Medicare and Medicaid combined now pay for 50% of health care in the United States. It would seem important for experts to be able to analyze the behavior of individual providers, particularly physicians, in treating patients under these programs. But CMS has not been permitted or not been willingly to grant access to data that would allow creation of practice patterns that could help in identifying physicians with poor care outcomes or who are high spenders. A new proposed rule goes part way to helping address this problem. (CMS Data Rule) The rule implements a PPACA provision allowing “qualified entities” to get extracts of Medicare data for purposes of provider performance evaluation.
To determine who can get access to the data, CMS is proposing to examine organizational and governance capabilities, ability to add claims data from other sources and data privacy and security. Organizations will have to pay for the data extracts. Applicants will have to detail their proposed methodology for analyzing the data. The providers profiled will have to be given the right to review the proposed reports. Reports must be generated and released to the public by the organizations which receive data extracts. CMS is still considering exactly what to require in the way of access to other claims data to be combined with the Medicare data. Providers would be profiled on performance measures, which CMS has rather narrowly defined and currently appear limited to quality outcomes. Cost performance should be of equal concern.
What CMS could do that would really facilitate consumers’ and payers’ ability to influence quality and cost outcomes in health care is work to sponsor a single database that crosses all payers and allows for comparisons of how hospitals and physicians treat patients under different benefit plans and reimbursement methods and would allow for the identification of providers who appear to have better or worse outcomes and higher or lower spending for similar patients. It is troubling that Congress and CMS have allowed the AMA and others to block or hinder even minimal releases of data that is crucial to real improvement in patient treatment and to getting spending under control. But we can expect continued efforts to inhibit free and open disclosure about health spending paid for by the general public. This proposed rule is a good first step toward helping the public see what it is paying for.