Final Rule Grants Public Access to Medicare Data

A new health care law that went on display in the Dec. 7 Federal Register gives qualified organizations access to provider and supplier claims data for the purpose of evaluating their performance and generating public reports. Congress required in this final rule that qualified entities combine data from sources other than Medicare when evaluating the performance of providers and suppliers.

“This is a giant step forward in making our health care system more transparent and promoting increased competition, accountability, quality and lower costs,” said Marilyn Tavenner, newly-named acting administrator for the Centers for Medicare & Medicaid Services (CMS). “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.”

The “Availability of Medicare Data for Performance Measurement” final rule makes a number of other important changes from the proposed rule. Here’s a short list:

  • Technical changes were made to the definitions of a qualified entity, provider, and supplier, and new definitions of claims data and clinical data. Clinical data is now defined as “registry data, chart abstracted data, laboratory results, electronic health record information, and other information relating to the care or services provided to patients that is not included in administrative claims data.”
  • CMS clarified that qualified entities do not need to be a single organization. Applicants may contract with others to achieve the ability to meet the eligibility criteria.
  • Changes to eligibility requirements were made to only require that entities demonstrate expertise in quality measurement and in the three areas of measurement (efficiency, effectiveness, and resource use) to the extent that they propose to use such measures.
  • CMS added language that would require qualified entities to also disclose any violations of applicable federal and state privacy and security laws and regulations for the preceding 10-year period, in addition to requiring qualified entities to disclose any inappropriate disclosures of beneficiary identifiable information for the preceding 10-year period.
  • CMS extended the time period between a qualified entity sending a confidential report to a provider or supplier and public reporting of measure results to at least 60 calendar days.

The final rule also makes claims data less costly for qualified entities to obtain. In the proposed rule, CMS estimates the cost of providing data for 2.5 million beneficiaries to a qualified entity would be $200,000. The final rule drops the program management portion of costs to bring the cost down to $44,000 in the first year of the program, based on an estimated 25 qualified entities participating in the program.

Physicians’ offices will incur internal costs for reviewing their performance reports. CMS estimates physicians will spend an average of 5 hours reviewing their annual report at a rate of $42.88 per hour, for a total expense of $214. Preparing and submitting an appeal would cost a physician another $429, CMS estimates.

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