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Medicare Claims Database Should Be Public

Medicare Claims Database Should Be Public

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william heisel, medicare database, health quality, transparency

Health reporters may be feeling a bit of whiplash.

Pushed by the 2010 Affordable Care Act, Medicare is taking a tentative step toward making public its database of billing claims from hundreds of thousands of physicians and hospitals nationwide.

The move comes just weeks after another branch of the federal government – the Health Resources and Services Administration, restricted access to the National Practitioner Data Bank, a separate database that aggregates data about physician discipline and malpractice.

HRSA told reporters that they had to promise not to use this anonymous database to track down physicians who have harmed and killed patients, or they would face the threat of fines and other penalties. Now, what Medicare calls "qualified entities" will be able to find out which doctors have charged the most for which types of procedures. Those entities include insurance companies and organizations that regularly compile health care data for rankings.

In explaining its rule change, Medicare wrote that qualified entities must be able to:

1) ensure the production of timely, high quality, and actionable reports on the performance of providers and suppliers, 2) protect beneficiary privacy and security, and 3) ensure providers and suppliers have an appropriate amount of time to review the reports, appeal, and, if necessary, correct errors prior to public reporting.

It's unclear whether any news outlets would be able to jump through all these hoops. Would U.S. News & World Report not be able to make a case that it has experience compiling health care data and making rankings while respecting privacy and giving those being ranked a chance to respond?

Ricardo Alonso-Zaldivar at the Associated Press wrote:

By analyzing masses of billing records, experts can glean such critical information as how often a doctor has performed a particular procedure and get a general sense of problems such as preventable complications. Doctors will be individually identifiable through the Medicare files, but personal data on their patients will remain confidential. Compiled in an easily understood format and released to the public, medical report cards could become a powerful tool for promoting quality care.

Big corporations – with all their political clout – like this move. The Business Roundtable has been asking for this data since at least 2006. Robert Pear at The New York Times wrote back then that the roundtable was in a tussle with President George W. Bush over what appeared to be a half-hearted pledge on his part to make health care more transparent.

Employers want to use the data to compare and rate doctors and to rein in soaring health costs - the very purpose advocated by the president. The data would show, for example, which doctors performed the most knee operations with the fewest complications. Employers said they could then compare the average cost per case for different doctors. And they could steer patients - workers, and retirees and their dependents - to doctors who achieved the best results and offered the best value.

The Wall Street Journal has been particularly good at using small slices of the database to write stunning investigative pieces, including its fantastic Secrets of the System series. That series has had real consequences. The Journal found, for example, that Dr. Vishal James Makker at Providence Portland Medical Center in Oregon was performing spinal-fusion surgeries at 10 times the rate of other surgeons. Within weeks of that story breaking, the hospital revoked Makker's privileges. Two powerful U.S. senators, Ron Wyden, an Oregon Democrat, and Charles Grassley, an Iowa Republican, introduced legislation to open the database.

The Journal's owner, Dow Jones, wasn't about to wait for federal laws to change. It sued to open access to the database, essentially reopening a case that was closed in 1979 when the Florida Medical Association (FMA) successfully blocked public access to the data.

Medicare officials did not mention the Dow Jones suit when announcing their decision to make the data public, but it must have been a factor. In September, U.S. District Judge Marcia Morales Howard ruled that Dow Jones had raised important questions about "whether Medicare records which identify Medicare providers' income should remain protected by the 1979 FMA injunction and its application of the Privacy Act and the privacy exemption to FOIA, given the alleged change in circumstances underpinning that injunction."

Let's hope that Dow Jones, Wyden, and Grassley keep up the pressure for Medicare to go beyond releasing the data only to "qualified entities."

While I'm toasting Dow Jones, though, I should note that over in the corner of the party are some folks grumbling about the database sowing more confusion in the health care system. Medical Quack's Barbara Duck has noted in the past that the data are likely to be error-prone and could lead to some doctors being unfairly targeted as fraudsters by companies or insurers.

"We don't know how to reasonably use data with a level of forgiveness," she wrote in a comment on the Los Angeles Times post about the Medicare decision. "[It's] sad as it makes money for corporations and does nothing for the 99%."

Medicare should take extra care to make sure its database has been checked and double-checked for errors. Journalism organizations and consumer watchdogs who have been pushing HRSA to get rid of its bizarre requirement for reporters to sign a loyalty pledge before accessing the National Practitioner Data Bank should push for similar restrictions to be lifted from the Medicare data. And news outlets should make the case to Medicare that they are just as qualified as any insurance company to examine claims data and provide useful information to the public.

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