government

Medicare doctor pay data release could be in next SGR bill

Senators want more payment transparency in Medicare, including publicizing how much physicians are paid for treating beneficiaries.

By Charles Fiegl — Posted July 1, 2013

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Price transparency and public disclosure of Medicare payments to physicians are goals some lawmakers hope to achieve in legislation that prevents upcoming rate reductions under the program’s pay system.

The Senate Finance Committee held a June 18 hearing centered on the recent Time magazine article “Bitter Pill: Why Medical Bills are Killing Us” by investigative journalist Steven Brill. The story detailed the prices facilities charge for inpatient services, and how uninsured or underinsured Americans can get stuck paying rates much higher than those with full medical coverage.

After the Time article, the Centers for Medicare & Medicaid Services released charge data for common services and procedures billed by hospitals and outpatient facilities. Many observers applauded the agency for the move, but other health policy officials have questioned the usefulness of the information. Hospitals are paid much lower rates by payers, so publicizing charges offers limited insight on the true cost or quality of care provided.

However, Finance Committee Chair Max Baucus (D, Mont.) complimented CMS for taking steps to increase openness in the health system. “We need to build on this and take a comprehensive look at transparency from the perspective of the consumer,” he said.

Sens. Ron Wyden (D, Ore.) and Charles Grassley (R, Iowa) have introduced legislation that would order Medicare to offer a searchable database of claims information for physician and other covered services. The bill also would require that Medicare payments to physicians and health professionals not be exempt from Freedom of Information Act laws.

During the June 18 hearing, Wyden said he would work to include his bill in legislation that would override the 25% sustainable growth rate cut scheduled for 2014.

“If doctors know that each claim they make will be publicly available, it might deter some wasteful practices and overbilling,” Grassley said. “Our bill accomplishes this by requiring the secretary of Health and Human Services to make available a searchable Medicare payment database that the public can access at no cost.”

Usefulness of data questioned

The American Medical Association is among the organizations questioning how useful releasing billing information in such a way would be.

“The AMA supports transparency that provides accurate health care information for patients, as well as timely, clinically relevant data to help physicians provide high-quality, high-value care,” said AMA President Ardis Dee Hoven, MD. “We are concerned that the public dissemination of raw Medicare claims data, which does not provide patients with helpful information on quality measures or treatment options, can be misleading. We will closely review the proposed legislation and urge the sponsors to adopt safeguards that help support informed health care decision-making.”

The four-page bill would accomplish a goal of lowering prices for consumers, said Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change and research director of the National Institute for Health Care Reform. Policy goals should aim to lower prices for patients, he said, but he also told the senators that many policy initiatives to increase transparency often miss the mark.

For instance, recent releases of Medicare price data offer awareness on price disparities throughout different areas of the country and varying charges for a service within a market. However, this alone does not achieve the goal of lowering prices, because billed charges have little relationship to the prices that actually are paid on behalf of virtually all patients, Ginsburg said.

The best opportunity to lower costs is through insurers and employers, he added. They are best positioned to assess physician efficiency and quality of care.

“I believe the greatest potential for obtaining lower prices comes from approaches where purchasers and health plans, rather than reporting prices to enrollees, analyze the complex data on cost and quality and provide simple incentives for enrollees to choose higher value providers,” Ginsburg said.

Giving the data to insurers, especially smaller health plans, would make insurance markets more competitive, he said.

Medicare numbers readily available

Congress and the Obama administration already have taken steps to open the Medicare billing database. The Affordable Care Act required standardized extracts of Medicare claims data to evaluate the performance of physicians and others treating beneficiaries.

In November 2012, CMS announced three qualified entities that will obtain Medicare billing data and develop reports on spending for physician services, hospital care and drugs. The groups — the Oregon Health Care Quality Corp., the Health Collaborative of Greater Cincinnati and the Kansas City Quality Improvement Consortium — are required to analyze the Medicare-specific information, along with data from other insurers, to produce reports for the public.

CMS since has allowed four additional groups to access Medicare data. They are the Maine Health Management Coalition Foundation, HealthInsight New Mexico, the California Healthcare Performance Information System and the Pittsburgh Regional Health Initiative.

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External links

Qualified Entity Program, Centers for Medicare & Medicaid Services (link)

“Bitter Pill: Why Medical Bills are Killing Us,” Time, March 4 (link)

“High Prices, Low Transparency: The Bitter Pill of Health Care Costs,” Senate Finance Committee, June 18 (link)

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