The Need for Access to Medicare Fee-for-Service Claims Data

JAMA – June 10, 2013

he Centers for Medicare & Medicaid Services (CMS) is the largest US payer of fee-for-service health care claims. However, health care providers have had, at best, limited access to Medicare fee-for-service data because CMS has not made the information broadly accessible. Access to Medicare fee-for-service data could help increase efficiency in health care delivery, reduce costs, and improve the quality of care. Recent remedies have taken shape as part of implementing the Affordable Care Act (ACA), but have yet to bear much fruit.

WHERE THE ACA FALLS SHORT

The ACA, enacted in 2010, has provisions to make Medicare fee-for-service data available so that provider performance can be measured and evaluated. A little-known but crucial provision, section 10332, permits Medicare claims data to be released to “qualified entities” (QEs) that meet certain criteria.1 QEs are expected to combine Medicare data with that from other payers to create publicly available performance reports that are more accurate than they would have been without Medicare data. This is a hopeful step, but more than a year after the regulations were finalized, CMS certified only 6 QEs, covering relatively small population bases. Progress has been slow partially because the legislation tightly limits what organizations can do with the data and their ability to support their own data maintenance infrastructures. Thus, the existing QE program faces 2 main barriers. Read more