Medicare opens gigantic claims database to the public

Posted Dec. 05, 2011, at 7:47 p.m.

WASHINGTON — Picking a specialist for a delicate medical procedure such as a heart bypass could get a lot easier in the not-too-distant future.

The government announced Monday that Medicare will finally allow its extensive claims database to be used by employers, insurance companies and consumer groups to produce report cards on local doctors — and improve current ratings of hospitals.

In Maine, a state with one of the largest Medicare populations in the country, access to the data will play a critical role in understanding health care needs and patterns, said Elizabeth Mitchell, CEO of Maine Health Management Coalition in Portland.

“You can’t improve what you can’t measure,” she said. “This is one of the richest sources of data in the country.”

By analyzing billing records, experts can glean such critical information as how often a doctor has performed a particular procedure and get a general sense of problems such as preventable complications.

Doctors will be individually identifiable through the Medicare files, but personal data on their patients will remain confidential.

“There are a lot of safeguards put in place that [ensure] this will be used appropriately,” Mitchell said.

Compiled in an easily understood format and released to the public, medical report cards could become a powerful tool for promoting quality care.

“There is tremendous variation in how well doctors do, and most of us as patients don’t know that. We make our choices blind,” said David Lansky, president of the Pacific Business Group on Health. “This is the beginning of a process to give us the information to make informed decisions.” His nonprofit represents 50 large employers that provide coverage for more than 3 million people.

Medicare acting administrator Marilyn Tavenner called the new policy “a giant step forward in making our health care system more transparent and promoting increased competition, accountability, quality and lower costs.” But some consumer groups said Medicare is still putting limitations on their access.

Early efforts to rate physicians using limited private insurance data have thus far focused on primary care doctors, but Medicare’s rich information could provide the numbers to start rating specialists as well, Lansky said. Consumers will see the first performance reports by late 2012, said a Medicare spokesman.

Medicare officials say they expect nonprofit research groups in California, Minnesota, Wisconsin, Massachusetts and other states to jump at the chance to use the data. With 47 million beneficiaries and virtually every doctor and hospital in the country participating, Medicare’s database is considered the mother lode of health care information.

Tapping it has largely been forbidden because of a decades-old court ruling that releasing the information would violate the privacy of doctors. Insurance companies tried filling with their own claims data, but their files are nowhere near as comprehensive as Medicare’s.

Following appeals from lawmakers of both parties on Capitol Hill, President Barack Obama’s health care overhaul changed federal law to explicitly authorize release of the information. Medicare followed through in regulations issued Monday.

Employer groups welcomed the new policy.

“There is pent-up demand for this data because everyone wants to be a more informed, intelligent consumer, especially as health care costs are still rising,” said Maria Ghazal, policy director at the Business Roundtable, which represents CEOs of major companies providing coverage to some 35 million employees, retirees and family members.

Companies will use the data analyses in their annual updates to their insurance plans. But Ghazal said they also want to put report cards directly in the hands of their employees.

“We want to make it understandable and usable by our employees,” said Ghazal.

Early ratings efforts using insurance company data have lacked sufficient statistical power to rank specialists. The numbers of cases of cancer and serious heart problems in the younger, working-age population simply weren’t big enough. The Medicare data could change that, since older people are more prone to chronic illnesses.

“If you want to look at heart disease or cancer, suddenly you have more data to look at each doctor with,” said Lansky. “It’s the power of numbers.”

In Maine, long a leader in making claims data available, doctors are accustomed to such transparency, said Gordon Smith, executive vice president of the Maine Medical Association. While MMA would like to see doctors report more of their own data into the system, Medicare’s move to share its information mirrors what other payers in the state have done for some time, he said.

“This is where the system is evolving to, and we’ve been telling physicians for years that they need to know their own data and understand their own data,” Smith said.

Doctors groups fought for years to prevent release of the Medicare data. The American Medical Association argued it could be misleading to untrained consumers. For example, a surgeon who has lots of patients who develop complications may actually be a top practitioner who takes cases that others less skilled would turn away.

Lately the medical groups shifted to putting conditions on the use of the data, with some success. For example, Medicare’s rule gives individual providers the right to review their information before it is publicly released, and 60 days to challenge it.

Some consumer groups said that particular restriction will make it difficult for them to produce ratings. Unlike employer associations, they don’t have economic leverage over doctors.

Consumers Union’s Health Ratings Center is currently rating hospitals and some medical providers. But Lisa McGiffert, director of the group’s patient safety campaign, said Medicare’s review requirement may be too cumbersome for a group like hers.

“These kinds of caveats will lead to fewer users of the data, and fewer communicators to the public,” she said. “There’s this protectionism about doctors’ information that we need to get beyond.”

BDN health editor Jackie Farwell contributed to this story.

SEE COMMENTS →

ADVERTISEMENT | Grow your business
ADVERTISEMENT | Grow your business

Similar Articles

More in Health