Medicare claims soon to be open for data mining

Researchers would be able to pay for individual physicians' claims information to develop quality reports for the public.

By Charles Fiegl amednews staff — Posted June 20, 2011

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Qualified organizations would gain access to Medicare billing data for the purpose of developing physician report cards for the public under a new proposed rule from the Centers for Medicare & Medicaid Services.

The health system reform law authorized the limited release of Medicare claims data to outside organizations meeting certain qualifications. The organizations would merge Medicare billing data with private insurance information to compile quality, efficiency and performance information on doctors, hospitals and other health care professionals, said CMS Administrator Donald M. Berwick, MD, in a statement accompanying the rule's release on June 3.

"Making more Medicare data available can make it easier for employers and consumers to make smart decisions about their health care," he said. "Performance reports that include Medicare data will result in higher-quality and more cost-effective care. And making our health care system more transparent promotes competition and drives costs down."

The American Medical Association and other members of organized medicine are reviewing the regulation and will provide comments by Aug. 8. The Association supports the use of physician data for generating meaningful quality performance reports only if certain safeguards are in place to ensure accuracy and validity, said AMA President Cecil B. Wilson, MD.

"For example, before reports are made public, physicians must have the opportunity to review their data, and adequate, well-tested risk-adjustment and attribution models must be incorporated during the development of quality performance reports," Dr. Wilson said. "Currently, we are reviewing this new regulation to determine if CMS has appropriately interpreted the application of these critical safeguards."

According to the proposed rule, physicians and other health professionals would have the opportunity to review and correct data before the information is released publicly. An organization compiling the information would explain the methodology, statistical reliability and interpretation of the results. The health professional then would need to request the Medicare data used to calculate the information he or she wants to appeal or correct.

"We want to ensure that providers of services and suppliers have the opportunity to correct their results in situations where there are errors, but also ensure that performance results are released in a timely manner," CMS stated.

CMS proposed providing at least 10 business days for a doctor to request data and another 10 business days to request an error correction.

"Notably, the proposal gives providers an opportunity to review the reports of the claims data and ask for corrections before they are released to the public," the Medical Group Management Assn. said in an email to members. "Providers can confidentially access the reports and other pertinent information regarding its methodology from qualified entities at least 30 days before publication."

Only qualified entities would gain access

The proposed regulation sets restrictions on who would qualify for access to the Medicare claims data. CMS would determine eligibility by:

  • Reviewing the intended use of the data, such as the organization's planned methods of creating and disseminating reports.
  • Reviewing how the recipient would supply physicians and others with reports before public release and how it would allow for error corrections.
  • Reviewing a report prototype.

Qualified organizations would be required to incorporate private claims data with the Medicare data when developing reports. CMS is considering a mandate that recipients have claims data from two or more other sources besides Medicare, such as private insurers and Medicaid.

"We believe that a requirement for claims data from two or more other sources may help further alleviate some of the methodological issues associated with performance measurement based on single-sourced data," CMS said.

Medicare's data trove is massive, and accessing just a piece of the claims database would be expensive. Obtaining three years of data on doctors serving 2.5 million patients would cost $200,000, according to the proposed rule. About $75,000 would cover the cost of the data, and $125,000 would pay for the costs of making the data available. CMS estimates that obtaining three years of data on the physicians for 5 million patients would have a $275,000 price tag.

Two organizations with strong interests in accessing Medicare physician claims data disagree with the restrictions under the proposed rule. Consumers' Checkbook/The Center for the Study of Services, a consumer service ratings group based in Washington, D.C., unsuccessfully sued to obtain access to individual doctors' claims data in 2006.

Robert Krughoff, president of Consumers' Checkbook, said restrictions should be applied to protect patient privacy but not to impede access to other information in the Medicare database. He said his firm would like to use Medicare data to provide patients with information on individual physicians' levels of experience to help them pick well-qualified doctors. For instance, a report card would tell consumers how many coronary artery bypass surgeries a cardiac surgeon has performed.

"The proposed rule is much more restrictive than it has to be under the law," Krughoff said.

The Wall Street Journal is engaged in a lawsuit against the federal government to gain access to identifiable doctor records in the Medicare database. The newspaper would use its access to investigate instances of potential fraud occurring in the program.

"The regulations contain numerous restrictions and other controls that severely restrict who has access, what data is analyzed, and what can be shared with the public," said Jason Conti, an attorney with Dow Jones, the WSJ's parent company. "Dow Jones will continue to fight for the right to access and disseminate this crucial information."

Some lawmakers who are reviewing the regulation proposed by CMS may comment on it as well. Sens. John Cornyn (R, Texas), Charles Grassley (R, Iowa) and Ron Wyden (D, Ore.), for instance, have proposed their own legislation that would open up Medicare data to the public. At least one Senate aide, who asked not to be identified, suggested that the proposed rule is more restrictive than the pending legislation would be.

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How to comment on making billing data public

The Centers for Medicare & Medicaid Services will accept comments until Aug. 8 on the proposed rule to allow qualified entities access to individual physicians' Medicare billing data for research purposes. Comments can be submitted:

  • Online by following the instructions for submitting comments (link). Enter keyword CMS-5059-P for the document file code.
  • By regular mail addressed to Centers for Medicare & Medicaid Services, Dept. of Health and Human Services, Attn: CMS-5059-P, P.O. Box 8012, Baltimore, MD 21244-1850.

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