New Medicare Data Regulations Will Support Regional Healthcare Improvement Efforts

Final regulations issued on December 5 by the Centers for Medicare and Medicaid Services (CMS) will significantly increase the ability of communities across the country to measure and improve the quality and cost of healthcare. “Regional Health Improvement Collaboratives have the most extensive experience in the nation in successfully implementing healthcare performance measurement and public reporting efforts,” said Harold D. Miller, President and CEO of the Network for Regional Healthcare Improvement, which had supported legislation and regulations to make the data available. “The new regulations will enable Collaboratives to obtain data needed to measure and report on the quality and cost of care for senior citizens, and also to make all of their existing quality/cost measures more robust and reliable.”

The new regulations specify the conditions under which Medicare claims data will be released to “qualified entities” for public reporting on the quality and cost of healthcare. Regional Health Improvement Collaboratives are expected to be the largest group of such qualified entities, since they currently are the principal source of information on the quality of healthcare in communities across the country.

In August, 2011, the Network for Regional Healthcare Improvement submitted extensive comments on the proposed version of the regulations. NRHI praised CMS for adopting almost all of NRHI’s recommendations. In particular, NRHI noted the following important changes made by CMS in the final regulations:

  • The cost of obtaining the data is being significantly reduced. Whereas CMS originally projected the cost of obtaining data for 2.5 million beneficiaries to be $200,000, CMS now projects the cost to be $40,000. The cost will presumably be lower for organizations in smaller states and regions.
  • CMS will allow organizations to apply to become qualified entities at any time, rather than limiting applications to the first quarter of each year. This will give Collaboratives more time to apply than the original deadline of March 31.
  • CMS will allow organizations to use contractors to meet the criteria for serving as a qualified entity. This will facilitate the ability of additional communities to form Regional Health Improvement Collaboratives to do measurement and reporting.
  • CMS will now provide data on a quarterly basis rather than an annual basis, allowing for more current measures to be reported.
  • CMS will allow reported measures be based on both claims and clinical data.
  • CMS will provide qualified entities with a crosswalk file of beneficiary names and identifiers as well as the claims data, so that qualified entities can (a) link claims and clinical data, and (b) give providers patient-specific data for accuracy verification.
  • CMS will make a 5% sample of national Medicare data available upon request so that qualified entities can create national benchmarks for their local data.
  • CMS will allow qualified entities to use a new measure if local stakeholders in their market support the use of that measure and there is scientific evidence to support it.


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