This entry was named an Honorable Mention.
Judge’s comments:
Mark Schoofs, John Carreyrou, Maurice Tamman, Tom McGinty, Anna Wilde Mathews and Barbara Martinez spent almost a year and a half prying Medicare payment data out of the federal government and digging through it, finding thousands of physicians enriching themselves at taxpayer expense through ineffective and even dangerous treatments, self-referrals, and kickbacks. But old-fashioned shoe leather-staking out two doctors’ homes, for instance-played a part. And the series set off investigations by the SEC, the Justice Department, and the Senate Finance Committee.
Shining a light on a huge and largely hidden slice of the federal budget, the Wall St. Journal provides a public service and some troubling examples of abuse.
1. Provide the title of your story or series and the names of the journalists involved.
Secrets of the System by Mark Schoofs, John Carreyrou, Maurice Tamman, Tom McGinty, Anna Wilde Mathews and Barbara Martinez.
2. List date(s) this work was published or aired.
- “In Medicare’s Data Trove, Clues to Curing Cost Crisis,” by Mark Schoofs and Maurice Tamman, page A1, October 26, 2010.
- “Physician Panel Prescribes The Fees Paid by Medicare,” by Anna Wilde Mathews and Tom McGinty, page A1, October 27, 2010.
- “A Device to Kill Cancer, Lift Revenue,” by John Carreyrou and Maurice Tamman, page A1, December 8, 2010.
- “Top Spine Surgeons Reap Royalties, Medicare Bounty,” by John Carreyrou and Tom McGinty, page A1, December 20, 2010.
- “Confidentiality Cloaks Medicare Abuse,” by Mark Schoofs and Maurice Tamman, page A1, December 22, 2010.
- “Home Care Yields Medicare Bounty,” by Barbara Martinez, page A1, April 27, 2010.
3. Provide a brief synopsis of the story or stories, including any significant findings.
Making use of data never before obtained by a news organization, The Wall Street Journal was able to demonstrate how mining Medicare claims can expose waste and potential fraud in the $500 billion government health program for the elderly and disabled. A computerized record of every billing claim submitted to Medicare and every dollar paid out, the Medicare databases the Journal gained access to are regarded as the single best key to understanding the American healthcare system. Through specific and deeply reported cases, the Journal showed how they can be used to contain the country’s spiraling medical costs. In particular, the series turned the spotlight on the secrecy that cloaks information about individual doctors — a restriction that results from a little-known, three-decade-old court ruling — and how that secrecy allows many physicians to abuse the taxpayer free from public scrutiny. Readers were introduced to the “Rock Doc,” a Florida physician who skirted Medicare regulations to draw $1.2 million from the system in one year, largely for things like massage and electrical stimulation. Readers also met a physical therapist whose billing patterns suggested superhuman endurance and dedication — or, more likely, fraud. And they learned of a Houston doctor who wasn’t cut off from Medicare until she had been a party to two separate alleged Nigerian fraud rings, the latter of which billed the system $11.6 million under her name in less than a year. The series also highlighted legal loopholes and other economic incentives that encourage doctors to perform unnecessary procedures to earn more money. One article showed how some of the nation’s leading urologists are establishing their own radiation facilities and funneling prostate-cancer patients toward the treatment that earns them the highest reimbursement. An examination of the Medicare claims of the biggest such urology group revealed that it made big profits by irradiating numerous patients older than 80 despite medical guidelines not to treat such patients. Another article demonstrated how medical-device makers have stoked the use of a controversial back surgery and driven up its accompanying costs for taxpayers by paying spine surgeons large sums of money that critics charge amount to kickbacks. Using one of the databases, the Journal showed that a Kentucky hospital whose staff includes five spine surgeons paid millions of dollars by device giant Medtronic Inc. performed an unusually large number of spine fusions on patients who merely suffered from aging disks. Yet another article made use of publicly available Medicare information to raise questions about the billing patterns of Amedisys Inc., the largest home health care company in the U.S. The article uncovered a pattern of home health care visits by Amedysis that closely tracked federal Medicare reimbursement thresholds, raising questions about whether financial incentives, rather than the needs of patients, were driving medical decisions.
4. Explain types of documents, data or Internet resources used. Were FOI or public records act requests required? How did this affect the work?
The Journal obtained a dozen enormous claims data files from the Department of Health, some spanning back as far as a decade. It initially requested this data under federal FOI statutes, but was told such information wasn’t subject to FOI. After a long negotiation, the Journal and the nonprofit Center for Public Integrity reached a deal with the Department of Health under which they agreed to jointly pay it $12,000 for the data.
5. Explain types of human sources used.
Critical as the databases were, they constituted only one part of a dogged investigative effort. Reporters cracked traditionally closed law-enforcement agencies, convinced billing clerks and others with knowledge of individual doctors’ practices to provide key information, obtained confidential corporate and legal documents, and pried out of doctors themselves crucial details about how they practiced medicine and billed Medicare. When doctors wouldn’t talk, the Journal still got the facts it needed. To find out where two doctors were working, a Journal reporter staked out their homes and then tailed them to their clinics, in one case for more than 30 miles.
6. Results (if any).
The series moved Dow Jones & Co., the Journal’s parent, to initiate court proceedings to have a 1979 injunction barring the release of individual doctors’ Medicare billings overturned in the public interest. The suit was filed on Jan. 25, 2011 in U.S. District Court for the Middle District of Florida. At a Senate Judiciary hearing the next day, Senator Chuck Grassley quoted from the Journal’s series and, referring to the 1979 injunction, said: “I think it’s time to revisit this issue and bring some transparency to this whole thing.” The article on Amedisys, the nation’s largest provider of home health services, triggered separate investigations by the Department of Justice, the Senate Finance Committee and the Securities and Exchange Commission. Shortly after the series’ first article ran, reporters were contacted by senior government medical auditors in two states asking for advice on how to screen for abuse. Officials at the Department of Health agency that runs the Medicare program have invited our reporters to make an internal presentation on how to make the data more accessible. After each article, reporters were deluged with emails from readers thanking them for the public service they performed. In one such email, following the article that exposed urologists’ gaming of Medicare rules for financial gain, a reader from New Jersey wrote that her husband had decided to cancel the radiation treatment he was scheduled to receive just two days later. “The article made us realize that my husband was not joining an exclusive men’s club but rather was embarking on a serious journey to deal with a serious disease,” she wrote. After arranging for a second opinion, she added: “We know that in the final analysis it could be that these doctors will offer the same advice and treatment as the ones we had seen, but we now have confidence that the treatment prescribed will be what is best for my husband and not for the bottom line of a large group of practitioners who have a major investment in equipment that may be more geared to income than outcome.”
7. Follow-up (if any). Have you run a correction or clarification on the report or has anyone come forward to challenge its accuracy? If so, please explain.
No.
8. Advice to other journalists planning a similar story or project.
Be patient and persevere. Don’t give up. Our negotiations with the government to obtain the data took the better part of a year. Once the data arrived, it took another six months for our data mining and reporting efforts to yield stories. Put reporters with different backgrounds together and leverage their respective strengths. The Journal paired its two computer-assisted reporting experts with veteran investigative reporters who had no computer skills to speak of but a proven track record of success in a variety of difficult assignments. The two groups worked together every day for months, producing groundbreaking results.