Interactive Tool Allows Easier Access Data on Physicians

Author: Niall Brennan, Acting Director, Offices of Enterprise Management

Today, the Centers for Medicare & Medicaid Services (CMS) released a new interactive search tool that can help consumers and other stakeholders navigate information about the types of medical services and procedures delivered by physicians and other healthcare professionals. Users can search for a provider by name, address, or National Provider Identifier (NPI). Once a user selects a provider, the tool returns information about the services the provider furnished to Medicare beneficiaries, including the number of services provided, the number of beneficiaries treated, and the average payment and charges for such services.

This new look-up tool makes it easier to use the large data set about physician information that CMS released on April 9, 2014 to look up specific providers. As with the data set, the look-up tool does not include information for cases where a provider administered a particular service 10 or fewer times to ensure the confidentiality of patients’ personal information. In addition, the information in the look-up tool only reflects the services provided to Medicare fee-for-service beneficiaries and does not include measurements of the quality of care provided by a provider.

The release of this data set provides unprecedented access to information on the types of services physicians and other healthcare professionals deliver under the Medicare program. Within the first week of posting the data, more than 150,000 users downloaded the data, and the CMS website where the data is posted had nearly 250,000 page views.

This is the next step in our effort to provide useful, privacy-protected data to improve transparency as well as the quality and affordability of health care in this country.

Historic release of data delivers unprecedented transparency on the medical services physicians provide and how much they are paid

By Jonathan Blum, Principal Deputy Administrator, Centers for Medicare & Medicaid Services

Today the Centers for Medicare & Medicaid Services (CMS) took a major step forward in making Medicare data more transparent and accessible, while maintaining the privacy of beneficiaries, by announcing the release of new data on medical services and procedures furnished to Medicare fee-for-service beneficiaries by physicians and other healthcare professionals (http://www.cms.gov/newsroom/newsroom-center.html). For too long, the only information on physicians readily available to consumers was physician name, address and phone number. This data will, for the first time, provide a better picture of how physicians practice in the Medicare program.

This new data set includes over nine million rows of data on more than 880,000 physicians and other healthcare professionals in all 50 states, DC and Puerto Rico providing care to Medicare beneficiaries in 2012. The data set presents key information on the provision of services by physicians and how much they are paid for those services, and is organized by provider (National Provider Identifier or NPI), type of service (Healthcare Common Procedure Coding System, or HCPCS) code, and whether the service was performed in a facility or office setting. This public data set includes the number of services, average submitted charges, average allowed amount, average Medicare payment, and a count of unique beneficiaries treated. CMS takes beneficiary privacy very seriously and we will protect patient-identifiable information by redacting any data in cases where it includes fewer than 11 beneficiaries.

Previously, CMS could not release this information due to a permanent injunction issued by a court in 1979. However, in May 2013, the court vacated this injunction, causing a series of events that has led CMS to be able to make this information available for the first time.

Data to Fuel Research and Innovation

In addition to the public data release, CMS is making slight modifications to the process to request CMS data for research purposes. This will allow researchers to conduct important research at the physician level. As with the public release of information described above, CMS will continue to prohibit the release of patient-identifiable information. For more information about CMS’s disclosures to researchers, please contact the Research Data Assistance Center (ResDAC) at http://www.resdac.org/.

Unprecedented Data Access

This data release follows other CMS efforts to make more data available to the public. Since 2010, the agency has released an unprecedented amount of aggregated data in machine-readable form, with much of it available at http://www.healthdata.gov. These data range from previously unpublished statistics on Medicare spending, utilization, and quality at the state, hospital referral region, and county level, to detailed information on the quality performance of hospitals, nursing homes, and other providers.

In May 2013, CMS released information on the average charges for the 100 most common inpatient services at more than 3,000 hospitals nationwide http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Inpatient.html.

In June 2013, CMS released average charges for 30 selected outpatient procedures http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Outpatient.html.

We will continue to work toward harnessing the power of data to promote quality and value, and improve the health of our seniors and persons with disabilities.

Next steps in Medicare data transparency

By Jonathan Blum, Principal Deputy Administrator, Centers for Medicare & Medicaid Services

In letters to the American Medical Association and Florida Medical Association http://downloads.cms.gov/files/Madara_Final_Signed.pdf, the Centers for Medicare & Medicaid Services (CMS) announced our intent today to take another major step forward in making our health care system more transparent and accountable. We plan to provide the public unprecedented access to information about the number and type of health care services that individual physicians and certain other health care professionals delivered in 2012, and the amount Medicare paid them for those services, beginning not earlier than April 9. Providing consumers with this information will help them make more informed choices about the care they receive.

The new data provides a better picture of how physicians practice in the Medicare program, and the payments they receive. This data contains information on more than 880,000 health care professionals in all 50 states who collectively received $77 billion in payments in 2012 for services delivered to beneficiaries under the Medicare Part B Fee-For-Service program. With this data, it will be possible to conduct a wide range of analyses that compare 6,000 different types of services and procedures provided, as well as payments received by individual health care providers.

CMS takes beneficiary privacy very seriously, and does not publicly release any personally-identifiable information about beneficiaries. To further protect beneficiary identities and safeguard this information in this new data, CMS will redact all data in cases where it includes fewer than 11 beneficiaries.

Data like these can shine a light on how care is delivered in the Medicare program. They can help consumers compare the services provided and payments received by individual health care providers. Businesses and consumers alike can use these data to drive decision-making and reward quality, cost-effective care. We look forward to describing how this information can inform consumers and health care providers when we release this data in the near future.

The new data initiative builds on the work we did last year to release information on charges submitted to Medicare by individual hospitals (http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Inpatient.html   and http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Outpatient.html).

The initiative announced today, as well as the previously released hospital data, build on the powerful tools we have from the Affordable Care Act to advance transparency in the health care system. For example, Medicare is beginning to pay providers based on the quality they deliver rather than just the quantity of services they furnish by implementing new programs such as value-based purchasing and readmissions reductions. In addition, last year, CMS made approximately $87 million available to states to enhance their rate review programs and further health care pricing transparency.

While we have made significant progress in making the health care system more open and accountable, we look forward to making this important, new information available so that consumers, Medicare and other payers can get the best value for their health care dollar.

Increasing Transparency in Health Care with Open Payments

By Ted Doolittle, Deputy Director, CMS Center for Program Integrity
At the Centers for Medicare & Medicaid Services, we are committed to transparency. Thanks to the Affordable Care Act, we have powerful new tools to advance transparency in health care and provide consumers with the information necessary to make informed choices. I’m pleased to share today the latest steps we are taking to bring accountability to health care under our national Open Payments program (commonly known as the Physician Payments Sunshine Act).
This program is designed to increase public awareness of financial relationships between drug and device manufacturers, group purchasing organizations (GPOs) and certain health care providers. Patients should know when their doctors have a financial relationship with health care facilities and companies that make or supply medicines or medical devices they may need. Disclosing these relationships allows patients to have more informed discussions with their doctors about the care they receive.
On February 18, some of these organizations will begin to submit data to CMS on payments made to health care providers, including gifts, consulting fees and research activities. This date marks the first of two phases of data submission implementation under the Open Payments program. Later, in May of this year, manufacturers will complete the second phase by submitting additional, detailed payment information. We believe that this approach helps to ensure the accuracy of the data collected, and provides the time organizations need to make their submissions, particularly those with large data files.
Once CMS completes the two phases of data submission, health care providers and manufacturers will have an opportunity to review and correct inaccuracies. CMS will then post the data on our website by September 30. We are also collecting and posting information on physician ownership or investment interests in manufacturers and group purchasing organizations.
Through the Open Payments program, the combined efforts of CMS, participating health care providers and other stakeholders are building on current efforts to improve health care quality by increasing transparency and accountability in our health care system.

Medicare’s delivery system reform initiatives achieve significant savings and quality improvements – off to a strong start

The Affordable Care Act is providing millions of Americans with access to quality, affordable health coverage—many for the very first time. But fixing America’s health care system means making health care affordable and high quality, as well as accessible.

Results we’ve released today show the progress we’ve made on slowing the rise in health care spending—bending the cost curve—while improving health care quality.

One of the key reforms in the Affordable Care Act is creating Accountable Care Organizations (ACOs). ACOs, are groups of doctors, hospitals, and other health care providers that have agreed to work together to give their Medicare patients better coordinated, high quality care. To the extent that they succeed in providing more effective and efficient care, they can share in the savings to the Medicare program. Interim financial results for 114 ACOs that began work in 2012 show that they generated $128 million in savings for the Medicare trust fund in the first year —while maintaining high quality patient care.

Additionally, initial results from an independent evaluation of 23 Pioneer ACOs, which are those that have more experience with coordinated care, show that they saved the Medicare program $147 million in their first year of operation.

ACOs are helping to improve the quality of health care and, in doing so, lowering costs for taxpayers and patients. While still early in the program, with some ACOs making greater progress than others, the $275 million in savings—and the high quality of care that has accompanied it—are admirable results. ACOs are designed to achieve savings over several years, not always on an annual basis, but this is a very strong start. Moreover, through regular webinars; tools for sharing information and best practices; opportunities for ACOs to connect with one another; and other activities, we’re providing ACOs the infrastructure and resources to learn from one another and to then diffuse what’s working and what’s not.

Delivery system reform takes time, but ACO’s are committed to the program. Dr. Kenneth W. Wilkins, President of Coastal Carolina Health Care said that “Our experience has shown that ACOs can increase quality while lowering costs. As a result of the programs we’ve initiated, our patients have experienced better access to their primary care physician, higher quality measures, and fewer trips to the hospital. We look forward to making continued progress and seeing future results.”

Additionally, as part of the largest and most ambitious test ever of a bundled payment model in Medicare, or any other payer in the U.S., 232 provider groups, hospitals and others have agreed to participate in the Medicare Bundled Payments for Care Improvement initiative. Bundling payment for services that patients receive across a single episode of care, such as heart bypass surgery or a hip replacement—instead of making payments to providers for every single service—rewards the quality of care instead of the quantity of services, and encourages better care coordination.

Congress is also working on a bipartisan and bicameral basis to pass long-term legislation to reform Medicare’s current physician payment system and replace the Sustainable Growth Rate formula with a system that will reward value over volume—and enable more physicians to participate in new models of care that will reward improvements in patient care and total cost reduction. The results we’ve announced today provide strong evidence that these legislative proposals are the right direction for the Medicare program and our nation’s healthcare delivery system.

CMS Modifies Policy on Disclosure of Physician Payment Information

By: Jonathan Blum, Principal Deputy Administrator

Today the Centers for Medicare & Medicaid Services (CMS) took a step forward in making Medicare data more transparent and accessible, while maintaining the privacy of beneficiaries.  Today’s Federal Register notice modifies the administration’s policy on disclosure of physician payment information.  Going forward, CMS will evaluate requests for individual physician payment information (or requests for information that combined with other publicly available information could be used to determine total Medicare payments to a physician) on a case-by-case basis.  The new policy released today will take effect 60 days after publication in the Federal Register. In addition, CMS will generate and make available aggregate data sets regarding Medicare physician services for public consumption.

In making the decision to replace the prior policy, the agency considered the more than 130 comments representing the views of over 300 organizations and individuals we received (http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Downloads/PublicComments.pdf).  Numerous of these comments identified ample benefits to releasing Medicare physician payment data, including use of the data by:

  • Providers to collaborate on improved care management and the delivery of healthcare at lower costs;
  • Consumers to gain broader, more reliable measures of provider quality and performance which drives innovation and competition while informing consumer choice; and
  • Journalists and others to identify waste, fraud, and abuse as well as unsafe practices.

The decision to modify the policy also takes into account HHS’ strong commitment to greater data transparency over the past several years.  In 2010, HHS launched the Health Data Initiative to promote transparent, innovative, and safe data use.  As part of this effort, CMS has engaged with a wide range of public, non-profit, and private sector stakeholders to foster the availability and use of health care data to drive innovations that improve health and health care. 

Given the advantages of releasing information on Medicare payment to physicians and the agency’s commitment to data transparency, we believe replacing the prior policy with a new policy in which CMS will make case-by-case determinations is the best next step for the agency.  However, CMS also recognizes the valid concerns raised by many stakeholders over protecting the integrity of the data.  As CMS makes a determination about how and when to disclose any information on a physician’s Medicare payment, we intend to consider the importance of protecting physicians’ privacy and ensuring the accuracy of any data released as well as appropriate protections to limit potential misuse of the information.  And as always, we are committed to protecting the privacy of Medicare beneficiaries.

This policy change follows other CMS efforts to make more data available to the public.  Since 2010, the agency has released an unprecedented amount of aggregated data in machine-readable form, with much of it available at www.healthdata.gov.  These data range from previously unpublished statistics on Medicare spending, utilization, and quality at the state, hospital referral region, and county level, to detailed information on the quality performance of hospitals, nursing homes, and other providers. 

In May 2013, CMS released information on the average charges for the 100 most common inpatient services at more than 3,000 hospitals nationwide http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Inpatient.html.

In June 2013, CMS released average charges for 30 selected outpatient procedures http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Outpatient.html.

Combating fraud and abuse in the Medicare Prescription Drug Program

By Jonathan Blum, CMS Principal Deputy Administrator

The Centers for Medicare & Medicaid Services (CMS) takes prescription drug abuse very seriously and actively works to detect and prevent fraud and abuse in order to protect the Medicare program, its beneficiaries, and taxpayers.

The Medicare Part D prescription drug benefit provides prescription drug coverage to more than 39 million seniors. CMS strives to ensure that beneficiaries have the medications they need while at the same time is being vigilant to safeguard the program from inappropriate use. 

A centerpiece of our strategy to combat fraud and abuse in Medicare Part D is the identification of Part D enrollees who have potential opioid or acetaminophen overutilization issues that may present a threat to patient safety. Overutilization of opioids or acetaminophen products can result in serious adverse events or death. The Medicare Part D Overutilization Monitoring System was implemented in 2013 to help CMS ensure that Part D plan sponsors are meeting CMS requirements to establish reasonable and appropriate drug utilization management programs to prevent overutilization of these medications.  Comparing recent data with 2011 Part D data that pre-dates the implementation of the monitoring system shows that there has been a substantial reduction in the number of opioid and acetaminophen overutilizers in Medicare Part D.  In 2011, more than 172,000 Part D enrollees were identified as meeting CMS criteria for potential opioid or acetaminophen overutilization.  Between January and June 2013, the number of Part D enrollees with potential opioid or acetaminophen issues dropped to approximately 35,600 – a rate that would represent a reduction of nearly 60 percent if maintained throughout 2013.  

CMS also released a proposed rule today that seeks to employ new tools when problematic prescribers and pharmacies are identified. Some of the proposed key fraud and abuse provisions include:

  • ·       Requiring prescribers of Part D drugs to enroll in Medicare and revocation such enrollment in cases of abusive prescribing practices and patterns;
  • ·       Allowing CMS to request and collect information directly from pharmacy benefit managers, pharmacies and other entities that contract with Part D sponsors to better detect fraud; and
  • ·       Improving CMS’ ability to collect identified Medicare overpayments from MA plans and Part D sponsors.

Combined with our ongoing efforts, the fraud and abuse provisions in the proposed rule will ensure that Medicare beneficiaries have access to affordable prescription drugs while making certain that plans provide value to Medicare and taxpayers.

For more information about our efforts to combat fraud, waste and abuse in Medicare Part D, please visit: http://www.cms.gov/Newsroom/Newsroom-Center.html.

To read the proposed rule, please see: http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1. The proposed rule will be published in the Federal Register on January 10, 2014.  CMS will accept comments on the proposed rule until March 7, 2014. 

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