What’s All This Nonsense About Transparency? A Look into the CMS Database Releases

By
Original story posted on: October 19, 2016

A couple of years ago, the Centers for Medicare & Medicaid Services (CMS), in a stated effort to be more transparent, released a database containing most of the procedures billed to Medicare by physicians for the 2012 calendar year. 

The next year, the agency released the same data for 2013, and again, earlier this year, it released the data for 2014. In each case, the data was two years old by the time it was released, and with the exception of data analytics groups, policymakers, and wannabe whistleblowers, it was not of much value to anyone. 

Oh, I know CMS touted how these data sets would allow the general public to evaluate and assess the quality of individual physicians, providing for more educated consumer decisions, but that was a bunch of baloney.

Nowhere within any of these data sets were there any quality measures – nor, contrary to what CMS said, was there anything that could be used to measure quality. I guess the idea was that you could identify how many times 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 was 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 files 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 its website, 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 it.

To keep the push for transparency going, in 2014 CMS released the Open Payments database. This database tracks pharmaceutical company contributions to doctors and teaching hospitals, and it was touted as a great way to be able to investigate potential influence that these companies might have on the folks doing the research. This sounds good, except the data was so messed up that at least one-third of the entries were not published, rendering it almost useless as well. Imagine if the U.S. 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 in this case. And what I didn’t mention was that the first run only contained limited data collected over 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 gives the illusion of transparency, doesn’t it? 

Just recently, CMS released a database that reported all kinds of data and statistics for hospice organizations across the country. On the CMS website, 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, this data is being made available to allow consumers (I guess) to make a more informed decision about selecting a hospital provider. But again, look again at the last paragraph, where it states that there isn’t any way to assess quality of care and that the data is not risk-adjusted.

So let’s look at some other information contained in this database that the typical consumer can use to his or her benefit. Let’s see: it contains the costs and payments, but those are pretty much fixed across the country. It lists 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 notes 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 for the typical consumer. And not to beat a dead horse, but this “new” release was also pretty close to two years old before it hit the street.

Lest you think I am complaining just for the sake of complaining, I wanted to talk about one more database, this one called the Integrated Data Repository (IDR). Here is CMS’s stated 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's 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 claimed to have prevented and/or recouped $42 billion – and much of that 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 is pretty current: in fact, it’s often only a few months old. So, despite CMS efforts 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 the agency wants 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 have access. 

In the end, I am convinced that this move toward more transparency is a smokescreen to keep people complacent 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 administrative law judge (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.

About the Author

Frank Cohen is the director of analytics and business intelligence for DoctorsManagement, a Knoxville, Tenn.-based consulting firm.  Mr. Cohen specializes in data mining, applied statistics, practice analytics, decision support, and process improvement.

Contact the Author

fcohen@drsmgmt.com

Comment on this Article

editor@racmonitor.com

This email address is being protected from spambots. You need JavaScript enabled to view it.