by Jacob Dahlke, Bioethics Program Alum (MSBioethics 2012)
Much is written – and justifiably so – about the disparities that exist in our healthcare system in the U.S. The CDC, for example, reports a few: non-Hispanic blacks die more frequently from stroke and coronary heart disease than whites; homicide deaths are 2.5 times higher for men than women, and over 6.5 times higher for non-Hispanic blacks than whites; non-Hispanic whites and American Indian/Alaska Natives than other ethnic groups. Health disparity can be viewed as a sort of volatility risk of the healthcare system: as the difference in health among various groups of patients increases, so does the possibility (or likelihood) than people within the system will be treated more unjustly or unfairly. This leads to likely further social disparities, increasing the likelihood that these groups will not be able to manage their health effectively. A vicious cycle, indeed.
A primary stakeholder in the health disparity discussion in the U.S. is the Centers for Medicare and Medicaid Services (CMS). This government agency manages the healthcare for nearly a third of the entire U.S. population – about 100 million people. They even covered me and my family for about four years. They play a deep role in American healthcare, and so it is usually when a group like that provides data in the name of transparency. This is just what they did, releasing Medicare payment records for physicians for 2012. It was a controversial move, opposed primarily by the American Medical Association (AMA). The AMA’s position was based on a concern that the data’s release would “mislead the public into making inappropriate and potentially harmful treatment decisions and will result in unwarranted bias against physicians that can destroy careers”. While I understand that view from the perspective of protecting the interests of it constituents – physicians – I think this view in particular comes off as condescending and paternalistic. Perhaps that can be discussed another time…
The data release shows some dramatic differences that is not unlike American society at large. The data includes payment information for 880,000 physicians who received Medicare payments from CMS in 2012, totaling $77 billion. To make simple comparisons about the disparity within this particular system, consider a ‘flat’ disparity, where every one of those physicians received an equal amount of payments. Payments would be $87,500 to each physician. To contrast, then: the top recipient of Medicare payments in 2012 earned $20.8 million. This comparison is far too simplistic, of course: it presumes that all physicians saw an equal number of patients with the same health conditions, and charged the same price for those services. None of these hold for every physician in the U.S. (I am waiting for Nate Silver to run some numbers on this- it could be another bestseller for him.)
This report – over 10 million lines of text – highlights a massive disparity in payments. $1.5 billion of the (almost 2% of the total payouts) was distributed to only 344 physicians (0.038% of the total number of physicians). About 1 out 4 of the physicians practice in the state of Florida. Over half of these top physicians (193 of the 344) practice in just five states – FL, CA, TX, NJ, and NY – whose populations account for only a third of the total US population. (Those states account for less than 16% of the total U.S. Medicare population.)
Whether all of this is a fair characterization remains to be seen. It is obvious that a physician that simply sees more payments ought to be compensated more than a physician who doesn’t. But the numbers appear so skewed – at this point, at least – that further scrutiny is surely warranted. If we as a nation are truly interested in maintaining or improving our social systems – and most of us are – then this improvement on transparency at CMS can lead to better things, and I hope that it continues.
As an alternative, though, we could just follow Vermont’s lead.
[This blog entry was originally posted in a slightly different form on Mr. Dahlke’s blog on April 9, 2014. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]