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    How expanded data access will affect health plans


    Section 105 of the Medicare Access and CHIP Reauthorization Act (MACRA), also known as HR 2, will expand the availability of Medicare data, possibly doubling the amount of healthcare data available to the public. Here's more on what the data expansion could mean for the industry.

    1. Broadened non-governmental access to claims data

    Joel White, president, The Council for Affordable Health, Washington, D.C., and a former staff director of the House Ways and Means Health Subcommittee, explains that Section 105 revises the Qualified Entity (QE) program by broadening non-governmental access to claims data collected under the Medicare program. Current law, enacted in 2010, gives QEs access only to Medicare claims data (Parts A, B, and D) and requires that all analyses be published.

    The reforms in HR 2 would permit QEs to sell analyses and, in some cases, data for a range of non-public uses. "Importantly, this framework converts the QE business model from that of a nonprofit think tank, dependent on contributions, to a profit-making consultancy," White notes.

    Depending on whether The U.S. Department of Health and Human Services (HHS) decides to release Medicaid and Children's Health Insurance Program (CHIP) data, the bill could double the trove of claims data accessible to QEs (Medicare and Medicaid/CHIP each account for about 20% of personal health spending).

    2. Implications of data analyses

    Permitting QEs to sell analyses and combined data for non-public uses fundamentally alters the QE business model and the use of data for population health management. Currently QEs are nonprofit research organizations, funded by contributions. Under the new legislation, they would be for-profit consultancies. "QEs would enjoy a privileged franchise in the analysis of public data on behalf of providers and private health plans, sectors whose gross revenues are expected to total nearly $40 trillion over the next decade alone," White says.

    Various studies, including Dartmouth's regional comparisons of Medicare claims data, indicate that 20% to 50% of health spending goes toward wasteful and unsafe medical practices. "To the extent insights derived from public data can help to curb such practices, profit-driven QEs could represent a significant business opportunity and a new source of data to help researchers identify which treatments work best."

    White agrees. "The public interest in data transparency has grown apace with our exploding technical capability to glean operational insights from multiple, very large data sets," he says. "In medicine, such analyses can be used to identify best practices with respect to clinical procedures and health system organization, as well as to create accountability and competition at the individual provider level."

    Next: How data expansion will affect outcomes, health plans



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