News 5 Investigates

Apr 18, 2014 12:47 AM by Andy Koen

News 5 Guardians: Medicare data shines light on health care costs

COLORADO SPRINGS - After a 35-year wait, taxpayers can now see just how much money doctors charge Medicare patients for their services. Additionally, patients can use the reimbursement data released last week by the Center for Medicare and Medicaid services to better gauge the price the federal government is willing to pay for specific treatments.

The News 5 Guardians reviewed the data for doctors practicing in Southern Colorado and found certain specialties end up billing at higher rates than others. The highest reimbursed specialties are ophthalmology and hematology/oncology.

In fact, Medicare ranks the doctors of the Retina Consultants of Southern Colorado as having the highest billings in Colorado Springs. Each of the clinic's four doctors billed Medicare between $988,775 and $1.48 million in 2012.

Dr. Ryan Rich says there a few simple explanations behind the high reimbursement amounts. For starters, the data is limited to just billing information for Medicare patients. Those clinics with a higher percentage of patients on private insurance will naturally have lower bills to Medicare.

Then there's the age of the patients to be considered.

"By nature, the majority of our practice is made up of Medicare patients," Rich said.

Age related macular degeneration is the most common cause of decreased vision in adults over the age of 55.

Treating failing eyesight is an expensive proposition. More than half of funds billed to Medicare by Rich's clinic are directly attributed to drugs. Medications such as Lucentis and Eylea which are used to treat Age-Related Macular Degeneration cost upwards of $2,000 a dose.

There are lower cost alternatives. In fact, Dr. Rich was among a team of researchers who discovered that the cancer medication Avastin could be used as an off-label treatment for macular degeneration at a lower cost.

In general, he says they will see how the well a patient responds to Avastin treatments before escalating to the higher priced medications.

"After treatment, if it appears the person is getting worse then absolutely we would want to do what was best for them and try a different drug," Rich said.

Consumer advocates with the Pikes Peak Area Council of Governments believe the reimbursement data are a valuable tool for patients. However, they urge caution because the raw spreadsheets can be challenging to read.

"It's not really easy for the average Medicare beneficiary to navigate through that," explained Lisa Hietala, the Insurance Programs Manager for the PPACG's Area Agency on Aging.

"All they see is that big number at the top and 'Oh my gosh, my ophthalmologist got $5 million from Medicare."

She thinks the most helpful information contained in the data are numbers that correlate the number doctor's experience with certain treatments.

"If you're having a hip replacement, for instance, you can go in and look at the procedure to see what doctor in this area did the most hip replacements," Hietala said.

While Dr. Rich and his fellow ophthalmologists at Retina Consultants of Southern Colorado welcome the public discussion about their billing information, they hope we will keep in mind that many costs are beyond their control.

"We have to walk a fine line between privacy of individuals of doctors and patients versus the wise stewardship of our federal dollars for use for health care."

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