Increasing the Transparency of Medicare Data

Medicare is the largest purchaser of healthcare services in the world. Medicare data is important to understanding the cost and quality of healthcare, and to finding meaningful ways to benchmark, measure and improve performance. Several states have attempted to improve the transparency of cost and quality information by creating all-payer claims databases that aggregate medical, dental and/or pharmacy claims from public and private payers to create a broader picture of quality and resource use. However, without Medicare outpatient and pharmacy fee-for-service claims, the information has been incomplete. On August 26, 2014, The Oregon Health Care Quality Corporation (Q-Corp) released the  nation’s first public reports on the quality of local primary care that include data provided by Medicare through the Qualified Entity Certification Program,

Public Reports Help Consumers Compare Care – Q-Corp Press Release August  26, 2014

CMS Program Comparison Grid July 2014

CMS Qualified Entity Map


The Establishment of Qualified Entities

Section 10332 of the Affordable Care Act amends section 1874 of the Social Security Act (the Act) by adding a new subsection (e) requiring standardized extracts of Medicare claims data under parts A, B, and D to be made available to ‘‘qualified entities” for the evaluation of the performance of providers and suppliers. Qualified entities may use the information obtained under section 1874(e) of the Act for the purpose of evaluating the performance of providers and suppliers, and to generate public reports regarding such performance.

10 of the 12 qualified entities are NRHI’s members. These include:

  • The Oregon Health Care Quality Corporation
  • The Health Collaborative
  • Maine Health Management Coalition Foundation
  • HealthInsight New Mexico
  • California Healthcare Performance Information System
  • Pittsburgh Regional Health Initiative
  • Minnesota Community Measurement
  • Wisconsin Health Information Organization
  • Center for Improving Value in Health Care
  • Midwest Health Initiative

The sharing of this rich Medicare data with qualified entities through this program and the resulting reports produced by qualified entities will be an important driver of improving quality and reducing costs in Medicare and will increase the transparency of provider and supplier performance, providing consumers with access to information that will help them make more informed decisions about their health care.

One of the many benefits of NRHI membership is the opportunity to leverage the collective experience, challenges and innovation of RHICs who are engaging in similar opportunities to drive healthcare improvement in communities.  The Qualified Entity Collaborative provides a forum for NRHI members who are already Certified Qualified Entities, as well as those interested in exploring the designation,  to support each other through sharing of best practices, increasing alignment for greater efficiency and cost savings, and collectively find solutions to overcome barriers.  The NRHI staff  facilitates this collaboration through meetings (both internal and with key external stakeholders) and maintenance of a resource library.