(Story updated at 12:50 p.m. ET Tuesday, April 14.)
Transparency advocates are hailing a little-noticed provision in the pending Medicare physician-payment bill that would widen the availability of Medicare claims data to insurers and providers for purposes such as designing provider networks and improving quality of care.
Supporters estimate that it would double the amount of publicly available data. They say it will enhance efforts to reduce costs and improve quality by allowing more rigorous analysis of best practices in the Medicare program. Experts argue the new provisions would give insurers greater incentives to share their claims data because they would be able to receive more information from public insurance programs.
“Anytime you expand the amount of data that's available to people who do analysis it makes the data more accurate,” said Joel White, president of the Council for Affordable Health Coverage, which is part of a new coalition, Clear Choices, seeking greater transparency in healthcare financing. “This is the logical next step.”
But some are worried about provisions allowing private groups to make money by selling public data. “I worry philosophically about creating little centers of monopoly power,” said David Newman, executive director for the Health Care Cost Institute, the only nationwide qualified entity participating in the Medicare data program. “It's public data.”
The SGR repeal package passed the House by an overwhelming margin last month. It's expected to be taken up by the Senate this week and appears poised to be enacted. The legislation would also extend the Children's Health Insurance Program by two years, provide $7.2 billion for community health centers and push doctors to move more patients into risk-based payment models.
The transparency initiative, which is in Section 105, has largely been overlooked given the focus on physician payment reform and repeal of the sustainable growth-rate formula. It expands a provision of the Affordable Care Act allowing “qualified entities” to access Medicare fee-for-service claims data. The new proposal would allow these entities to use that data for private uses, such as helping insurers design provide networks or providers assess quality metrics.
The provision defines qualified entity as a public or private entity that is qualified to use claims data to evaluate the performance of service providers and suppliers on measures of quality, efficiency, effectiveness and resource use, and that agrees to meet specified requirements, such as ensuring data security.
It authorizes qualified entities to use claims data combined with data not from claims the entity has received, as well as information derived from evaluation of service provider and supplier performance, to conduct additional private analyses and provide or sell them to authorized users for private use, including to assist service providers and suppliers to develop and participate in quality and patient-care improvement activities, including new models of care.
Authorized users could include healthcare providers, suppliers, employers, insurers, medical or hospital associations, or other entities approved by the HHS secretary.
“Previously we could only use the data for public reporting, end of story,” said Margy Wienbar, executive director of HealthInsight New Mexico, which has qualified-entity status. “This would allow us to segment the data and target the data.”
The expanded data transparency initiative is part of a broader effort to reduce costs and increase quality by shaking up payment models and expanding best practices.
“This is going to enable providers, payers and patients to get access to useful information to help them make informed decisions about who are the best providers, what are the most effective treatments and what are the most cost-effective ways to provide care,” said Bill Kramer, executive director for national health policy at the Pacific Business Group on Health, which contracts with the qualified entity operating in California.
Under the current program, insurers have no incentive to share their data with qualified entities because the entities could offer nothing in return, the Health Care Cost Institute's Newman said. The new rules would create greater potential for claims to be exchanged across commercial and public insurance markets. “It creates a quid pro quo for sharing,” he said.
The provision in the pending doc-fix legislation would allow qualified entities to sell the data, which previously was prohibited. Many of these entities have struggled financially because obtaining and manipulating the data is costly. Just a dozen organizations have enrolled in the program since its inception, according to the CMS.
“It's virtually impossible to create a sustainable business model,” Kramer said.
Newman expressed disappointment that the legislation didn't expand the program to include access to Medicaid claims data, arguing that it's unfair to low-income beneficiaries. “The absence of the Medicaid data still creates gaps in what we're able to report on,” he said. “They remain a stepchild with respect to the commercial insured and the Medicare population.”