JAMA Forum: Transparency in Action: “The Imperfect is Our Paradise”

Eli Adashi, MD, MS

Eli Adashi, MD, MS

Just 6 months ago, on April 9, 2014, the Centers for Medicare & Medicaid Services (CMS) released a data file for public use comprising all Medicare payments for 6000 services and procedures under the Part B program, which covers things like physician visits, outpatient services, preventive services, and some home health visits. The recipients of the $77 billion paid in fiscal year 2012 were more than 880 000 Medicare-participating health care providers.

This release of CMS data capped a 35-year legal saga that began when the Florida Medical Association sought and secured a precedent-setting injunction against the public disclosure of payments to individual physicians.

In making its case, the Florida Medical Association maintained that disclosure of payments to individual physicians would constitute an unwarranted invasion of personal privacy. However, by 2013, on the strength of accumulating legal precedents, the US District Court for the Middle District of Florida reversed itself to conclude that the ongoing imposition of its 1979 injunction against disclosing Medicare payment information “was no longer equitable.”

This reversal meant that transparency about Medicare payments to individual physicians is here to stay.

The public-use data file released by CMS on April 9, 2014, had complete information on the types of procedures carried out (and their official codes), the relevant charge and payment per procedure, and the number of procedures carried out and billed. Individual clinicians were tracked by their name, identification number, specialty or subspecialty, and place of service (city and zip code).

But the data were hardly all-inclusive. Regrettably, no effort was made to risk-adjust the data to reflect the relevant case mix or to furnish metrics that indicate the quality of care provided by an individual. Moreover, the information provided did not give the consumer any level of insight concerning outcomes of treatment by individual clinicians. Indeed, CMS has yet to incorporate treatment outcomes into its surveillance systems. Also, the data file neither took stock of inpatient procedures (Medicare Part A), nor did it provide information about medical care reimbursed by private-sector payers (a deficiency that cannot be helped because the proprietary information in question is not in the public domain).

Imperfect as the public-use data file released by CMS might be, we would probably do well not to hold this against it. After all, “perfect is the enemy of good.”  Or, “[t]he imperfect is our paradise,” to borrow a phrase from the poet Wallace Stevens.

In its native unprocessed state, the CMS public-use data file is not user-friendly. Consumers would be hard pressed to deal with the raw body of data released. Making sense of the 10 million lines of data requires that it be further processed to yield tools in the form of interactive consumer-friendly apps. Access to some apps is inevitably limited to consumers enrolled with qualified private health insurance issuers. However, other user-friendly tools remain in the public domain. Despite limitations, the private and public consumer-centered resources are making a difference. Clearly, the amount of information available to the public has changed dramatically. Opaqueness no longer reigns supreme.

The utility of the newfound transparency may be best driven home by an illustration of its practical application. A colleague in need of an outpatient endoscopic procedure has been struggling to identify an experienced local surgeon. Until recently, such efforts would have been limited to seeking word-of-mouth recommendations. Subjective and unverifiable, this “grapevine” strategy is akin to guesswork or to a poorly conducted poll. It follows that whatever conclusions are ultimately reached, they have everything to do with hearsay and nothing to do with facts. This is hardly the place to be when your health is on the line.

It need not be this way. Unfortunately, though, most surgeons are not in the habit of listing and sharing their case volumes (how often they perform a given procedure in a year) and patient outcomes.

Enter health care data transparency. It took my colleague all of 10 minutes using a searchable version of the public-use data file released by CMS to generate a listing of high-volume local surgeons. Although hardly synonymous with good outcomes, high procedural volumes are predictive of such. A surgeon who frequently performs a particular procedure is more likely to have better outcomes than one who does not.

My colleague’s experience would not have been possible before April 9, 2014. I call this progress.

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About the author: Eli Y. Adashi, MD, MS (eli_adashi@brown.edu) is a professor of medical science and the former dean of medicine and biological sciences at the Warren Alpert Medical School of Brown University in Providence, Rhode Island. A member of the Institute of Medicine, the Association of American Physicians, and the American Association for the Advancement of Science, Adashi has focused his writing on domestic and global health policy at the nexus of medicine, law, ethics, and social justice. A former Franklin fellow, Adashi served as a senior advisor on global women’s health to the Secretary of State office of Global Women’s Issues during the first term of the Obama Administration.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



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