CMS releases rules regarding medicare data release
CMS releases final rules regarding Medicare Data release.
CMS has changed a number of rules regarding data release.There are still many problems and concerns from the perspective of the leadership of the Wisconsin Health Information organization which is the All Payer Claims Data Base created for Wisconsin. These problems, unless corrected, may not allow for significant intergration of the Medicare data with other claims data and may not allow for physician performance to be compared on key cost and quality attributes.
Overall, we believe this rule makes some minor improvements and responds to some of the concerns that WHIO expressed in its comment letter. However, major barriers exist in this program to accessing Medicare data in a way that is useful for WHIO and the other all-payer claims databases (APCDs). Specifically, the restrictions on downstream disclosures that remain in the Final Rule are particularly problematic in permitting the database search function and individualized reports for subscribers. In addition, much of the program rigidity in terms of prior approval of measures and methodologies are maintained. These and other primary concerns are described in greater detail below.
Inability for APCDs to use Medicare data for subscriber reports. Our primary concern with the proposed rule was whether the Medicare data released under this program could be integrated and used consistent with the APCD business model (meaning subscribers could search the database and develop tailored reports). The final rule makes no improvements in this regard. In fact, the final rule states at page 4 that although commenters requested that qualified entities be able to use the Medicare data for other purposes, in CMS‘ view, the Affordable Care Act bars the re-use of Medicare claims data for purposes other than the performance reports on providers and suppliers. The final rule provides that Medicare data cannot be used for any purpose other than to produce the prototype reports that have been previously approved by CMS.
Program costs and resource investment. The three years of data would cost approximately $104, 000. Note this does not encompass any cost associated with formatting the data for WHIO use.
Obtaining Data. CMS estimates that it would cost $40, 000 for the first year of the program and $32, 000 for each subsequent year of the program (down from an estimated $200, 000 per year in the proposed rule).
Formatting data and creating reports. We anticipate, based on the rule, that the data will need to be formatted from CMS format to WHIO format. CMS estimates that the QE will spend 5, 500 hours processing the data and creating reports.
Applications. CMS estimates that the initial application process will take each applicant an average of 500 hours per applicant at an estimated cost of $23, 102. Re-application is estimated to take 120 hours at a cost of $5, 544.
Monitoring Reports. CMS requires that QEs submit annual reports to CMS as part of CMS‘ ongoing monitoring of qualified entity activities. The total estimated burden associated with this requirement is 150 hours at $6, 819.
Financing mechanisms. CMS states in the final rule that QEs may not charge providers or suppliers for the confidential copies of the pre-publication reports that QEs are required to provide in advance of publication. QEs must make the required public reports available free of charge.
Rigidity of the requirements relating to submitting and updating prototype reports. WHIO had expressed concerns that the requirements relating to specifying the measures set in the prototype report and CMS approval for subsequent changes to measures sets was too rigid. Although the final rule contains some minor modifications, we believe the final rule maintains the basic problem of a rigid structure that would inhibit the APCD‘s ability to rapidly respond to the evolving needs of health care providers.
Provider review prior to public release of report. The final rule maintains the requirement from the proposed rule that providers and suppliers be afforded an opportunity to review the QE‘s measures, methodologies, and results at least 60 days before the report is made public. A QE must allow providers and suppliers the opportunity to request the data or request error corrections within a specific timeframe. CMS requires that the measures be publicly reported on the stated date whether or not appeals have been resolved.
CMS estimates 5, 000 hours for handling provider appeals for data or measurement correction in year 1.
Data Use Agreement (DUA). CMS indicates that it will use the current research data use agreement (DUA) for this program but will use the "addendum feature" provided in that DUA to address the specific needs of the Medicare data sharing program. We remain concerned that this DUA will not be flexible enough to accommodate the business needs of APCDs.
Areas of Improvement or Change from Proposed Rule
Beneficiary Crosswalk. In the proposed rule, CMS considered potential options for sharing beneficiary identifiers with qualified entities. CMS acknowledges the need for qualified entities to match private payer claims data and Medicare claims data for the same patient. In the final rule, CMS states that it will adopt the policy of automatically releasing a crosswalk file with appropriate privacy and security protections linking the encrypted ID to both the beneficiary name and the beneficiary Medicare HICN to all qualified entities. This is minimally sufficient but better than none at all.
Timeliness of data. CMS proposed providing QEs with the most recent three calendar years of Medicare data available at the time the QE is approved for participation in the program. WHIO commented that data must be much timelier in order to be useful. CMS amends its proposal to make more timely data available to QEs. CMS will provide the most recent available historical data. For QEs approved at the beginning of the program, CMS expects this to include CY 2009, CY 2010 and the first two quarters of 2011. CMS will provide quarterly data updates on a rolling basis.
Availability of nationwide data set. CMS clarifies in the final rule that nationwide data access would be provided as long as the QE can produce a sufficient data set from other claims sources.
Application deadline. In its comments, WHIO had expressed concerns about the feasibility of a March 31, 2012 application deadline. In the final rule, CMS changes this requirement and implements a rolling, electronic application process.
Provider matching. Provider matching will be possible via the NPI. This will be less effective on older data but improve over time.
Practical Considerations for WHIO Business Model
WHIO (the QE) will need to produce the reports and share them publicly (with everyone - not just members). It may be possible to somehow apply jointly as a QE with all WHIO members and subscribers listed as contractors for reporting purposes however I do not think this is within the spirit of the rules.
Any organization currently working with a physical copy of the data set (WMS or Thedacare for example) could not receive a copy of the data mart that included Medicare claims. It would seem inadvisable (cost wise as well as administratively) and confusing to have multiple versions of the data mart in distribution.
Member matching and provider matching will not be as high quality when incorporating the Medicare data as we currently achieve with Commercial and Medicaid data because the amount of individually identifiable information about each beneficiary or provided is limited.
Public reports can be used to design payment reform initiatives or tiered networks, if we obtain approval for and develop the right set of public reports.
It seems there is much more to be done with CMS if this data will be meaningful to anyone let alone individual patients.Read the CMS release from December 5th below.
John S. Toussaint, MD
President and CEO, ThedaCare Center for Healthcare Value