CMS to Make Medicare Info on Quality,
Cost of Health Care Providers Available
Affordable Care Act opens opportunity
for public to select better care and lower cost
June 9, 2011 -
New rules have been proposed by the Centers for Medicare & Medicaid
Services to make available to U.S. consumers and employers information
generated by Medicare that will enable them to select higher-quality,
lower-cost physicians, hospitals and other health care providers in
their area. The proposal and request for comments were published
yesterday in the Federal Register.
The new rules
will allow organizations that meet certain qualifications access to
patient-protected Medicare data to produce public reports on physicians,
hospitals and other health care providers. These reports will combine
private sector claims data with Medicare claims data to identify which
hospitals and doctors provide the highest quality, cost-effective care.
is part of a broader effort by the Obama Administration, made possible
by the Affordable Care Act, to improve care and lower costs.
Medicare data available can make it easier for employers and consumers
to make smart decisions about their health care,” said CMS Administrator
Donald M. Berwick, MD.
reports that include Medicare data will result in higher quality and
more cost effective care. And making our health care system more
transparent promotes competition and drives costs down.”
For many years
employers, consumers, providers, and quality measurement organizations
have been frustrated with the limited and piecemeal availability of
health care claims data. This has led many health plans to create
provider performance reports based solely on the health plan’s own
claims, which often represent only a small proportion of a provider’s
receive multiple, sometimes contradictory, reports from different
insurers. Often, providers are unable to appeal or correct what they
perceive to be inaccurate results in these reports. These factors
sometimes lead to reports that neither providers nor consumers feel they
These rules seek
to change the quality measurement landscape in a way that increases
transparency for all stakeholders, according to CMS.
entities” that have the capacity to process the data accurately and
safely would be required to combine the Medicare claims provided by CMS
with private sector claims data, to produce quality reports that are
more representative of how providers and suppliers are performing. The
reports will help employers and consumers understand more about the
relative performance of physicians and other providers in their area. In
addition, these rules include strict privacy and security requirements
for entities handling Medicare claims data.
CMS says this new
program would provide for the following activities:
● CMS would
provide standardized extracts of Medicare claims data from Parts A, B,
and D to qualified entities. The data can only be used to evaluate
provider and supplier performance and to generate public reports
detailing the results.
● The data
provided to the qualified entity will cover one or more specified
qualified entity would pay a fee that covers CMS’ cost of making the
● To receive
the Medicare claims data, qualified entities would need to have claims
data from other sources. Combining claims data from multiple sources
creates a more complete and accurate picture about provider and supplier
reporting the results calculated by the qualified entity is important
for transparency in health care and consumer empowerment. To prevent
mistakes, qualified entities must share the reports confidentially with
providers and suppliers prior to their public release. This gives
providers and suppliers an opportunity to review the reports and provide
released reports would contain aggregated information only, meaning that
no individual patient/beneficiary data would be shared or be available.
● During the
application process, qualified entities would need to demonstrate their
capabilities to govern the access, use, and security of Medicare claims
data. Qualified entities would be subject to strict security and privacy
● CMS would
continually monitor qualified entities, and entities that do not follow
these procedures risk sanctions, including termination from the program.
encouraged by CMS on this set of proposed rules.
CMS released the
following statement with the news released on the rules.
rules are the next step in our effort to improve health care quality and
ensure consumers have access to the best available information, using
important new tools provided by the Affordable Care Act.
Value-Based Purchasing initiative will reward hospitals for the quality
of care they provide to people with Medicare and help reduce health care
costs. This initiative will be based on quality measures that hospitals
have been reporting to the Hospital Inpatient Quality Reporting Program
since 2004, and that information is posted on the
Hospital Compare website.
for Patients is bringing together hospitals, doctors, nurses,
pharmacists, employers, unions, and state and federal government
committed to keeping patients from getting injured or sicker in the
health care system and improving transitions between care settings.
“CMS will invest
up to $1 billion to help drive these changes. In addition, proposed
rules allowing Medicare to pay new Accountable Care Organizations (ACOs)
to improve coordination of patient care are also expected to result in
better care and lower costs. This proposed rule will complement the
overall effort by the Obama Administration to improve quality, lower
costs, and improve health by providing consumers and employers a more
accurate picture of provider and supplier performance.
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