The Department of Health and Human Services (HHS) continues to draft regulations to support the implementation of The Patient Protection and Affordable Care Act (a.k.a. “Health Care Reform”). On June 8th, the Department of Health and Human Services (HHS) issued proposed regulations to set forth the guidelines for publishing standardized extracts of Medicare claims data submitted under Parts A, B and D. The intent of providing the data extracts is to allow “qualified entities” to evaluate the performance of healthcare providers on measures of quality, efficiency, effectiveness, and resource use. Under the guidelines, “qualified entities” are defined as those entities that can demonstrate their ability to:
- Accurately calculate quality, efficiency, effectiveness, and resource use measures from the claims data,
- Identify an appropriate method to attribute a particular patient’s service to specific providers of services,
- Ensure statistical validity,
- Use methods for risk adjustments to account for variation in case-mix and severity,
- Identify methods for handling outliers,
- Correct measurement errors and assess measurement reliability, and
- Identifies peer groups of providers.
The “qualified entities” must combine the Medicare claims data with claims data from other payer sources. The methodology for calculating the metrics, from the combined data source, must be able to demonstrate, to the satisfaction of HHS, that the concerns expressed by healthcare providers (and other stakeholders) are addressed regarding the performance measures from the single payer data source.
As long as the above mentioned criteria are met, a “qualifying entities” can be a health maintenance organization, healthcare research organization, or other similar entities. The regulations require the “qualified entities” to share their analysis with providers 30 days prior to a public release in an effort to reduce the risk of error in the analysis.
Click here to view the proposed regulations
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