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5.5 Medicare Program Data Transparency

As part of the Obama administration’s work to make our health care system more affordable and accountable, CMS has released data that summarize the utilization and payments for procedures and services provided to Medicare fee-for service beneficiaries by specific inpatient and outpatient hospitals, physicians, and other suppliers.

CMS has released hospital-specific payment and utilization data for FY 2011 and 2012 (http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Inpatient.html) for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments.  This data set includes for the top 100 most frequently billed discharges, paid under Medicare based on a rate per discharge using the Medicare Severity Diagnosis Related Groups (MS-DRGs). These MS-DRGs represent approximately 60 percent of total Medicare IPPS discharges from an acute care hospital that year. CMS has also released selected hospital outpatient payment and utilization data (http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Outpatient.html) that includes estimated hospital-specific charges for 30 Ambulatory Payment Classification (APC) Groups paid under the Medicare Outpatient Prospective Payment System (OPPS) for Calendar Year (CY) 2011 and 2012. These data show significant variation in charges from hospital to hospital, including those within the same community, for services that may be provided in connection with a given inpatient stay or outpatient visit. Hospitals determine what they will charge for items and services provided to patients and these charges are the amount the hospital bills for an item or service.  For both the inpatient and outpatient data sets, CMS is planning annual data releases.

In addition, CMS has released the Physician and Other Supplier PUF (http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html) and the Physician and Other Supplier Look-up Tool (https://data.cms.gov/use-agreement/data-limitations/provider-explorer).  The PUF contains information on utilization, payment (allowed amount and Medicare payment), and submitted charges organized by NPI, Healthcare Common Procedure Coding System (HCPCS) code, and place of service. It contains 100 percent final-action physician/supplier Part B non-institutional line items.  CMS has also published this information in a look-up tool format on data.cms.gov.   The look-up tool allow users to search for a provider by name, address, or NPI and returns information about the type and number of services provided, the number of beneficiaries treated, and the average payment and charges for such services.  For each of these platforms, CMS is planning annual data releases.

Finally, CMS is planning to release a Medicare Part D Prescriber Utilization and Payment Data Public Use File (PUF) that contains information on utilization and costs (beneficiary out of pocket and total drug costs) of prescription drugs from the Medicare Prescription Drug Program.  This data will be aggregated at the prescriber (using the National Provider Identifier (NPI)) and drug name (First Databank brand name variable). The data in the Part D Prescriber Utilization and Payment Data PUF will cover calendar year 2013 and contain 100% final-action Part D prescription drug events from all beneficiaries enrolled in the Medicare Part D program.  This information has been of great interest to the public and has been the focus of several FOIA requests.  Public release of this information creates greater transparency in the country’s largest federal prescription drug program. CMS also plans to release a companion look-up tool to quickly find information on prescriptions prescribed by a provider by entering the provider name and/or location.   An interactive dataset with filtering and sorting capabilities will also be available. CMS plans to release the PUF and look-up tool in late 2014.

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