Archived Content

Letter to Donald M. Berwick on CMS Stakeholder Listening Session

Donald M. Berwick, M.D.
Administrator, Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
200 Independence Avenue,
S.W. Washington, D.C. 20201

RE: CMS Stakeholder Listening Session on September 20, 2010

Business Roundtable (BRT) is an association of chief executive officers of leading U.S. companies who provide health coverage to over 35 million employees, retirees and their families. We appreciate the opportunity to respond to the issues posed by CMS relating to the release of Medicare data.

Business Roundtable CEOs have long advocated making Part B Medicare claims data available so that payers may aggregate their own claims data with Medicare data to have a broader and reliable measure of the quality of care rendered by health care providers and their relative performance in treating important medical conditions. Combining Medicare with private claims data will also permit consumers to have more accurate cost information.

Since 2006, we have called for the release of claims data so that consumers can have access to actionable information. While we have seen some important improvements since then on such information, we have been informed that more can be done if qualified entities can have more claims data.

BRT’s November 2009 report, for example, Health Care Reform: Creating a Sustainable Health Care Marketplace, recommended that health reform legislation include “release of Medicare professional services claims data, with full protection of patient privacy.” It went on to explain BRT’s view that, “By making this broader set of claims data available to employer-provided health plans, consumers will be able to consider the cost and quality of services rendered by providers and make informed decisions about their treatment.” 

Accordingly, BRT is very supportive of the new provisions in the Affordable Care Act and thanks the Centers for Medicare and Medicaid Services (CMS) for conducting the listening session on September 20, 2010, and giving BRT and other stakeholders the opportunity to make brief comments during the session.

In addition, we are pleased to submit this written statement addressing:

I. Several key considerations, and
II. Responses to selected questions posed by the Agency.

I. Key Considerations

  • Timely and effective implementation of the new provisions is critically important and the January 1, 2012 effective date should be a firm deadline. In addition to the beneficial effects of the provision as described above, the claims data provides a direct link to enhancing value-based purchasing initiatives, which our Member companies have pioneered and which, under the Affordable Care Act, can lead to a directional change in the broader marketplace in which reimbursement to providers reflects value and quality. From the perspective of large employers who have sought this data for many years now, release of this data is already overdue from a market perspective. We also are sympathetic to the comments made by others at the listening session that an even earlier effective date would be desirable, if feasible, but more importantly, the effective date of January 1, 2012, should not be allowed to slip.
  • In implementing the new data release, we urge CMS to choose the path that will lead to the greatest availability of privacy-protected claims data at the soonest possible date. BRT is commenting in response to some of the process surrounding the various questions posed by CMS in its slides for the listening session. But beyond all the details, the guiding principles should be that with full protection of patient privacy, the greatest amount of detailed data be released for use by Qualified Entities (QE). More specifically, the Agency posed a series of questions (Group 2) regarding data provided to QEs, to which we are responding.
  • To encourage ongoing innovation and improvement, the Secretary should not discourage the use of alternative quality measures in addition to the standard measures. On the contrary, appropriate alternative quality measures should be encouraged. This is consistent with the Affordable Care Act that creates incentives for ongoing improvements in the measures themselves and the resulting interpretation and application of the data. In response to the CMS questions in the Listening Session slide deck on this subject, BRT strongly recommends that alternative measures be approved and encouraged. In further response to the questions, the process should include documentation by the QE of the methodology for the alternative measures intended to be used and a description provided of how the alternative measures are consistent with the statute-provided flexibility for approval in terms of being “more valid, reliable, responsive to consumer preferences, cost-effective, or relevant to dimensions of quality and resource use not addressed by such standard measures.” The statute also authorizes the Agency to consult with others.
  • The Agency should use great care in designing the appeals process. The Agency has wide latitude in structuring this process and again, the guiding principle should be the release of accurate data as quickly as possible. The statute does say that the report must be made available confidentially to any provider or suppliers named in the report, prior to the public release, and provide an opportunity to appeal and correct errors. We certainly agree that providers must have the opportunity to identify and correct errors in the report prepared by the QE. Indeed, inaccurate data can cause harm. By the same token, however, the correction and appeals process should also not become an open-ended process that may inadvertently create incentives or opportunities for certain providers to use these procedures to block or delay issuance of an accurate report that shows marginal or poor performance by the provider. The Agency should also consider setting an expedited process for decisions on appeals to the QE, so that they cannot drag on or create backlogs if a pattern of such appeals emerges.
  • The Listening Session is an important first step but more consultation will be needed. BRT encourages the Agency to make this the first of many future efforts to gather input from stakeholders, including the employers who provide the health coverage for their employees. BRT stands willing to provide such input on an ongoing basis and again, with the assistance of Hewitt Associates, we offer the following responses to selected questions.

 II. Responses to Selected CMS Questions (In the order they appear in the CMS slides for the Listening Session):

Q. What specific eligibility criteria should QEs be subject to?

A. The QE must demonstrate to the Secretary that it is qualified to use claims data to evaluate performance of providers on measures of cost, quality, efficiency, effectiveness, and resource use, and the statute gives the Secretary the authority to define basic eligibility requirements. In doing so, it is important to allow for private contractors to be QEs, those which can demonstrate that they have the competencies to do the analysis, and have the staff, technologies and systems to execute on their plans. Among the basic requirements should also be that the QE has risk adjustment mechanisms in place for data analysis. The QEs should demonstrate that they have the programs in place to train staff on the protections of the privacy of the data received, the procedures needed to ensure the integrity of the data and security protocols to ensure the security of the data.

Q. What information and level of detail should be collected on QE applications?

A. Detail should be collected that is sufficient to evaluate the capabilities of the QE to meet the required criteria and the methodologies and risk adjustment mechanisms that it will deploy. The Agency could facilitate this process by having a common application that would allow for electronic submission of the application itself and any supporting documentation.

Q. What types of organizations are interested in participating as a QE under Section 10332?

A. Local and regional business groups, Chartered Value Exchanges, Aligning Forces for Quality, consumer organizations, employers, health plans, private vendors, academic institutions and research organizations among others should be permitted to participate.

Q. What process will HHS use for ongoing monitoring of QEs to ensure compliance with requirements in the statute?

A. The agency may want to review sample reports of what is being provided by the QE, and undertake periodic audits to ensure that the ongoing administration of the QE’s work matches the information provided in the application that was approved, and appropriate sanctions and enforcement actions linked to any serious breaches of the approved measures, privacy, security, or data integrity.

Q. Should there be any federal standards regarding the appearance, format, content and/or structure of reports generated by QEs?

A. We recommend that the Agency invite creativity and therefore not mandate uniform federal report standards, but rather give ample flexibility to the QEs to generate reports in the most efficient and effective ways of conveying the results to the target audiences.

Q. What should the requirements for the appeals process be?

A. In addition to our comments above, it is important that a provider not be given the opportunity to “opt out” if the provider is dissatisfied with the report and the results of the appeal.

Q. How frequently will QE reports be generated and how long will reports be valid?

A. The QE should be given some flexibility to determine the durational validity of the reports that are generated. We hope that cost and quality reports will result in both quality and cost improvements.

Q. How will reports be used to communicate to providers in a way that brings about behavioral changes?

A. Presenting provider results in comparison to their peer groups will likely be an effective way of communicating with providers about their performance. There will also be indirect effects on behavior over time as the performance results may support future changes in provider reimbursement methods, with reimbursement also serving as a large driver of behavioral change.

Q. What types of claims data extracts are necessary for QEs to produce performance reports?

A. For provider performance, the QEs need the raw claims data file from all the entities that pay or process the claims de-identified, and not be a subset or a sample of that data.

Q. Will QEs need claims data for areas other than the geographic region they serve?

A. Yes. The value of providing provider performance data includes comparing utilization and performance with local, regional and national provider norms. Such comparisons are also the most compelling way to convey the performance to providers and bring about behavioral change (which was the subject of another question posed by CMS).

Q. What type of beneficiary and provider identifiers would potential QEs need to calculate measure results?

A. The provider ID is a minimum requirement, and it should be unique to that provider. The Unique Physician Identification Number (UPIN) now used by Medicare for voluntary reporting would be a great place to start.

Q. What other claims data sources are appropriate for use with Medicare claims extracts in producing performance reports?

A. Data from employers, health plans and Medicaid would provide the richest combination of data sources.

Q. How much additional claims data should be required of QEs for use with Medicare claims extracts in producing performance reports?

A. We recommend that enough additional claims data should be required such that the performance data being generated is statistically valid

Q. What documentation should be required for data requests?

A. Documentation should include a clear description of the uses of the data, i.e., in what manner and to whom would the data be provided, and under what circumstances. In addition, the QE should provide documentation to establish that it is using a reasonable analysis methodology, as well as the documentation regarding the procedures in place to warrant the security and privacy protection of the data.

Q. What is the anticipated frequency of data requests by QEs?

A. We expect that there would be data requests made semi-annually at the most frequent. Annually may be appropriate as well.

Q. What is the expiration of the use of the data?

A. We recommend that use of the data be permitted for at least five years.

 In closing, BRT commends CMS for recognizing the need to get a quick start on regulations implementing Section 10332 of the Affordable Care Act, “Availability of Medicare Data for Performance Measurement,” and for seeking the input of stakeholders in the early stages of this process. BRT strongly supports the goals of this provision, and stands ready to provide any additional support or input that CMS might find beneficial.

Sincerely,
Maria Ghazal
Director, Public Policy and Counsel
Business Roundtable

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