Summary
Effective January 2012, authorizes HHS to provide standardized extracts of Medicare claims data by geographic area to public and private entities that meet certain criteria for provider performance evaluation purposes.
Implementation Status
On December 7, 2011, CMS published a Final Rule governing implementation of this provision. The Agency also released a fact sheet summarizing the contents of the rule.
In an August 6, 2013, blog post, CMS announced that it seeks public feedback through on or around 5pm EST on September 6 regarding ways the agency might consider moving forward on Medicare physician payment transparency efforts. Comments may be emailed to: Physician_Data_Comments@cms.hhs.gov. As noted in this post, CMS also announced that 4 additional qualified entities (QEs) will join the existing 7 designated QEs that are authorized to combine Medicare and private payer data for evaluative purposes. See here for details.
On September 5, 2014, CMS issued a notice announcing its request for an extension of an existing information collection pertaining to entities qualified to receive Medicare data for performance measurement pursuant to this provision of the ACA.
On July 1, 2016, CMS finalized a proposal expanding how qualified entities may use and disclose data under the qualified entity program to the extent consistent with applicable program requirements and other applicable laws, including information, privacy, security and disclosure laws.
On Oct. 14, 2016, CMS released a rulefinalizing requirements for implementing the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) incentive payment provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
Statutory Text
SEC. 10332. AVAILABILITY OF MEDICARE DATA FOR PERFORMANCE MEASUREMENT. (a) IN GENERAL.—Section 1874 of the Social Security Act (42 U.S.C. 1395kk) is amended by adding at the end the following new subsection: ‘‘(e) AVAILABILITY OF MEDICARE DATA.— ‘‘(1) IN GENERAL.—Subject to paragraph (4), the Secretary shall make available to qualified entities (as defined in paragraph (2)) data described in paragraph (3) for the evaluation of the performance of providers of services and suppliers. ‘‘(2) QUALIFIED ENTITIES.—For purposes of this subsection, the term ‘qualified entity’ means a public or private entity that—‘‘(A) is qualified (as determined by the Secretary) to use claims data to evaluate the performance of providers of services and suppliers on measures of quality, efficiency, effectiveness, and resource use; and ‘‘(B) agrees to meet the requirements described in paragraph (4) and meets such other requirements as the Secretary may specify, such as ensuring security of data. ‘‘(3) DATA DESCRIBED.—The data described in this paragraph are standardized extracts (as determined by the Secretary) of claims data under parts A, B, and D for items and services furnished under such parts for one or more specified geographic areas and time periods requested by a qualified entity. The Secretary shall take such actions as the Secretary deems necessary to protect the identity of individuals entitled to or enrolled for benefits under such parts. ‘‘(4) REQUIREMENTS.— ‘‘(A) FEE.—Data described in paragraph (3) shall be made available to a qualified entity under this subsection at a fee equal to the cost of making such data available. Any fee collected pursuant to the preceding sentence shall be deposited into the Federal Supplementary Medical Insurance Trust Fund under section 1841. ‘‘(B) SPECIFICATION OF USES AND METHODOLOGIES.—A qualified entity requesting data under this subsection shall— ‘‘(i) submit to the Secretary a description of the methodologies that such qualified entity will use to evaluate the performance of providers of services and suppliers using such data; ‘‘(ii)(I) except as provided in subclause (II), if available, use standard measures, such as measures endorsed by the entity with a contract under section 1890(a) and measures developed pursuant to section 931 of the Public Health Service Act; or ‘‘(II) use alternative measures if the Secretary, in consultation with appropriate stakeholders, determines that use of such alternative measures would be more valid, reliable, responsive to consumer preferences, cost-effective, or relevant to dimensions of quality and resource use not addressed by such standard measures; ‘‘(iii) include data made available under this subsection with claims data from sources other than claims data under this title in the evaluation of performance of providers of services and suppliers; ‘‘(iv) only include information on the evaluation of performance of providers and suppliers in reports described in subparagraph (C); ‘‘(v) make available to providers of services and suppliers, upon their request, data made available under this subsection; and ‘‘(vi) prior to their release, submit to the Secretary the format of reports under subparagraph (C). ‘‘(C) REPORTS.—Any report by a qualified entity evaluating the performance of providers of services and suppliers using data made available under this subsection shall— ‘‘(i) include an understandable description of the measures, which shall include quality measures and the rationale for use of other measures described in subparagraph (B)(ii)(II), risk adjustment methods, physician attribution methods, other applicable methods, data specifications and limitations, and the sponsors, so that consumers, providers of services and suppliers, health plans, researchers, and other stakeholders can assess such reports; ‘‘(ii) be made available confidentially, to any provider of services or supplier to be identified in such report, prior to the public release of such report, and provide an opportunity to appeal and correct errors; ‘‘(iii) only include information on a provider of services or supplier in an aggregate form as determined appropriate by the Secretary; and ‘‘(iv) except as described in clause (ii), be made available to the public. ‘‘(D) APPROVAL AND LIMITATION OF USES.—The Secretary shall not make data described in paragraph (3) available to a qualified entity unless the qualified entity agrees to release the information on the evaluation of performance of providers of services and suppliers. Such entity shall only use such data, and information derived from such evaluation, for the reports under subparagraph (C). Data released to a qualified entity under this subsection shall not be subject to discovery or admission as evidence in judicial or administrative proceedings without consent of the applicable provider of services or supplier.’’. (b) EFFECTIVE DATE.—The amendment made by subsection (a) shall take effect on January 1, 2012.