Fourteen Maine physicians received more than $1 million each in payments from Medicare in 2012, and 37 received more than $500,000.
In all, nearly 5,800 Maine doctors and other medical providers were paid a total of $300 million for services they provided to the state’s Medicare clients in 2012.
The numbers are in a data set released Wednesday by the federal Centers for Medicare and Medicaid Services that provides, for the first time, detailed information on how much money physicians receive in Medicare payments for services ranging from major surgeries to routine laboratory tests.
The data also gives the public a look into how Medicare, the federally funded health insurance program for senior citizens, operates and how much various services cost.
The American Medical Association tried for years to block the release of the information, citing privacy concerns. Last year, a federal judge ruled that it can and should be released.
The data includes information on more than 880,000 health care providers nationwide who collectively received $77 billion under Medicare’s fee-for-service program in 2012, the most recent year for which data is available.
The information offers a window into an industry that affects many, especially in a state like Maine, which has an older population and a high percentage of Medicare recipients. Twenty-one percent of Maine residents, 276,467 people, were Medicare recipients in 2012, according to the Kaiser Family Foundation, which tracks health statistics.
Maine’s top lobbyist for physicians cautioned against drawing conclusions without proper context, noting that the money reflects reimbursements, not profits.
“We’ve known for a long time this was coming, and in the basic interest of transparency, we don’t think it’s a bad idea,” said Gordon Smith, executive vice president of the Maine Medical Association. “I think there is a lot of interest among consumers about where these dollars go, but just because a doctor is paid a certain amount from Medicare doesn’t mean that is what they netted.”
The 14 Maine doctors who received more than $1 million in Medicare payments in 2012 comprise just three specialties: ophthalmology, which deals with diseases of the eye; hematology/oncology, for cancer; and rheumatology, which deals with joint problems and tissue disorders.
Eight of the 14 are ophthalmologists, whose most common service to Medicare patients in 2012 was injection of a drug called Lucentis, to treat macular degeneration.
At $2,000 per injection per eye, Lucentis is among the most expensive drugs on the market, with a large portion of Medicare reimbursement covering its cost.
Dr. Scott Steidl, an ophthalmologist with Eyecare Medical Group in Portland, was paid more than $2 million by Medicare for 10,453 procedures in 2012 – the second-highest total among Maine physicians. He said the amount does not indicate that he has a high salary, but that he sees a large number of patients who need expensive injectable drugs like Lucentis.
“We have a drug that is literally a miracle drug, but it is incredibly expensive,” Steidl said.
COSTS EAT UP REIMBURSEMENTS
Eyecare Medical Group serves as a referral center for complex procedures and treatment. Clement Berry, the group’s CEO, would not disclose the number of patients Steidl treats, but said the practice, which has nine doctors, sees 200 to 300 patients a day. Not all of the patients use Lucentis, but many who do are treated indefinitely.
In 2012, Eyecare Medical Group paid $1.8 million to the manufacturer for 4,888 doses of Lucentis, but was reimbursed only 80 percent, $1.56 million, through Medicare. The practice must collect the other 20 percent through secondary insurance or other arrangements, Berry said.
The practice bought $500,000 worth of Lucentis last month, but won’t be reimbursed by Medicare for at least 21 days.
Steidl and Berry said they are concerned that people who look at the federal data will assume that doctors are getting most of the reimbursement, when much of it goes to the drug companies and to pay operating costs for the practice. “Everyone thinks (Steidl) is bringing home millions of dollars,” Berry said. “It’s about the drug costs, not about what the practice is keeping.”
Dr. Sirus Hamzavi, an ophthalmologist who practices in Lewiston, specializes in macular degeneration and treats his patients with Lucentis.
Hamzavi, who had not seen the figures released Wednesday, said he worries about the public perception of how much he is reimbursed. The figures show Hamzavi billed Medicare for more than $1.2 million for 7,058 procedures in 2012.
“If someone simply looks at the amount paid by Medicare, they think we made that money when it was, in fact, a simple reimbursement,” Hamzavi said. “It’s unfortunate the numbers don’t tell the whole story.”
Smith, with the Maine Medical Association, said that in most cases, a relatively small amount of money billed to Medicare goes to physicians. In some, the money pays for overhead for certain procedures. In others, a portion goes to pharmaceutical companies or manufacturers of medical devices.
ACCURACY OF DATA QUESTIONED
The data allows comparisons by physician, specialty, location, type of medical service or procedure delivered, and submitted charges. Health care professionals determine what they charge for services and procedures, and generally bill those amounts to Medicare.
The Wall Street Journal and The New York Times, which received the data before Wednesday, noted that 2 percent of doctors account for nearly a quarter of the total amount of reimbursements, about $15 billion.
In Maine, the 14 physicians who each received more than $1 million in Medicare payments accounted for about 8 percent of the state’s total in 2012.
The average amount paid to Maine’s 44 hematologist/oncologists in 2012 was $224,965, compared with $366,677 nationally.
The state’s 70 ophthalmologists averaged $440,092, compared with $327,239 nationally.
The 12 rheumatologists averaged $621,958, compared with $257,701 nationally, according to the data.
Smith said his biggest concern with the release of the data is that there is no way for physicians to challenge the accuracy of the numbers. He said, for example, that a doctor may collect Medicare payments for his or her entire practice.
“I worry whether the billing is precise enough to indicate that,” he said. “It might look like one doctor is clearing $30 million but it’s actually many, many doctors.”
Geoff Gratwick, a state senator from Bangor who is a practicing rheumatologist, was paid about $800,000 by Medicare for 30,792 procedures in 2012, according to the data, but he challenged that total. “Some of the numbers are off,” he said. “If they are going to do this, they need to do it well and accurately. These numbers are upsetting.”
Gratwick said most of his patients are on Medicare, which is reflected in the high reimbursement, but he estimated that his profit was only about 5 percent of that in 2012.
“We use some very complicated, expensive medications, called biologics, that have revolutionized rheumatology in the last 15 years,” he said. “It used to be that we gave patients with rheumatoid arthritis or lupus aspirin or cortisone. These days, we have very specific medicines, specific antibodies that are tailor-made for patients.”
Gratwick said that while the drugs are effective, they are costly. “I wish it were true that I took home all that money,” he said. “It’s the drug companies who are making out like bandits.”
Reuben Allen, a consultant in Wilmington, N.C., represents rheumatologists from all over the East Coast, including Dr. Robert Sylvester of Lewiston, who was paid the most in Medicare reimbursements of any doctor in Maine in 2012 – about $2.4 million for 153,681 procedures. Allen agreed with Gratwick’s assessment.
“Of that total, $1.84 million goes directly to biologic drugs,” he said Wednesday.
DATA MAY BE USED TO FIGHT FRAUD
Not all providers who received Medicare payments in 2012 were doctors. Many were ambulance services or clinical laboratories that do tests outside doctors’ offices.
In Maine, 382 of the 5,778 providers in 2012 were facilities. Nordx, a lab in Scarborough, received the most Medicare money in 2012, a total of $3.9 million for 469,537 separate services, the most services in Maine.
Northeast Mobile Health Services of Scarborough, at $3.4 million, and Affiliated Laboratory of Bangor, at $2.4 million, were second and third on the list of highest-paid providers.
The city of Portland ranked ninth, for its ambulance service. In 2012, the city was reimbursed just over $1 million in Medicare payments, which represented about 40 percent of the city’s total budget for ambulance service.
One reason cited by the Obama administration for releasing the data was to guard against fraud or overbilling. A federal report released in December suggested that high Medicare billers should be subject to more scrutiny. None of the doctors who billed over $1 million in Maine has any disciplinary actions listed against their state medical license, according to the Maine Board of Licensure.
Smith acknowledged that high payments could indicate fraudulent behavior, but said that’s most often not the case.
“I hope this data doesn’t cause any physicians to be targeted unfairly,” he said. “There are any number of fraud investigators from several agencies that look into these things and, if I’m not mistaken, they have had access to this data for years.”
John Martins, spokesman for Maine’s Department of Health and Human Services, said state investigators “are evaluating this data to see what value it has in relation to our ongoing data mining and investigative efforts around Medicaid data.”
Staff Writer Gillian Graham contributed to this report.
Eric Russell can be contacted at 791-6344 or at: