Medicare opens physician claims to researchers

Washington -- The lack of a sufficient physician appeals process and other issues have physicians concerned about a new regulation that will allow the release of Medicare claims data for developing doctor quality scores starting in 2012.

On Dec. 5, the Centers for Medicare & Medicaid Services finalized a regulation granting access to physician billing data to qualified organizations, including consumer groups and employers. Doctors' claims from 2009, 2010 and the first two quarters of 2011 will be available for analysis starting next year, according to the final rule.

"This is a giant step forward in making our health care system more transparent and promoting increased competition, accountability, quality and lower costs," said acting CMS Administrator Marilyn Tavenner. "This provision of the health care law will ensure consumers have the access they deserve to information that will help them receive the highest quality care at the best value for their dollar."

To qualify, groups must show that they have experience evaluating performance measures, analyzing claims data and safeguarding information. Entities also are required to have access to claims data from other health payers, either private insurers or public payers such as Medicaid, to combine with the Medicare data.

The Medicare agency issued a proposed rule in June on the claims data release. The American Medical Association and 81 other physician organizations wrote a letter in August encouraging CMS to take steps ensuring that the data in performance reports are reliable. If done correctly, public reporting could help improve quality at the point of care, the organizations said.

But the final rule failed to create the mechanisms and safeguards needed to ensure that published information on doctors is correct, said AMA President Peter W. Carmel, MD. In some areas, restrictions on the data were relaxed. For instance, changes from the proposed rule would allow claims data to be distributed even if the accuracy of the information is in dispute and subject to an appeal. Dr. Carmel said this "is misleading to patients and does a disservice to physicians."

"The AMA supports the use of accurate physician data when it improves quality of care for patients, but we are concerned that CMS' easing of some requirements for receiving Medicare data could result in the distribution of physician performance reports that are inaccurate and not meaningful for patients or physicians," he said.

Patient advocacy groups and employers have supported the release of physician billing data. Health coverage has become less affordable, and runaway health spending is adversely affecting other sectors of the economy, the Coalition for Affordable Health Coverage wrote in an August letter in support of data sharing. Improving public access to performance measures "will help facilitate incentives to provide higher-quality, lower-cost care," the coalition stated.

Transparency is critical to making informed choices about doctors and medical services, the U.S. Chamber of Commerce said in its letter to CMS. "As purchasers of health care coverage and services, employers and individuals are eager to have access to more data on provider performance and quality to permit more informed health care decision-making."

Physician appeal rights still a concern

Files sent to qualified organizations would encrypt patient information to protect beneficiary privacy. Patient identification numbers would allow those analyzing the data to track patients over time -- and determine which services and supplies they received -- without exposing the patients' names.

Physicians would be identified by the national provider identifiers they are required to use on claims for services, which then could be used to determine the physicians' names. CMS also would give researchers the unique physician identification number associated with each claim.

Qualified recipients of the claims data would be able to link physicians to the Medicare beneficiaries that they treated. However, CMS would not require the qualified groups automatically to provide doctors with those patient lists. With physicians unable to review the lists associated with them, the accuracy of the reports would be difficult, if not impossible, to confirm, the AMA said.

The Medicare agency in the final rule agreed to release beneficiary information when a physician appeals a performance measure in a report during the review process. Qualified entities must provide preliminary reports to physicians at least 60 days before publication. The proposed rule had mandated that the findings be given to physicians at least 30 days before they were publicized. Organized medicine had asked for at least 90 business days.

"We hope that by extending the amount of time between confidentially sharing reports with providers and suppliers and publicly reporting results to at least 60 calendar days, we are allowing both providers and suppliers ample opportunity to resolve the appeals process," CMS said.

The AMA also had urged CMS to require that qualified entities include physicians' comments in the public reports, but the agency rejected the request. CMS said it would not be involved with the appeals and error correction process, but it will monitor the groups receiving claims data to determine if they respond promptly to physician requests for corrections.

CMS does not intend to limit the number of qualified entities that will gain access to the data, according to the final rule. The agency predicts that 25 groups will participate. Applicants will be required to provide prototypes of the reports they plan to generate before gaining access to the data.

Interested parties had suggested to CMS that it lower the proposed price the agency will charge to cover the cost of generating the data and that it exclude expenses to manage the overall program. CMS agreed to drop the total price from $200,000 to $40,000 and noted that costs could drop further if more than 25 qualified entities are approved to receive data. The price would increase if fewer than 25 entities are approved, the agency said.