH-funded effort to determine pediatric dosing information for things like hypertension drugs and antibiotics. The $95-million initiative will fund 16 clinical trials, most of which will enroll 100 to 200 participants, Hobson reports.

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Photo by woodleywonderworks via Flickr

Even then, Hobson said, the new study will only make a “dent” in the larger problem. She found that, at present, “virtually all” pediatric drug use is off-label, and that physicians get pediatric dosing wrong about a third of the time. The FDA already does some baseline work to make sure drugs are kid-safe, but the PTN represents a large step beyond present efforts.

Some brand-name drugs do get scrutinized under a program that gives drug makers an extra 6 months of patent protection for conducting FDA-requested studies in kids. And experimental drugs up for FDA approval must assess the effects in kids if they’re likely to use them. But that leaves a big knowledge gap for the host of generic drugs used to treat everything from infectious diseases to cancer.

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.