AMGA Senior Advocacy Leaders on CMS’s New Pilot Program Around Claims-Data Sharing with MDs

Aug. 16, 2019
Leaders of the American Medical Group Association share their perspectives on CMS’s new pilot program that will involve the sharing of claims data with providers—and its implications for the future

On August 14, the Alexandria-based AMGA (American Medical Group Association) published a press release on its website that commended the federal Centers for Medicare & Medicaid Services (CMS) for initiating a pilot program that has been signed to appropriately share claims data on Medicare patients with clinicians and providers, and encouraging CMS to move forward to increase and enhance that activity.

As stated on its website, the press release began, “AMGA today endorsed two new Centers for Medicare & Medicaid Services (CMS) initiatives that are designed to ensure providers have access to claims data. Expanding access to administrative claims data for providers and their patients has been a longstanding AMGA priority. The initiatives,” the press release stated, “include Data at the Point of Care (DPC) and MyHealthEData. DPC is a new pilot application programming interface (API) program that would make beneficiaries’ Medicare claims data available to the provider for treatment. MyHealthEData, relies on Medicare’s Blue Button 2.0 initiative to provide beneficiaries and their providers with claims data. AMGA appreciates CMS enabling providers to access Medicare beneficiary claims data directly within their existing workflows through APIs, and we share CMS’ belief that access to a patient’s complete health record is crucial to managing a patient population and improving health outcomes.”

The press release quoted Jerry Penso, M.D., AMGA’s president and CEO, as saying that “Access to claims data from all payers has been a longstanding priority for AMGA and its members. CMS’ latest initiatives support AMGA’s work by allowing providers to access Medicare claims data, and in effect, ensuring the successful transition from volume to value. If successful, CMS’ initiatives should inspire commercial insurers to follow suit in data sharing, a crucial step in delivering the most effective care for patients and improving health outcomes.”

As the press release noted, “Over the past four years, AMGA members repeatedly have indicated that access to timely Medicare and commercial payer administrative claims data is the most significant barrier to assuming risk. The DPC pilot and the MyHealthEData initiative could benefit organizations transitioning to value-based care. A study in the Annals of Internal Medicine further found that access to this data could be very helpful in providing effective courses of treatment with patients; however, care coordination challenges were still present. AMGA looks forward to working with CMS to help ensure the success of these initiatives and demonstrate the need for data sharing in the commercial setting.”

The press release highlighted the fact that AMGA had sent a letter, also on Aug. 14, to CMS Administrator Seema Verma, on the subject. The letter, sent under Dr. Penso’s signature, stated, among other things, that “CMS explains that its rationale for the DPC pilot is that providers cannot easily access their patients’ complete health record. AMGA shares this concern and notes that successfully managing a patient population requires that providers have access to claims data to ensure the most effective course of action in improving health outcomes. Without this data, it is challenging to manage the cost and quality of care to a patient population, which is a goal of value-based care. CMS notes that it wants clinicians to be able to access Medicare beneficiary claims data as a way to reduce burden in the exam room and give clinicians more time to deliver high-quality care for their patients.”

Further, the letter stated, “AMGA and our members share this vision. Access to claims data from all payers has been a longstanding priority for AMGA and its members. For the past four years, AMGA has conducted annual risk-readiness surveys of our membership to obtain a snapshot of the progress and challenges providers face during the value-based transformation of the U.S. healthcare system. In these surveys, AMGA members expressed concern with the lack of access to timely Medicare and commercial payer administrative claims data as the most significant barrier to assuming risk and transitioning to value-based care. While AMGA understands that the DPC pilot allows providers to access only Medicare beneficiary claims data,” Dr. Penso wrote, “our members also require access to data for patients who are commercially insured, which is outside CMS’ purview. We anticipate that if this DPC pilot is successful, other insurers will follow your example and further move our healthcare system to one based on value.”

Following the publication of the press release, Chet Speed, AMGA’s chief policy officer, and Lauren Lattany, the association’s director of government relations, spoke with Healthcare Innovation Editor-in-Chief Mark Hagland, regarding the association’s press release and the broader implications of the current moment. Below are excerpts from that interview.

Do you believe that CMS will respond in the way that you would like, per the letter that has been sent under Dr. Penso’s signature?

Chet Speed: We are thrilled that CMS and HHS [the Department of Health and Human Services] are acknowledging what we’ve been saying for the past four years, which is, if we’re going to make this shift towards value, we need to share data. And if you look at Ms. Verma’s comments around the pilot, she says the same thing, that if you want to make the shift, you need to share data. So we’re thrilled by that. Do we think they’ll do what we want them to do? It’s a pilot. And there’s a Google listserv is around the pilot, and questions are being asked.

Lauren Lattany: Yes, there are ongoing questions from providers and vendors, and CMS has someone running point on this. And one basic question is, when will this happen? Apparently, data will start rolling out this week. They expect a full rollout by September at the earliest, October at the latest. And the list of providers involved will eventually be publicly available. How long is this pilot going to last? They don’t know. Some even asked which groups will be able to see the data, and they haven’t responded. So there are still a lot of questions, including who can access the data on the part of patients. And if care coordination and utilization are the points of the pilot, then there are still some outstanding questions.

Will this pilot be significant enough that private payers will follow suit quickly?

Speed: That certainly is the hope. Private payers tend to follow Medicare; but that’s on payment. Now, historically, private payers have wanted to keep data firmly in house. But hopefully, the large commercial payers will decide to get involved in this. What we’d like commercial payers to see is, when you start to share data … And in order to control the total cost of care, you need claims data. And we hope that payers will see that, too, and that you’ll see reductions in cost, and the closing of care gaps.

Lattany: And some of the latest initiatives in Congress do look at data gaps. So having this linkage with actual legislative authority, only strengthens our argument. And we have it currently debated in the Senate, so the actual viability of turning it into law would be very strong. It’s called the Lower Health Care Costs Act.

When looking at these issues most broadly, do you think that CMS and HHS officials are moving in the right direction, overall, and that this pilot program reflects a broadly progressive direction?

Speed: Yes, I agree about that. When [Health and Human Services Secretary Alex] Azar took over, one of his biggest planks was value. And I think they’re moving it in that direction, whether through their approach around risk in the MSSP; and also now, this. It’s about paying for outcomes; and also transparency, per the regs that just came out around the OPPS. So yeah, they’re in a way, a fairly aggressive administrative administration, in terms of paying for value.

Lattany: I think this is a huge signifier to the healthcare industry. And it’s nice to see the work being validated from our perspective, because our members have been doing the work; and this will help us to do more.

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