Doctors who tweet aren’t ones who bill Medicare for millions

The government dropped a gigantic dataset: details on nearly every single procedure performed by a U.S. doctor on a Medicare patient.

The release was greeted with some serious gnashing of teeth, at least as far as doctors were concerned. The American Medical Association, which has always been staunchly opposed to the release of this sort of data, made sure it’s objection was — again — on the record. MedPage Today leads their doctor-focused site with a story that cataloged criticism. It’s title? “None of Your Business.” The Wall Street Journal said that the data release “sparked an outcry.”

But there’s one group that met the news with a resounding “meh”: the 12,000-plus tweeting doctors that we track online as part of our MDigitalLife database. A quick scan late yesterday suggested that there were just over 200 tweets on the topic. And there was nary a peep of protest. The closest anyone came to an “outcry” was Chicago-based primary care doc Atul Jain, who tweeted out: “Transparency + muddied data = confusion.”

A closer look at the Medicare release may explain why digital docs saw the data dump as something less than than assault on their way of life. As it turns out, doctors who tweet are very, very different from doctors who bill Medicare for millions. Here’s how we looked at the data.

First, we created a list of doctors who appeared both in the dataset of Medicare providers and our MDigitalLife database of verified doctors in the United States with Twitter handles: 8,000 doctors who both used Twitter and received Medicare payments. We compared that group to the top 14,000 or so providers in the Medicare dataset (every single person who received $500,000 or more from the Medicare). There wasn’t a lot of overlap. Only 230 docs made both the top-tweeter and the top-biller list. And among the real outliers — the top 1,000 recipients of Medicare dollars — only 13 were on Twitter, with a measly median follower count of 112.

What’s more, there was an inverse association between Twitter followers and money received from Medicare. The more physician followers a doctor had, the lower his or her Medicare billing tended to be. And that was true not only in aggregate, but for individual specialties, too. It held for ophthalmologists, the per capita leaders in Medicare payments. It held for cardiologists. It held for dermatologists. And it would have held for oncology, too, if not for a single, highly followed oncologist. (Not surprisingly, there was a strong correlation between real-world interactions — referral relationships around Medicare patients — and increased Medicare spending.)

To be sure, the data isn’t clean enough to claim that there is some magic protective effect that makes doctors on Twitter less likely to file millions in claims with Medicare; there are clearly confounding factors that may be at work. And it bears noting that receiving large Medicare payments isn’t necessarily indicative of anything questionable and that the dataset itself has more than a handful of quirks.

Still, it is not a leap to conclude a doctor who chooses to take a plunge into Twitter is showing a commitment to transparency that can and should be applauded by patients. Clearly, that is a group of physicians that don’t fear sunshine.

One of the biggest questions raised by the enormous data dump is what, exactly, patients can glean from dozens of data points on more than 800,000 doctors. And while we plan to take a closer look, one of the tentative conclusions — judging from both the Medicare data and the reaction to the data — is that consumers would be well-served by doing a quick Twitter search. Seeing their provider pop up on the screen is not a guarantee of straight talk, but is sure is a strong signal.

Brian Reid is group director of media relations, WCG (a W2O Group Company).  He can be reached on Twitter @brianreid.

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  • guest

    I looked myself up – in 2012 I apparently billed medicare $1537.00. Clearly I’m doing something wrong.

  • Patient Kit

    In the name of trying to understand the data, a question: The oncologist in Newport Beach, CA, who is reportedly Medicare’s highest paid doc in CA, receiving $11.5 million from Medicare in 2012 but who says he’s not because all 5 docs in his practice bill under his name — Is that common practice for doctors to routinely bill under another doctor’s name? And, if so, why? Why don’t they each bill under their own name?

    • Vamsi Aribindi

      Because it’s really annoying to keep 5 people’s medicare billing accounts renewed every year. Federal paperwork is really annoying- as is figuring out exactly which doctor saw which patient on which visit, taking into account calls, emergencies, vacations, and since none of the electronic systems talk to each other. The practice isn’t illegal or even unethical- the work was done after all, so why not save time and money?

      Also, Oncologists are especially highly paid because they bill for the drugs. In most medical specialties, drugs are paid for directly. In Oncology, Medicare pays the Oncologist, who then turns around and buys the drug, with a small profit that is already well regulated by the government. This is a legacy system of payment- no real reason to keep doing it other than the fact that it’s what was done.

      • Patient Kit

        Thank you for your eye-opening response about how docs routinely bill Medicare under other doctors’ names. I had no clue and am still trying to digest this. Well, this is one thing I didn’t know before this data was made public.

  • Vamsi Aribindi

    I’m all for transparency- but it’s important to recognize that it can have harms as well as benefits.

    A group of hospitals in New York, under the name of transparency, were forced to reveal complication and death rates for patients undergoing CABG. They got “report cards” on their performance. What happened?

    The sickest patients (who still should have had surgery, but had a higher risk of dying than the average patient) were denied surgery because the surgeons and hospitals didn’t want a bad grade. Those patients died of their disease, but because they didn’t die on the operating table the surgeons’ grades didn’t go down. Everyone thought it was a success story- until a study out of Northwestern and Stanford’s Economics departments found that no actual improvement in outcomes took place- only more deaths.

    Dranove D, Kessler D, McClellan M, Satterthwaite M. Is more information better? The effects of report cards’ on health care providers. The Journal of Political Economy; Jun 2003.

    There were no financial penalties, no pay for performance- only “transparency”.

    I don’t think the data in this case will be harmful. But I also don’t think it will be useful to anyone, except political opponents of doctors. They can now look up and accuse individuals doctors of making too much money. Ironically, the doctors that have high medicare payments are the ones who are forgoing high payments from private insurers to treat the sicker and usually less well paying elderly. But I doubt the tactic will be effective- most patients still like and trust their doctors (per Gallup we’re one of the three most trusted professions in America) and won’t mind the relatively high salaries.

    • Patient Kit

      No doubt, humans in general don’t seem to be particularly good at anticipating the possible unintended consequences of their actions. I’ve always assumed that docs with absolutely perfect outcomes all the time must not take any complex difficult cases. Yet peeps seem to want docs with perfect outcomes. Transparent data is one thing but knowing how to interpret it is another thing. That said, deeply hidden data has it’s own set of perils.

  • Margalit Gur-Arie

    Another explanation of this interestingly strange study of the Medicare data as it relates to Twitter could be that people who spend lots of time tweeting may have less time for working…. just kidding….. :-)

    This entire circus has very little to do with “transparency”, not that I know what “transparency” is supposed to mean… My take on this is here:

    • Dr. Drake Ramoray

      Very good link

      • Margalit Gur-Arie

        Thank you.

    • buzzkillerjsmith

      Hi Margalit, I liked your blog post, especially the very end where you mentioned that the median was around 30k. Exactly. This is exactly what I was thinking about while I was walking to work today.

      Say the average family doc bills 360k /year. Overhead is half or so, so the doc brings home 180k. Now, chop out the Medicare and he or she grosses 330k per year and brings home 165k A bit of a salary cut, but what about the work decrease? I would submit that Medicare pts are much, much more work per dollar earned than younger patients, especially ones with good insurance. While I’m not accountant, it seems at first glance that your median 30k ham-and-egger family doc is making a serious business error by seeing old folks. The doc could see well-insured pts instead of just spend more time on the yacht or at the country club.

      Of course we family docs are not known for our business acumen, as evidenced by the fact that we went into family medicine. But still. It might get some family docs thinking even more.

      And what about Medicaid? It’s pays even worse than Medicare.

      • Margalit Gur-Arie

        Thanks, buzz. Unfortunately, nobody cares to dive into
        the details. I just saw a headline saying “344 Doctors You Should Be Afraid Of”. It doesn’t matter if you are taking/not taking Medicare/Medicaid, are cash only, salaried, or volunteer in free clinics. The goal is to change people minds because it seems we trust doctors way too much, and we should be trusting computers programmed by thought leaders instead….

    • MightyCasey

      Yeah, the screaming headlines are all about THE.WRONG.THING. First, it’s Medicare: higher-utilization patient demographic. Second, there’s no mention of overhead in running the doc’s practice. Medicare billing numbers are less than half the story on healthcare cost.

      • Greg Matthews

        One of the real pioneers in exploring health data, Fred Trotter, wrote a fantastic post about all of the cautions that must be applied when reviewing this data:
        In full disclosure, I work with the author (Brian Reid) and I can tell you that we’re being incredibly careful about jumping to conclusions with any of these findings … it’s time for observations and teeing up the next round of questions.

      • Bob

        And in many specialties there are devices or expensive drug injection treatments that are billed in a lump sum basis, such as eye lens implants that cost as much or more than the physicians labor costs.

  • Vamsi Aribindi

    The patient’s chart is signed by the treating doctor, with the exception of teaching hospitals where the supervising doctor may sign instead, depending on the rank of the trainee physician.

    The problem is that the full patient’s chart is usually not available to the billing specialists (this is a good thing, since I doubt that patients want their name and diagnosis visible by every billing specialist) This was especially true in the era of paper charts, which many doctors still use. But, many EMR systems still suffer these problems.

    Say you are Dr. Y’s patient. You want to see the doctor tomorrow for a cold. Dr. Y is on vacation, and his or her partner Dr. X sees you instead. Dr. X signs the chart. Later, billing specialist Z only sees that you came in for a visit with a given acuity level. Z may or may not see which doctor you actually saw, but Z doesn’t care. To save money, paperwork, and time each year, Dr. X is the only listed doctors for the practice in Medicare’s databanks. Z bills Medicare under X’s license for you being seen. At the end of the year, Drs. X and Y will divide the total earnings over the year based on days worked and vacation taken- generally not on patients actually seen.

    Is it possible for shenanigans and fraud to occur? Certainly. But that is the exception. This is a perfectly legitimate practice that goes back decades, according to my instructors who were discussing the topic today.

    • EmilyAnon

      “At the end of the year, Drs. X and Y will divide the total earnings over the year”

      Doesn’t that make for confusion at tax time when Medicare reports total earnings in only one doctor’s name? In any other field, pension and SS benefits would also be affected with such an arrangement.

  • Vamsi Aribindi

    The last scenario is what I was referring to, while attempting to avoid complicating the issue. That last scenario would feature payments to one person for all the activities of the group- in a legal and ethical situation manner.

  • Patient Kit

    Perhaps we need an analysis of the demographics of doctors who tweet. For example, what percentage of tweeting docs are young and what percentage of tweeting docs are not as young? Perhaps if we knew the dominant demographics of tweeting docs, we’d know the dominant demographics of tweeting docs. ;-)

    • Greg Matthews

      We don’t know the age of the doctors in the MDigitalLife database – not exactly, anyway. We do have Med School graduation year for about 75% of them, though … and that data suggests that 70% of the tweeting docs are over 40. Oh, and if that was a rhetorical question I apologize for spoiling the fun! ;-)

      • Patient Kit

        I was just being a little silly and rhetorical. Clearly, I’m ready for a pitcher of Friday night margaritas (and a Yankees/Red Sox game). But it is interesting that you think 70% of tweeting docs are over 40. I would have guessed the opposite.

        • heartdoc345

          Uh since most doctors are over 40 (unless still in residency) I don ‘t know that 40 is a valid cut-off!

          • Patient Kit

            I guess I was counting residents as young doctors because I thought they are called doctor once they graduate from med school with their MD, even while they continue training. And I further guessed that most young resident doctors tweet. I guess I guessed wrong. :-p. I think the lesson here is that we have to make sure we’re defining our terms the same way — in this case, what do we mean by “doctor”?

          • Greg Matthews

            We count residents as doctors in the statistic I cited … and those under 40 folks are all in the “other 30%.” It’s the well-established, mature MDs that are leading the way online.

  • Greg Matthews

    Your point is well-taken … I guess I see this as “basecamp one.” We don’t know what the summit is going to look like, but we do now have a platform on which to build the next set of questions – and hopefully to canvas others to crowdsource that next set of questions. What would you ask, Brian?

  • Dinah
  • RocK8Doc

    May be the doctors who tweet are in Administrative roles, working for MCOs/Tech companies/Pharma/Government etc…

  • RocK8Doc

    The main point that was lost in the data dump was it was ~ 10 % of what is spend, the real waste is in the rest of the 90 %.

  • White Coat Investor

    The only thing interesting about this release of information was that I discovered that Medicare pays me just $7 to read an EKG and just $130 to see a chest pain patient. Apparently these “crazy-high” ER bills aren’t due to the doctors making a killing.

    The other interesting thing I found, that really makes me question the accuracy of the database, is that one of my partners who works the same number and type of shifts and sees about the same number of patients on those shifts had a total that was only 60% of mine. I find it hard to believe that’s an accurate database when I see things like that.

  • Sara Stein MD

    I remember tweeting about “attacked by an orca” as a specific diagnosis. If ICD-10 wasn’t so bloated and confusing that it could cripple medicare billing on both sides, it would be great entertainment. Interesting cross analysis of tweeting and billing, btw. Do you lose the docs who work in ER or bill as institution, not individual?

  • Bob

    Since Medicaid is front and center does the governments plan on releasing physician data on this entitlement program?

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