The Federal program we know as Medicare, became a reality on 30 July 1965, when it was signed into law. But, the first patients could not sign up for benefits until 1 July 1966. And, by 1979, the American Medical Association managed to get a ruling that the moneys paid to doctors under the program could not be revealed to the public. The reasoning (sic) was that this was an invasion of the physician’s privacy.
Right. It really meant we had no clue how much our Medicare health care costs on a case-by-case basis. And, that situation existed for 33 years. Until 31 May 2013, when Judge Marcia Morales Howard ruled in favor of the Dow Jones Company (parent of the Wall Street Journal), thereby providing access to the (heretofore confidential) database of Medicare Insurance claims.
The Carrier Standard Analytic File (CSAF) is comprised of data on providers (physicians and other registered health providers) who are recompensed by Medicare on a fee-for-service basis. Any claim that Medicare pays directly is within these records. It came to be used only by Federal investigators seeking out fraud, because of that 1979 injunction (as filed in the US District Court, Jacksonville Florida) disallowing public viewing of the records.
And, this ban was not a one time ruling. It was continuously challenged and the AMA repulsed the attacks relentlessly (always claiming it violated the physicians right to privacy under the 1974 Privacy Act). The Wall Street Journal in 2011 published a series of articles that demonstrated that the CSAF would be critical for citizens to ferret out fraud and abuse. Given the size of the program at the time ($ 549 billion), such revelations would be useful for the public to know.
The parent company of the Wall Street Journal, Dow Jones, therefore filed a request to lift the ban on 25 January 2011. On 31 May 2013, with many friends of the court joining in the case, Judge Howard determined that other court rulings have restricted the wide reach that had been afforded the case under the Privacy Act. Her exact words were that the 1979 injunction was based on “a legal principle that can no longer be sustained” . (It is rumored that the AMA may appeal Judge Howard’s ruling.)
Under PPACA (2010 Affordable Care Act, known as “Obamacare”), HHS in 2012 began letting community groups and some academic researchers garner access to the database. The goal of that effort was to improve health care at the local level. But, this provision did not extend to news organizations.
However, in spite of Judge Howard’s ruling, we shouldn’t expect to see all the data suddenly appear in print. The ruling only affords news organizations the right to file Freedom of Information Act requests (FOIA); this then means that the Health and Human Services Administration (HHS) must rule on each request– on a case-by-case basis.
Physician’s right to privacy? Seriously? This all seems so absurd to me.
Amen to that, Suerae. That’s why i used that editorial insert (sic)- because I found it an interesting choice, too.
In other words, people can only get this for themselves after begging? How does that help us make useful decisions about doctors based on cases of obvious fraud? If I write a blog does this make me a publication like the Wall Street Journal? I believe that has been around the block a few times.
Ann Mullen recently posted..In Home Care: House Sharing and the Tax Man
Well, Ann, I don’t think going for a FOIA is begging. And, I am not sure most of us are equipped to analyze the volumes of data that exists in this database.
Even ProPublica, when it analyzed the dialysis industry, missed the boat (https://www.adjuvancy.com/wordpress/reactions-to-the-atlantic-propublica-dialysis-article/ ).
And, you can apply to be considered a news organization- and would then be able to do so.
I could request the data as a researcher, which is another approach.
In Canada they do a lot of auditing of the medical billing by doctors. I once received a letter asking if I actually had had an appt. with a particular Dr. Fortunately I had.
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That’s good to know, Carol…
Thanks for sharing that tidbit.
It’s getting to the point that i really don’t trust any part of the federal government to act on behalf of voters interests. I kind of would like to know how American Airlines can continue with their bankrupt proceeding and introduce new fancy aircraft at the same time. Aircraft that cost millions to lease from the manufacturer?
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Let’s see, Chef William. They are not buying the aircraft, but leasing them- and they got price concessions from the manufacturer, besides…
Not bad, if you can get it.
I have to deal with our version of Medicare every day…tell me about it…
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I am not sure that has anything to do with the data on effectiveness or costs, though, Caro…
And, I think your situation is more a propos of Medicaid and not Medicare. (Not that it makes you feel that you’ve been treated better…)
Well, I have to admit that I didn’t expect the ‘physician’s right to privacy’ to be used like this. How can we make sure that the system is under control? That’s the bit that I don’t understand. The FOIA seems quite a heavy process to get the necessary information.
MuMuGB recently posted..Kensington Palette
I don’t get the right to privacy thing for physicians, either, Muriel.
And, FOIA is a process, but probably a valid one, to insure we know who is getting this information.
I read this with interest, Roy, As I have been taking my father-in-law to many doctor appointments in the past 1.5 years, I have become aware of some physicians padding the amount of visits necessary. This is distressing as I see the toll it takes on some of the elderly as they wait for services or have to come back for (what I deem as) unnecessary visits. One doctor in particular has distressed me in this area and I have discontinued being serviced by that practice. I wonder if those records were under scrutiny if questions would be raised.
That will stop soon, Bonnie, as the regs kick in and begin paying for wellness and not fee-for-service. I have doubts that it will stop a lot of the (self-referred) diagnostic tests, though…
And, the payment records include all payments rendered, so I am guessing yes.