Dec 14, 2011
Authors: Ian Spatz | Ariana Ornelas | Wendy L. Krasner
On December 5, 2011, the Centers for Medicare & Medicaid Services (CMS) released a Final Rule to implement a provision of the Affordable Care Act (“ACA”) giving qualified entities access to Medicare claims data for use in evaluating the performance of health care providers.
This Final Rule incorporates changes based on public comments to the Notice of Proposed Rulemaking (“NPRM”) published on June 8, 2011. In our report on the NPRM we described how the rule sets forth guidelines on how an organization that meets extensive qualification requirements may pay an annual fee to access patient-level Medicare Parts A, B, and D data. These entities will combine Medicare data with private-sector claims data that they already have access to in order to prepare public reports measuring the performance of physicians, other providers, and suppliers. The goal is to help consumers and payers make informed decisions about their health care by selecting the highest-quality providers in their areas.
The following update highlights the key changes between the NPRM and the Final Rule released by CMS and presents key takeaways from the Final Rule.
What Are the Key Changes and Additions in the Final Rule?
Eligibility Process for Qualifying EntitiesAs we described in our earlier report, in order to be eligible to receive Medicare Parts A, B, and D data for purposes of measuring provider and supplier performance, an entity must meet specific criteria, including: (1) ability to prove it can keep the data secure; (2) access to at least one other source of non-Medicare commercial payer data; (3) ability to produce accurate performance reports; and (4) development of a review and grievance procedure for providers.
Key Changes and/or Additions
Standard and Alternative Quality MeasuresQualifying entities must use a standard performance measure or an approved alternative measure. The NPRM defined a “standard measure” as one that can be calculated using only claims data and that is endorsed by the National Quality Forum. Standard measures also included any claims-based measure of provider performance that has been adopted through rulemaking and that is currently used in a CMS program that involves performance measurement.
As formerly proposed and retained by the Final Rule, an entity may suggest use of an “approved alternative measure” for evaluating performance even if a standard measure already exists. Public comment may be sought by CMS through notice and comment rulemaking, so it may determine if the alternative measure is more valid, reliable, and responsive to consumer preferences.
Dissemination of Medicare Data By CMSThe NPRM sought comment on whether Medicare claims data should be released to qualified entities on both a regional and national basis. CMS proposed releasing nationwide claims data only if a qualified entity reached a particular threshold of non-Medicare data to match with the Medicare data released. The NPRM also sought comment on how to improve efficiency and timeliness in release of such data to qualified entities for use in performance evaluation.
Provider Grievance ProceduresThe NPRM emphasizes the importance of the establishment of a confidential review and grievance procedure by the qualifying entity to allow providers and suppliers to review reports, measurement methodologies, and the actual data relied upon, prior to publication of measure reports. This ensures an opportunity to correct measurement errors where necessary and a greater degree of accuracy and consistency.
How Does the Final Rule Improve Upon the Existing Landscape for Provider Performance Appraisal?
What Are Potential Pitfalls and Questions Left Unanswered by the Final Rule?
The Final Rule is available here.
For more information please call: Ian - 202.556.1234, Wendy - 202.585.6548 orAriana - 212.790.4506
Helen R. PfisterPartner
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