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CMS Updates Data Mining Rule to Enrich Patient Care

(July 6, 2016) - by Tracey Walker, Managed Healthcare Executive

CMS has updated rules that will allow qualified entities (QEs) to confidentially share or sell analyses of Medicare and private sector claims data to providers, employers, and other groups who can use the data to support improved care. In addition, QEs may provide or sell claims data to doctors, nurses, and skilled nursing facilities among others.

The release of finalized changes to what is called the Qualified Entity Program (QEP) may have a significant impact, according to experts.

"Allowing access to the CMS data vault could have an enormous impact on patients and consumers," according to Managed Healthcare Executive (MHE) Editorial Advisor Don Hall, a former health plan CEO, and current principal Delta Sigma LLC, in Littleton, Colo. "Quality information by provider, success of various treatments on patients by age and disease and pharmacological impacts are just a few of the benefits we could see."

Selling data through these new CMS rules will not improve clinical decision making, according to Art Papier, MD, CEO of VisualDx.

"The information that goes into the reports is as useful as the information that comes out," Papier says. "What will really generate better care and quality at hospitals is investments in health information technology to support better decisions by the clinician and patient. It's unlikely that selling claims data will have any impact on accuracy, quality and safety for people, but on the other hand it may possibly enrich an enterprising business person marketing the data as meaningful."

The QEP program was created under the Affordable Care Act. Currently, 15 organizations have applied and were approved by CMS as QEs to receive patient-identifiable claims records from Medicare, Medicaid and the Children's Health Insurance Program. To date, two have completed public reporting.

"Qualified entities must combine the Medicare data with other claims data [e.g., private payer data] to produce quality reports that are representative of how providers and suppliers are performing across multiple payers, for example Medicare, Medicaid, or various commercial payers," explains MHE Editorial Advisor Joel Brill, MD, FACP, chief medical officer, Predictive Health, LLC.

For example, qualified entities can conduct analyses on chronically ill or other resource-intensive populations to increase quality and drive down costs in the healthcare system," Brill says.

CMS also modified the definition of hospital association to include local-level organizations and is considering making Medicaid and Children's Health Insurance Program data available to qualified entities in future rulemaking, according to Brill.

"Managed care entities that are looking to identify value-based providers will likely be purchasers of QE data," he says.

About VisualDx

VisualDx is an award-winning diagnostic clinical decision support system that has become the standard electronic resource at more than half of U.S. medical schools and more than 1,500 hospitals and institutions nationwide.  VisualDx combines clinical search with the world's best medical image library, plus medical knowledge from experts to help with diagnosis, treatment, self-education, and patient communication. Expanding to provide diagnostic decision support across General Medicine, the new VisualDx brings increased speed and accuracy to the art of diagnosis. Learn more at