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From Health Law Daily, June 1, 2015

Increasing transparency, hospital and physician utilization data issued

By Anthony H. Nguyen, J.D.

Fact sheets regarding Medicare hospital utilization and payment data for inpatient and outpatient facilities, as well as physician and other supplier utilization and payment data, were issued as part of the Obama Administration’s efforts to provide a clearer understanding of Part A and B costs, services, and trends. Comprised of fiscal year (FY) 2013 values, the third annual inpatient and outpatient hospital data and second annual physician data sets were promoted at the annual Health Datapalooza conference in Washington, D.C.

Hospitals, physicians, and other health care providers determine what they will charge for services and procedures provided to patients and these “charges” are the amount the hospital or provider generally bills for the service or procedure, but the amount paid is determined by Medicare’s physician fee schedule or other payment methodologies.

The Administration set measurable goals and a timeline to move Medicare toward paying providers based on the quality, rather than the quantity, of care provided to patients. The data releases are part of a wide set of initiatives to achieve better care, smarter spending, and healthier people through our health care system.

Hospital utilization and payment. The Medicare hospital utilization and payment fact sheet detailed the average amount a hospital billed for services that could be provided in an inpatient stay or outpatient visit. Included in the data was information for services connected to the 100 most common Medicare inpatient stays, which represented approximately $62 billion in Medicare payments and over 7 million hospital discharges. In addition, data on services connected to 30 selected outpatient procedures was provided. The data was collected from over 3,000 hospitals in all 50 states and the District of Columbia.

The data also provided average Medicare payment information for the top-100 inpatient discharges to provide a point of comparison against hospital charges for the services. CMS used inpatient data from the Medicare Providers Analysis and Review (MedPAR) dataset for FY 2013 to produce the new data. The MedPAR dataset contains Medicare inpatient hospital claims for all Medicare beneficiaries enrolled in Medicare Part A.

Major joint replacement continued to be the most frequently occurring discharge nationally with over 446,000 total discharges and total allowed amount cost of $6.6 billion, with the highest discharge rates in the Midwest and Rocky Mountain areas. Generally, charges increased over time at a modest rate. For example, major joint replacement grew at a rate of 4.3 percent—from $50,116 to $52,249 between 2011 and 2012—and 3.8 percent—from $52,249 to $54,239—between 2012 and 2013.

Physician data. The Medicare Part B physician, practitioner, and other supplier utilization and payment data consisted of information on services and procedures provided to Medicare beneficiaries by physicians and other healthcare professionals. The 2013 dataset has information for over 950,000 distinct health care providers who collectively received $90 billion in Medicare payments.

CMS created the data set using information from the Physician/Supplier Part B Claims File, also known as the Carrier File, which has final action fee-for-service (FFS) claims that are submitted by physicians and other non-institutional health care providers, such as non-physician practitioners, ambulatory surgical centers, clinical laboratories, and ambulance providers.

For the physician data set, new features were incorporated, including: (1) flagging whether the Healthcare Common Procedure Coding System (HCPCS) product/service is a drug as defined in the Medicare Part B average sale price list; (2) better HCPCS descriptions, expanded to include consumer friendly descriptions; (3) comprehensive summary files, summarized from Medicare Part B claims; and (4) state-level and hospital referral region-level Medicare enrollment data.

Results from the Part B physician data indicated that hematology/oncology and medical oncology had the highest overall average cost per provider, yet when examining only medical services, these specialties had some of the lowest average costs among the group. Additionally, a large number of internal medicine physicians billed medical services in 2013 and thus these physicians had a large combined total cost to the Medicare program, but their average allowed amount per service was low compared to some other specialties. Nationally, the number of office visits per capita was six visits per enrolled beneficiary; the highest utilization was in the south, the west, and on the east coast, with lowest utilization rates in the north-central states.

MainStory: TopStory AgencyNews IPPSNews CMSNews BillingNews PartANews PartBNews PhysicianNews OPPSNews QualityNews

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