TRANSPARENCY: Embracing CMS’s Push To Publicize Your Organization’s Performance

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Obermayer Rebmann Maxwell & Hippel LLP
[author: Brandon Danz]

(This is the first in a two-part article on healthcare data transparency and how providers and payers can leverage transparency as a population health opportunity.)

The Centers for Medicare and Medicaid Services (CMS) is launching new value-based programs with great fervor as a central strategy to bend the healthcare cost curve. Value-based reimbursement models linked to achieving the Triple Aim have received broad bipartisan support and are widely seen as a new ‘normal’ within healthcare. In a recent new program announcement, CMS Director Seema Verma stated that “as we seek to unleash innovation in our health care system, we recognize that the road to value must have as many lanes as possible.”

Traveling these lanes requires meaningful investments in care redesign and a willingness to loosen ties to traditional fee-for-service strategies. But there is a largely under-utilized companion hitching a ride in most of the lanes leading to value-based reimbursement: data transparency.

Transparency has been an important component to CMS reforms. Take Medicare Accountable Care Organizations (ACO) as an example. A health system or large physician group that becomes a traditional Medicare ACO agrees to have their quality, cost, and utilization data publicly reported by CMS on Public Use Files that can be downloaded by anyone to compare the quality and cost of competing health systems and physician groups. In fact, CMS requires each ACO to post their performance data on their own organization’s website (Google the name of a Medicare ACO near you, followed by “public reporting information” and it will probably appear in the first result).

This movement toward greater data transparency is also impacting individual physicians. Starting this year physicians’ quality data based on their performance within the MIPS program is publicly reported on Medicare’s Physician Compare website with a sleek and simple physician lookup tool.

At The Fingertips of Consumers:

The importance of this movement to publicly report performance data – and the opportunities that it presents — deserves consideration. CMS is now acting to maximize the sharing and transparency of healthcare data directly to consumers. In February of this year, CMS issued a proposed rule which would require Medicare Advantage plans, Medicaid, CHIP, and health plans sold on the federal exchange to electronically share claims data with their enrollees by 2020. This would make comprehensive healthcare data available to 85 million consumers in a standardized digital format. Leadership at CMS is painting a clear picture to providers and payers who resist making this data available. When asked if CMS Director Verma would “name and shame” bad actors under the new rule, she responded that “we are going to use every lever that we have to drive patients getting access to their records” (source: ).

Perhaps the most groundbreaking transparency reform of all is CMS’s new “Blue Button 2.0”. This is a tool available to Medicare beneficiaries, allowing them to access and share their claims data. The tool is currently under development with a host of app developers (including forward-thinking health systems) looking to capitalize on this new market opportunity. Once available, beneficiaries will be able to access their data using their smartphone and securely share their data with their doctor, researchers, or approved app developers.

An Opportunity Or A Threat?

Transparency will become the new normal and embracing it early on as a necessary companion to true value-based transformation can position a provider or payer for long-term success. Conversely, transparency may become a threat to providers who resist redesigning traditional fee-for-service care models to focus on quality over cost. In a follow-up article, I will share strategies underway by providers and payers to leverage transparency as an opportunity to advance population health strategies. In the meantime, I will leave you with this anecdote: Last year, Yelp gained access to various states’ Departments of Health restaurant inspection scores and is now publishing those scores on restaurant review pages within the Yelp app. If Yelp did this in the restaurant industry, how long until a company realizes the newfound ability to do it within healthcare? In the near future, an Apple watch will tell its wearer, who it knows (from claims data) to have high blood pressure and (from its own biometrics) to have too little exercise that based on Apple’s proprietary analytics, the person is at rising risk of an adverse health event and should schedule a doctor’s appointment. It might also tell the wearer the average quality performance and costs of various cardiology or primary care groups operating in the region and serve up the phone number of the best pick. Or it could go a step further and ask the person if they would like a consult with an Apple- employed physician. Sound far-fetched? Apple hired their first 50 physicians in 2018.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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