- In a recent letter to CMS Acting Administrator Andy Slavitt, the American Hospital Association detailed several recommendations related to the proposed rule expanding the uses of Medicare claims data under the Qualified Entity (QE) Program.
The CMS proposed rule allows QEs to sell claims data analysis from Medicare and private insurers. Under the new rule, QEs may create and sell non-public analyses to authorized users, including providers, suppliers, employers, health insurance issuers, and hospital associations.
The QE program was established under the Affordable Care Act and grants eligible organizations access to patient-protected Medicare data. QEs use Medicare and private insurer claims data to produce quality reports. They can also supply Medicare data or combined Medicare and private insurer data at no cost to authorized users.
AHA supports the expansion of Medicare data use by QEs, but AHA Executive Vice President Tom Nickels gives CMS eight suggestions for enhancing the proposed rule.
Publicize Medicare claims datasets
AHA encourages CMS to require each QE to publicize the list of Medicare claims datasets and the datasets it intends to combine.
In order to increase the transparency of the data sharing program, the public list of claims datasets should include a description of the dataset, source, time period, geography or region, estimated number of beneficiaries included, and the quality measures and measure methodology of the report.
Expand the amount of available data
CMS should require a health insurance issuer to provide the QE with data on all covered individuals in the geographic region during the time period of the non-public analyses before a QE can supply or sell information.
CMS proposes that health insurers only provide 50 percent of covered individuals.
“Granting the QE access to 100 percent of the issuer’s covered lives in the same region and during the time period for which the analyses are requested would allow for a more complete analysis of the beneficiaries using the combined data and allow for better care coordination and quality assessment and improvement activities based on these analyses,” the letter explains.
Redefine the meaning of the “patient”
CMS currently defines a patient as “an individual ‘who has visited the provider or supplier for a face-to-face or telehealth appointment at least once in the past 12 months,’” Nickels says.
But he proposes that a patient should be defined as an individual who has seen the provider or supplier in person or in a telehealth appointment during the time period in which the analysis is taking place.
Give business associates access to claims data
Nickels urges CMS to add business associates to the list of entities who can link “combined data, Medicare-only data, and/or non-public analyses that contain patient identifiable data and/or any derivative data to any other identifiable source of information.”
The CMS proposed rule requires QEs to prohibit the downstream recipients from linking the combined data, except for the data on their own patients, in the data use agreement between the QE and authorized user. CMS acknowledges that it cannot legally enforce requirements on authorized users, but it can impose restrictions on the QE agreements.
Expand the definition of “hospital association”
CMS defines a hospital association as “a nonprofit organization or association that provides unified representation and advocacy for hospitals or health systems at a national or state level and whose membership is comprised of a majority of hospitals and health systems,” the letter states.
While CMS added hospital associations as an authorizer user, the AHA suggests that CMS expand its definition to include the local level of association.
The definition should also include “any affiliated entities” of hospital or health systems, AHA says.
“There are local hospital associations that, while affiliated with their state hospital associations in some quality and patient safety initiatives, might partner with other organizations in other such initiatives, and hence might benefit from receiving the non-public analyses, combined data or Medicare-only data, directly from the QE,” the letter points out.
Grant access to Medicaid and CHIP claims data
The data available to QEs should include standardized claims data under Medicaid and the Children’s Health Insurance Program (CHIP), AHA states.
“If CMS also allows them access to the MSIS data (or whatever other format the Medicaid and/or CHIP data may be available), it will obviate the need for additional application processes the QEs may have to undergo with one or more state agencies, particularly since the data in MSIS have already been converted into a national standard,” AHA explains.
Additionally, healthcare providers and suppliers need access to Medicaid and CHIP claims data to improve quality and care coordination for beneficiaries who are eligible for both Medicare and Medicaid. It is more efficient to provide access to the data through the QE program, rather than applying to each state separately.
Add rural hospitals to quality reporting
AHA encourages CMS to include specific regulatory impact analysis for small rural hospitals rather than just hospitals in metropolitan areas.
CMS expects that most QEs will focus their quality reports on metropolitan areas because more health services are provided in those regions. Therefore, the proposed rule would not have substantial impact on small rural hospitals.
However, AHA reports that three QEs have been approved to obtain national data for public performance reports for all hospitals in the US. The reports will impact the small rural hospitals included in national reports.
Recalculate the potential financial impacts of the program
CMS calculated that the total impact on healthcare providers and suppliers is an estimated $30 million, but the AHA argues that this figure may be too low.
According to CMS, providers and suppliers spend an average three hours to review non-public analyses and seven hours to create and submit appeal requests.
AHA claims that these calculations are too low because non-public analyses are more complex than the public performance reports. Providers will take more time to review QE-generated reports, which contains data on numerous quality measures.
CMS also excluded small rural hospitals from their calculations.
AHA applauds CMS for expanding the use of Medicare claims data for quality reporting, but the suggested changes to the proposed rule aim to create a more comprehensive method for sharing claims data.