Overview:
Health care policy experts believe that measuring and publicly reporting information about the performance of physicians and hospitals will be critical in improving the quality of care Americans receive while reining in costs. Community-based organizations around the country, such as those in the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative, are demonstrating the concept using private medical claims data. They would like to use Medicare claims data, too — a vast pool of information about how health care is being delivered in America, which, if combined with private data, could facilitate more accurate measurement of providers’ performance and better public reports to empower consumers and spur improvements in quality.
Congress is currently considering a number of policy measures to improve quality. Most of these measures would give the Centers for Medicare & Medicaid Services (CMS) new or expanded demonstration authority to test various provider performance measurement, delivery system and payment reform models. However, the Senate bill, as passed on December 24, 2009, also includes a specific provision further authorizing the release of Medicare claims data to “qualified entities.” Those entities could use the released information to evaluate and even report on provider performance.1 If this provision became law and depending on its implementation, it could potentially allow community-based organizations like those in Aligning Forces to use Medicare claims data for performance measurement, public reporting and quality improvement activities.
A separate but related question pertains to existing data release authority. Under current rulemaking authority, what kinds of things could the administration do to allow greater release of Medicare data to use for measurement, reporting and improvement? This brief concludes that under current law, CMS has the ability to adopt policies allowing for the release of Medicare claims data for research projects and demonstrations with community organizations that meet standards specified by CMS, including capacity to ensure data security and to safeguard patients’ privacy.
Indeed, under its current authority, CMS has developed a number of initiatives involving the release of Medicare data for quality improvement purposes. For example, CMS has moved in recent years — albeit carefully and incrementally — to release Medicare claims data to improve quality and increase efficiency at the physician-practice level.
A series of federal laws govern the release of Medicare data by CMS, including the Social Security Act (SSA), the Health Insurance Portability and Accountability Act (HIPAA), the Privacy Act of 1974, and the Federal Information Security Management Act (FISMA). This brief outlines the relevant provisions of all these and then summarizes current CMS initiatives aimed at promoting broader release of performance data on physicians and other health care providers. It concludes with a discussion of how existing CMS authority can be used to expand access to Medicare data for community-based research or demonstration projects.
Our analysis does not address changes in CMS funding, staffing, oversight or administrative practices that inevitably would be required to facilitate more widespread release of timely Medicare data for ongoing community-based initiatives. Our recommendations merely build on CMS’ considerable advances to date and are designed to deal with the threshold legal questions that arise in this type of information-driven reform.
Author(s):
Jane Hyatt Thorpe, Erica Pereira, Sara Rosenbaum
Contacts:
Jane Hyatt Thorpe, School of Public Health and Health Services, Department of Health Policy
Erica Pereira, School of Public Health and Health Services, Department of Health Policy
Sara Rosenbaum, School of Public Health and Health Services, Department of Health Policy
Citation:
Pereira, E, Rosenbaum S., and Thorpe, J., Releasing Medicare Claims Data to Support Quality Improvement Initiatives: Legal Barriers and Opportunities, March 2010.
