Doctors want policy changes before Medicare releases claims data

CMS must ensure the information is accurate before letting research groups publish quality report cards, physician organizations say.

By Charles Fiegl — Posted Aug. 18, 2011

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The agency administering the Medicare program must ensure that the data that will be used to measure individual physicians' performance are accurate and reliable before they become public, members of organized medicine wrote to the Centers for Medicare & Medicaid Services in an Aug. 8 letter.

The American Medical Association and dozens of other physician organizations said CMS has several critical issues that must be resolved before the agency finalizes a proposed rule allowing the release of Medicare billing information to qualified groups for analysis. CMS would make Medicare claims data available to entities for the development of quality, efficiency and performance reports for patients to use when making health care decisions. Reports also would provide feedback to individual physicians on the quality of care they provide to patients.

"The release of accurate data provides an opportunity to inform patients and physicians and to advance the quality of care in the Medicare program," said AMA President Peter W. Carmel, MD. "CMS has included critical safeguards in this proposed rule, but further action is needed to ensure the information is reliable and the process is equitable."

Physicians must have the opportunity and enough time to review individual data before reports are made public to ensure their accuracy, the AMA and 81 other associations representing physicians wrote in the letter to CMS. The health system reform law requires those compiling reports on physicians to allow health professionals an opportunity to correct errors. CMS has proposed such a process, but the physician organizations recommended a stronger confidential review of data before release.

For instance, they said, comments made by physicians on their claims data during the review process should be included with any publicly reported analysis of physician claims.

"Just as the release of reliable information can be helpful for patients and physicians, the release of incorrect information could harm patients and the entire Medicare system," Dr. Carmel said. "The reports should compare apples to apples -- using the same data from both private insurers and Medicare -- and allow a full review and appeals process before publication to provide the most accurate information."

The physician organizations have called for more time to allow health professionals to review and appeal performance results. Physicians must have 90 business days, instead of 30, before the results are made public, the AMA said. The proposed rule also would give doctors 10 business days to request data and an additional 10 days to request any error corrections. The AMA recommended at least 10 days to make a request for data and an additional 30 days to request corrections.

Under the proposed rule, qualified research groups would need to show significant experience with analyzing claims data before gaining access to Medicare's database. A group would be required to merge the Medicare information with claims data from two or more other sources, such as private insurers and Medicaid, when compiling performance reports.

"We caution CMS against approving applicants that do not have extensive experience handling claims data and calculating performance measures, as this may jeopardize the integrity of the program," the letter said.

Many organizations interested in obtaining data may have difficulties meeting the requirements proposed by CMS, according to the nonprofit Robert Wood Johnson Foundation, based in Princeton, N.J. The foundation supports 16 regional alliances in the Aligning Forces for Quality initiative, a multistakeholder effort to improve health care in communities across the country.

"The proposed rule seems to require that a [qualified entity] have a full, rigid, in-house array of capability which could needlessly disqualify an otherwise perfectly suitable potential" qualified entity, the foundation said.

The Federation of American Hospitals suggested that CMS should limit the use of Medicare claims. Specifically, it warned against the prospect of using the analysis as a basis of pay-for-performance programs.

"The 'science' of data aggregation is in an early stage of development, and the methodologies used for the purposes of this program could potentially provide insights into best practices; however, that could and should only be determined after thorough, evidence-based evaluation," the federation said.

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