CMS wants to publicly report on providers

The Centers for Medicare & Medicaid Services (CMS) has proposed rules that will allow certain qualified organizations access to patient-protected Medicare data to produce public reports on physicians, hospitals and other healthcare providers. These reports will combine private-sector claims data with Medicare claims data to identify hospitals and doctors providing cost-effective care, according to the agency.

The limited, piecemeal availability of healthcare claims data has caused health plans to create provider performance reports based solely on the plans' own claims, which often represent only a small proportion of a provider’s overall practice, CMS stated. Providers might receive contradictory reports from different insurers and have no way to appeal or correct inaccuracies in these reports.

“Effective Jan. 1, 2012, section 10332 of the [Patient Protection and Affordable Care Act] would amend section 1874 of the Social Security Act by adding a new subsection (e) requiring standardized extracts of Medicare claims data under parts A, B and D be made available to ‘qualified entities’ for the evaluation of the performance of providers of services and suppliers,” the 93-page proposed rule states. The information obtained may be used only for evaluating the performance of providers of services and suppliers, and to generate specified public reports.

The proposed rules include strict privacy and security requirements for entities handling Medicare claims data, CMS stated. Publicly released reports would contain aggregated information only—no individual patient/beneficiary data would be shared or be available. Qualified entities would pay a fee to cover CMS’ cost of making the data available, according to the proposed rule, which also requires qualified entities to have claims data from other sources in order to receive the Medicare claims data.

These entities would be required to use standard measures for evaluating the performance of providers of services and suppliers unless the Department of Health and Human Services secretary, in consultation with appropriate stakeholders, determined that alternative measures would be more valid, reliable, cost-effective or relevant to dimensions of quality and resource use not addressed by standard measures, according to the proposed rule.

Qualified entities would share reports confidentially with providers and suppliers prior to public release, giving providers and suppliers an opportunity to review reports and provide corrections.

During the application process, qualified entities would need to demonstrate their capabilities to govern the access, use and security of Medicare claims data, as well as their access to and use of claims data from other sources. Qualified entities would be subject to strict security and privacy processes and would be monitored for compliance, and could face sanctions or termination from the program for noncompliance. CMS doesn’t plan to limit the number of qualified entities, the rule states.

The proposed rule will be published in the Federal Register on June 8 and comments will be accepted for 60 days following publication. Click here to see the proposed rule.