Fact Sheets

New Medicare data available to increase transparency on physician utilization

New Medicare data available to increase transparency on physician utilization

As part of the Administration’s efforts to promote better care, smarter spending, and healthier people, CMS has released the first annual update on the medical services physicians provide and how much they are paid under Medicare Part B Fee-For-Service for 2013. The Physician and Other Supplier Public Use File (PUF), now available for 2012 and 2013, has information on the number and type of health care services that individual physicians and certain other health care providers furnished under the Medicare Part B fee-for-service (FFS) program, as well as information on the amount that Medicare paid them for those services. The new 2013 data set has information for over 950,000 distinct health care providers in all 50 states, DC and Puerto Rico who collectively received $90 billion in Medicare payments.

Data Source

CMS created the data set using information from the Physician/Supplier Part B Claims File, also known as the Carrier File, which has final action FFS claims that are submitted by physicians and other non-institutional health care providers, such as non-physician practitioners, ambulatory surgical centers, clinical laboratories, and ambulance providers. The data set does not have information for institutional health care providers, such as hospitals or nursing homes, or for suppliers of durable medical equipment.

The data set identifies individual providers using their National Provider Identifier (NPI) and the specific services that they furnished using Healthcare Common Procedure Coding System (HCPCS) codes. For each provider and service, the data set has the total number of services that were furnished, the provider’s average charge, the average Medicare payment, and the average Medicare-allowed amount, which is the sum of Medicare’s payment and any deductible or coinsurance owed by the beneficiary. The data set also has the standard deviation for each payment metric, so that users of the data can better understand how much the payment amounts varied, even for a specific service. CMS did not include information in cases where a provider furnished services to 10 or fewer Medicare beneficiaries to ensure the confidentiality of patient-specific information. CMS protects beneficiaries’ personal information in all its data releases.

Additional Features

CMS added a few new features in this new release of 2013 data and the 2012 data were re-published to reflect all updates.  These changes incorporate the same privacy protections as described above as any summary information that is based on 10 or fewer beneficiaries has been redacted from the datasets.

1. Flagging HCPCS for drugs: A new variable (hcpcs_drug_indicator) is now included in the data to identify whether the HCPCS product/service is a drug as defined from the Medicare Part B Drug Average Sale Price (ASP) list. The HCPCS/Place of Service summary files also include the new variable to identify drugs. In addition, the summary file at the provider level includes separate totals for medical services and drug services as well as the totals for all services.
2. Better HCPCS descriptions: The HCPCS descriptions have been expanded to include consumer friendly descriptions provided by the American Medical Association for Current Procedural Terminology (CPT) codes and long form descriptions for the CMS Level II codes (i.e., alpha-numeric HCPCS codes).
3. More comprehensive summary files: The two types of summary files, the summary file at the provider-level (i.e., one record per NPI) and the summary files at the HCPCS/Place of Service (national and state levels), are now individually summarized from the Medicare Part B claims and are no longer based on redacted data from the Physician and Other Supplier PUF.
4. New enrollment file: A new state-level and hospital referral region-level Medicare enrollment data file is being made available on the website to facilitate additional analyses which require enrollment denominators for rate calculations.

Data Analyses

The Physician and Other Supplier data allows for many types of analyses to be performed. For example, since health care providers indicate the specialty that best describes the type of health care services that they furnish when they obtain an NPI, the data allow for summary analyses to be conducted by provider specialty. Furthermore, the new variables added to the data now allow for analyses to be conducted for all services from a provider or run separately for medical procedures versus administered drugs. Table 1 below displays ten individual provider specialties with high average Medicare allowed amounts per provider, reported separately for medical versus drug services. This analysis shows that a large portion of the costs for several of these specialties is due to the cost of drugs administered.  For example, Hematology/Oncology and Medical Oncology have the highest overall average cost per provider, yet when examining only medical services, these specialties have some of the lowest average costs among the group.

_{Table 1. Average Medicare Allowed Amounts by Specialty for Medical Services and Drug Services, 2013.}

Source:  Medicare Provider Utilization and Cost Physician and Other Supplier NPI Aggregate, 2013. Summary data in this table exclude any HCPCS procedures where redaction on medical and drug statistics was necessary due to either types of services being performed on 10 or fewer beneficiaries.

The detailed NPI and HCPCS data file can also be used to examine how patterns of service use vary across physicians and specialities. Chart 1 below shows the distribution of routine office visits (a.k.a., Evaluation and Management services) for some common specialty types. Medicare has five different HCPCS billing codes (99211-99215) for routine office visits based on the length of the visit ranging 5 minutes for 99211 (level 1) to to 40 minutes for 99215 (level 5). As may be expected, specialties such as Dermatology bill a higher proportion of shorter-length office vists (e.g., level 2) than Internal Medicine or Nurse Practitioners, where as specialties such as Cardiology and Hematology/Oncology bill a higher proportion of higher-length office visits (e.g., levels 4 and 5).

_{Chart 1. Distribution of Medicare Evaluation and Management (E&M) Office Visits by Level of Service for Selected Top Specialties, 2013.}

Chart 2 below, derived from the NPI Aggregate summary file, shows the relationship between the average Medicare allowed amount billed for medical services for the top specialties (y-axis) compared to the total aggregated allowed amount billed (x-axis), as well as the number of providers in that specialty (bubble size). A large number of Internal Medicine physicians billed medical services in 2013 and thus these physicians had a large combined total cost to the Medicare program, but their average allowed amount per service was low compared to some other specialties. For example, Ophthalmologists and Orthopedic Surgeons comprised much smaller groups of providers and had lower total allow amounts, but both had higher average costs per service.

_{Chart 2. Average Medicare Allowed Amount per Service versus Total Medicare Allowed Amount for Selected Top Specialties, Medical Services Only, 2013.}

Since the data contains information on provider location, this data can be used to make geographic comparisons of cost and utilization of services. When combined with enrollment data on the number of beneficiaries with Medicare Part B coverage, per capita averages can be calculated to make comparisons across regions of different size. Map 1 below displays the average number of services per capita for evaluation and management office visits (HCPCS codes 99211, 99212, 99213, 99214, and 99215) by state for 2013. Nationally, the number of office visits per capita was 6.0 visits per enrolled beneficiary. As the map shows, some states had higher utilization rates than others, with the highest utilization in the south, the west, and the east coast, and lowest rates in the north central states.

_{Map 1. Average Number of Medicare Office Visits Per Capita by State, 2013.}

The data can also now be used for trend analyses because two years of data are now publicly available. The map below (Map 2) displays the change in the number of services per capita for these same evaluation and management office visits by state over the period of 2012 to 2013. Overall, the number of per capita office visits increased by 0.9% during this time period. However, there was variation by state in this change with a few states experiencing a decrease and many states with slight increases in the average number of office visits.

_{Map 2. Change in Number of Medicare Office Visits Per Capita by State, 2012 to 2013.}

Data Parameters

Although the Physician and Other Supplier PUF has a wealth of payment and utilization information about many Medicare Part B services, the dataset also has a number of limitations that are worth noting.

First, the data in the Physician and Other Supplier PUF may not be representative of a physician’s entire practice. The data in the file only has information for Medicare beneficiaries with Part B FFS coverage, but physicians typically treat many other patients who do not have that form of coverage. The information presented in this file also does not indicate the quality of care provided by individual physicians. The file only contains cost and utilization information, and for the reasons described in the preceding paragraph, the volume of procedures presented may not be fully inclusive of all procedures performed by the provider.

In addition, Medicare allowed amounts and Medicare payments for a given HCPCS code/place of service can vary based on a number of factors, including modifiers, geography, and place of service. For example, modifiers (which are two-character designators that signal a change in how the HCPCS code for the procedure or service should be applied) may impact allowed amounts and payments. Allowed amounts and payments also vary geographically because Medicare makes adjustments for most services based on an area's cost of living. Medicare also pays differently when services are provided in a facility setting versus a freestanding physicians’ office (or other non-facility setting). Payments for drugs are also handled differently. In general, when a provider administers drugs to a patient, the provider purchases the drug and Medicare pays the provider 106% of the average sales price (ASP) for the drug.   

More Information

Visit http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html to view the new physician dataset.  

To view the interactive Medicare Physician and Other Supplier Lookup Tool, visit: https://data.cms.gov/

To read the press release, visit: http://cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-06-01.html.

CPT codes, descriptions and other data only are copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).

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