What’s All This Nonsense about CMS Transparency? - DoctorsManagement What’s All This Nonsense about CMS Transparency? - DoctorsManagement

What’s All This Nonsense about CMS Transparency?

A look into the CMS Database Release

A couple of years ago, CMS, in a stated effort to be more transparent, released a database that contained most all of the procedures billed to Medicare by physicians for calendar year 2012. The next year, they released the same database for 2013 and again, earlier this year, released the database for 2014. In each case, the data were two years old when they were released and with the exception of data analytics, policy makers and wannabe whistle-blowers, the data were not of much value. Oh, I know, CMS touted how these data sets would allow the general public to evaluate and assess the quality of individual physicians, given them a more educated consumer decision, but that was a bunch of bologna. Nowhere within any of these data sets were there any quality measures nor, contrary to what CMS said, anything that could be used to measure quality. I guess the idea was that you could identify how many time a given provider performed a given procedure but this was wholly dependent upon their Medicare payer mix (which was not given) as well as the number of times that same procedure was performed on non-Medicare patients (also not given). For this purpose, the data were completely useless.

There was also this idea that consumers would download the data and be able to import it into Excel or SQL or some other database management program but with a file as large as these, I don’t see that happening to any degree. The Wall Street Journal compiled the data into a search engine that could be accessed from their web site and ProPublica put together an excellent search utility on their website that provided not only the data but some guidance on how to read it. But that still didn’t change the issue of usability; the typical consumer would not be able to get much of value from the data.

To keep the push for transparency going, in 2014, CMS released the Open Payments database. The database tracks pharmaceutical company contributions to doctors and teaching hospitals and was touted as a great way to be able to investigate potential influence that these companies might have on the folks doing the research. Sounds good, except that the data were so messed up that at least one third of the entries were not published, again, rendering it almost useless. Imagine if the census bureau released the 2010 census data but information for one third of those responding wasn’t released. I don’t imagine there would be much excitement over that, yet that is what we saw. And what I didn’t mention was that the first run only contained limited data for five months; August through December, 2013. Subsequent releases have not been a whole lot more accurate or useful than the original posting. But hey, it give the illusion of transparency, doesn’t it?

Just recently, the CMS released a database that reported all kinds of data and statistics for hospice organizations around the country. On the CMS website (https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Hospice.html), the opening paragraph begins like this: “As part of the Obama Administration’s efforts to make our healthcare system more transparent, affordable, and accountable, the Centers for Medicare & Medicaid Services (CMS) has prepared a public data set, the Hospice Utilization and Payment Public Use File (herein referred to as “Hospice PUF”), with information on services provided to Medicare beneficiaries by hospice providers.” And then, it ends with this: ”Although the Hospice PUF has a wealth of payment and utilization information about hospice services, the data set also has a number of limitations. The information presented in this file does not indicate the quality of care provided by individual hospice providers. The file only contains cost and utilization information. Additionally, the data are not risk adjusted and thus do not account for differences in patient populations.”

Now remember, these data are being made available to allow consumers, I guess, to make a more informed decision about selecting a hospital provider. But look again at the last paragraph where is states that there isn’t any way to assess quality of care and that the data are not risk-adjusted so let’s look at some other information that the typical consumer can use to their benefit. Let’s see, it contains the costs and payments, but those are pretty much fixed across the country. It gives the number of physician services, which, as far as I can tell, without knowing anything about those services, is nothing more than an empty number. It talks about the average hours per day for Home Health visits, skilled nursing home visits and social services visits, whatever they mean. I couldn’t assign any value to them. It reports total live discharges, which really tested my understanding of what hospice is all about. It even gave demographics, like average age, gender distribution and a breakdown by race and ethnicity. Again, I just don’t see any benefit of these data for the typical consumer. And not be beat a dead horse, but this ‘new’ release is also pretty close to two years old before it hits the street.

Lest you think I am complaining just for the sake of complaining, I wanted to talk about one more database, called the Integrated Data Repository. Here is CMS’s sated IDR objective:

“An integral part of the CMS data warehouse strategy, the IDR ensures a consistent, reliable, secure, enterprise-wide view of data supporting CMS and its partners in more effective delivery of quality health care at lower cost to CMS’ beneficiaries through state-of-the-art health informatics.”

Now that sounds pretty interesting and it really is because, according to the Annual Report to Congress on the Medicare and Medicaid Integrity Programs for Fiscal Years 2013 and 2014, CMS claims to have prevented and/or recouped $42 billion dollars and much of their success was credited back to the IDR. In fact, it is described in the report as follows:

A key resource that supports the FPS [Fraud Prevention System ] in analyzing nationwide claims and building models is the Integrated Data Repository (IDR), an existing and continuously expanding repository of nationwide Medicare claims data. To develop and test more comprehensive models more quickly, analysts use historical claims from the national IDR to analyze patterns and develop models for the FPS. In turn, FPS models screen the IDR’s aggregate, nationwide, historical information about billing behavior, creating more effective analytics using historical national data in both the development and implementation of the models.”

Now there is a database that sounds useful and you know what? The data are pretty current; in fact, often times only a few months old. So, in its effort to be “more transparent”, why can’t I get access to this database? What might I use it for, you ask. I would use it in the same way the government and their lucky partners use it; to help providers identify, in advance, potential billing and coding issues that could result in costly audits and appeals. So why in the world would CMS want to give me access to something that might help providers identify potential problems a priori? Well, first would be this amazing dedication to more transparency and second, in CMS’s own words:

“CMS’s program integrity strategy is moving beyond the reactive “pay and chase” method toward a more effective, proactive strategy that identifies potential improper payments before they are made, keeps unscrupulous providers and suppliers out of Medicare and Medicaid at the outset, quickly removes wrongdoers from the programs once they are detected, and corrects improper payments as quickly as possible.”

So not only is transparency apparently important to CMS, but they want to get beyond “pay and chase” methods, which prove to be more expensive than prevention. So, the way I see it, CMS has this database that analysts like me could use to help providers identify potential improper payments before they are made (CMS’s words, not mine) but they don’t want me to get access to it because I guess I am not the kind of partner they want to get access to the data.

In the end, I am convinced that this move towards more transparency is a smoke screen to keep people busy while the valuable information is kept restricted to those that provide benefit only to CMS. It is illusory; and it’s a shame because in light of the complete suspension of due process with regard to appeals and ALJ hearings, it would seem that, if providers were more involved in understanding how to prevent improper billing and coding events, we could reduce the need for audits and hearings and bring some equanimity to an otherwise unfair and unreasonable process.

And that’s the world according to Frank.

Frank Cohen (fcohen@drsmgmt.com) is Director of Analytics and Business Intelligence.