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New Rule Means Greater Health Care Transparency

by EINSURANCE

Let’s say you need a medical procedure that requires a specialist. How do you find one? Most of us rely on a recommendation from our primary-care doctor, family member or friends and hope for the best. But what
if you had access to one of the world’s richest sources of health insurance claims information? This week, the Centers for Medicare & Medicaid Services (CMS) announced a final ruling that will give broader access to its extensive Medicare claims database. The information in those records is a treasure trove containing data-rich performance reports on every doctor and hospital serving America’s 48 million Medicare
beneficiaries (and that’s just about every doctor and hospital in the country).

According to a press release from acting CMS Administrator Marilyn Tavenner, “This is a giant step forward in making our health care system more transparent and promoting increased competition,
accountability, quality and lower costs.” Tavenner added that the ruling will “ensure consumers have the access they deserve to information that will help them receive the highest quality care for
their dollar.”

We’re all for that, but don’t expect to see folks tweeting report cards about your local cardiologist anytime soon. The information will cost around $40,000, will only be released once a year, and access will be limited to “qualified organizations.” In a December 8 article, the Wall Street Journal reported that the CMS estimates there are about 25 of these qualified organizations nationwide, comprised of community groups made up of doctors, health insurance companies, businesses and consumer groups.

Even at the hefty price tag, Medicare expects plenty of people to jump on the opportunity, and we, the consumers of health care, are sure to benefit. Up till now, this kind of performance data came piecemeal from private insurance companies and focused on primary care physicians. The release of the Medicare data adds specialists to the mix. By extracting Medicare claims data for Parts A, B and D, for providers and suppliers, and combining it with other data sources, we’ll have a much broader and deeper evaluation platform that allows us to compare physicians apples-to-apple on specific procedures. Ultimately, the data could help identify which doctors and hospital provide the best care at the best price.

The rule includes privacy and security requirements, along with penalties for violations that will maintain the anonymity of patients and protect against misuse of the data. To address the American Medical Association’s long-standing objection to the release of this data, CMS has put in place reasonable safeguards to make sure any evaluations are accurate. Individual health care providers will have the right to see the information before it goes public and 60 days to challenge any of the content.

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