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Another Step Toward Transparency — Brian Klepper

It was the great economist Adam Smith who said that, for markets to work, they need (among other things) "perfect information." Health care hasn’t worked, in large measure, because its markets have had almost no information.

So in what could be a huge step forward for the health care transparency movement, a federal court has ruled that the public interest outweighs concerns about physician privacy, and that, next month, CMS should release to a consumer advocacy group the Medicare data sets for 4 states and the District of Columbia. Here’s a snippet from Saturday’s Wall Street Journal article (subscription required):

The data at issue include medical-procedure and
billing details that physicians send to Medicare to get reimbursed by
the federal insurance program for the elderly and disabled. Although
collected largely for billing and administrative purposes, the data
could be analyzed to see how often a doctor performs a given procedure
and even to compare mortality rates among patients of different doctors.

The government has until Sept. 21 to release the data,
covering Maryland, Illinois, Washington state, Virginia and Washington
D.C., to the nonprofit Consumer’s CHECKBOOK/Center for the Study of
Services. The group said it will set up a free database on its Web site
for public use. It has filed similar public-information requests for
Medicare claims data for all 50 states.

It’s worth noting that this Administration, which has prided itself on its advocacy for EMRs, transparency, RHIOs and all the rest of it, when it counted, sided with keeping doctor performance secret. When the chips were down, this is how it actually worked.

You can bet that analytical groups all over the country will pounce on this information, profile and post the performance of physicians in these states, and campaign for access to the rest of the data.

Until recently, despite a lot of very worthwhile effort, data that could be used to develop performance information have been scarce. Health plans, who had the largest health care data sets, weren’t forthcoming with them. Now they’re publishing pricing data, which are somewhat useful, but not as useful as some of the other information embedded in their repositories.

The importance of this case can’t be overstated. The release of the Medicare data, if it happens, will go far toward making physician performance data more available and commonplace. This is a major victory for health care reformers, and many thanks go to Consumer’s CHECKBOOK, the advocacy group that sued for the data. It’s still too early to break open the champagne, of course, because the powers that oppose transparency still have a month to get the decision reversed.

Read the court’s opinion here, and CHECKBOOK’s press release here. This is just one more brick in the wall, of course. But there’s steady progress. It’s happening. And everything will eventually change in health care as a result.

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4 replies »

  1. Recently, Texas said it was releasing worker’s comp data that listed physician data/costs… after days of navigating the website I had no luck.
    I did discover there was a fee for CDs of the data, but did not really no who to make what out to, and I did discover a summary of the data which outlined the format of the tables.
    Beyond that nada! tried calling- nada!
    Effectively, for someone with my resources the information was carefully wrapped behind red tape.
    –my experience makes me believe that this will be the case here as well

  2. I agree with both Matt and Peter on this one. Hopefully, the court decision will be sustained and then applied to the rest of the country. Medicare payment rates for hospital procedures would also be a useful benchmark.
    We need to develop decent quality and performance metrics to evaluate doctors, hopefully, with plenty of input from the medical specialty societies. Primary care metrics are trickiest. However, I note that the UK’s NHS developed a list of 147 measures that it used to evaluate primary care doctors with meaningful bonuses going to those who performed best. Points were assigned to each metric with the maximum possible score being 1,050 points. While no system is perfect and we can always find faults and exceptions, we need to attack waste and inappropriate care any way we can. Both price and performance transparency would be especially useful to primary care doctors in selecting specialists when their patients need referrals.
    The final piece of this puzzle is electronic records which will be needed to collect and assimilate data that needs to be reported to determine performance as well as to reduce or eliminate duplicate testing and adverse drug interactions and to better determine what works and what doesn’t.
    If successful, the ultimate dividend will be to both improve outcomes and to drive cost growth to a lower and more sustainable level. I have no idea how close we are to that “payday,” but it will, hopefully, come sooner rather than later. Whatever we do, I repeat again the need to pay attention to two key constants that apply to all economic activity, both public and private, for profit and not for profit. They are: (1) incentives matter and (2) beware of unintended consequences.

  3. Too bad we can’t get transparency from health insurers and hospitals on their charges and billing practices. Have you ever tried to ask your insurer how much you can expect to pay for a particular procedure? Ever tried to get the chargemaster information from a hospital – even a state run and subsidized one? Let’s pull the secrecy veil off the entire industry – not just doc performance.

  4. This is a hugely underappreciated story and could potentially have major ramifications for the health care industry.
    The major problem is the health plans have had with physician profiling is that they just don’t have the numbers to make it statistically reliable enough. Even a dominant Blues plan might only account for 30 to 40 percent of a physician’s payer mix. Still, have at least 50 percent of the physician’s payer mix in that “black box.”
    That is the single biggest problem that the Bridges to Excellence (BTE) program has run into repeatedly. They were successful in enrolling large employers in a geographic area but even that was not enough to get significant numbers and traction. Simply put, it doesn’t mean much to an individual doctor since he only likely has a handful of patients who are employees (and their dependents) of employers enrolled in the BTE program.
    Subsequently, BTE has tried to overcome this problem by licensing their program to health plans and larger employer buying coalitions but the impact still has been mixed.
    There have been a few exceptions on the commerical side in gathering claims data to get a comprehensive picture of a physician’s practice patterns including the IHA’s efforts in CA and Mass Health Quality Partners in MA but these are the exceptions and not the norm. Not only are there are a number of technical elements that need to be addressed (e.g., standardizing Provider ID numbers) but it requires a real political commitment by a number of different entitites that is pretty difficult to achieve let alone maintain over a period of years.
    If this lawsuit does succede and the other lawsuits follow suit, it will suddenly provide a reliable benchmark for health plans to compare physician performance against. Imagine if a health plan has a physician’s Medicare and Commerical claims data. The defense by a physician about poor ratings due to a payer having insufficient data on their payer mix becomes mute. There are still other issues (including the reliability of claims data, timeliness of claims data, etc) but this would be huge.
    I bet that a few savvy companies will make quite a nice profit by figuring out how to crush down this data and it present this information to a health plan in a format that is simple and can be readily incorporated into their business processes.

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