A data mining final rule from CMS, issued on July 1, clears the way for qualified entities to create data analyses using Medicare and other claims data and sell them to providers – but you’ll have to be a provider with big data needs to directly benefit from these products.
Qualified entities (QEs) were created in the Affordable Care Act and established in a 2011 federal rule. There are now 11 regionally-approved and four nationally approved QEs.
QEs are given access to Medicare data and create methodologies for working with that data to reveal trends and pattern that will, it is hoped, be used to create care efficiencies. For example, CMS said in its announcement, “qualified entities can conduct analyses on chronically ill or other resource-intensive populations to increase quality and drive down costs in the healthcare system.”
CMS assures providers and patients that "strict privacy and security requirements for all entities receiving patient identifiable and beneficiary de-identified analyses or data" will be observed. They also required that Medicare data be combined with other kinds of claims data, such as from private payers, “to produce quality reports that are representative of how providers and suppliers are performing across multiple payers,” says CMS.
As required by the Medicare Access and CHIP Reauthorization Act (MACRA) passed last year, CMS is allowing QEs to “provide or sell” the results of their work to Medicare providers as well as to insurers and other kinds of health care organizations.
These kinds of products are most likely to appeal to entities that are looking to identify value-based providers – such as a Medicare Advantage or private insurer looking to create or fill out a select network, says Joel V. Brill, M.D., chief medical officer of Predictive Health, LLC in Phoenix. Among providers, risk-bearing organizations such as accountable care organizations are most likely to want them, Brill says.