Fact Sheets

Better Care, Smarter Spending, Healthier People: Improving Our Health Care Delivery System

Better Care, Smarter Spending, Healthier People: Improving Our Health Care Delivery System
September 29, 2015

Our Administration is committed to building a better, smarter, healthier system that puts an educated, empowered, and engaged consumer at the center of their care. This system delivers better care, spends our dollars in a smarter way, and leads to healthier communities, a healthier economy, and ultimately, a healthier country. This requires us to find better ways to deliver care, pay providers, and share and utilize information.

Tremendous progress has been made to transform our system into one that rewards value of care delivered versus volume, strengthens delivery of care through greater integration and coordination, and makes information more readily available to consumers and providers. This progress has resulted in fewer unnecessary hospital readmissions, reductions in healthcare-associated infections and hospital-acquired conditions, and improvements in quality outcomes and cost efficiency.

It is our role and responsibility to continue leading this change and to continue partnering with lawmakers, health care providers, consumers, and other stakeholders across the nation to make a transformed system a reality for all Americans.

In January 2015, the Administration announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients. The Administration set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to alternative payment models – such as Accountable Care Organizations (ACOs), advanced primary care medical homes, or bundled payment arrangements – by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. The Department of Health and Human Services (HHS) also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs. This was the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments.

At the same time, we understand the importance of engaging partners who are also committed to improving our health care system. Patients, physicians and other providers, government, and businesses all have a stake in this effort. This is why we helped launch the Health Care Payment Learning and Action Network to:

• Serve as a convening body to facilitate joint implementation of new models of payment and care delivery,
• Identify areas of agreement around movement toward alternative payment models and how best to analyze data and report on these new payment models,
• Collaborate to generate evidence, share approaches, and remove barriers,
• Develop common approaches to core issues such as beneficiary attribution, financial models, benchmarking, quality and performance measurement, risk adjustment, and other topics raised for discussion, and
• Create implementation guides for payers, purchasers, providers, and consumers.

More than 4,000 individual patients, insurers, providers, states, consumer groups, employers and other partners have registered to participate in the Health Care Payment Learning and Action Network and over 610 organizations have committed to participate.  

Significant progress has already been made and more efforts are underway.

Health care cost growth has slowed

The United States is in the midst of a sustained, historic slowdown in the growth of health care costs.  

• Health care prices have risen at the lowest rate in 50 years. Over the 64 months of data since March 2010, health care prices have risen at an average annual rate of just 1.6 percent, as measured using price data from the Bureau of Economic Analysis, slower than any prior 64-month period since data began in 1959. Health care prices have risen at an even slower 1.1 percent pace over the last 12 months.
• The average premium for employer-based family coverage rose just 4.2 percent in 2015, well below historical averages and continuing a recent pattern of unusually slow growth. Medicare spending per beneficiary is projected to rise just 1 percent in 2015, only slightly faster than overall inflation. Since 2010, growth in per-enrollee Medicare spending has been roughly in line with economy-wide inflation, whereas it exceeded overall inflation by 3.6 percentage points over the preceding decade (even after adjusting for the introduction of Medicare Part D).
• During the past several years, the Congressional Budget Office has made a series of downward adjustments to its projections of spending for Medicare and Medicaid. Since August 2010, the Congressional Budget Office has reduced its projections of Medicare and Medicaid spending in 2020 by $175 billion. This $175 billion decline represents a 13 percent reduction in projected spending and primarily reflects the recent slow growth in health care spending.

From 2009 to 2013, Medicare spending was significantly lower than expected. Specifically, Medicare spending was $316 billion less over the 2009 to 2013 period than would have occurred if previous growth rates had continued.

Health outcomes are improving and adverse events are decreasing

Patient safety has improved dramatically, thanks in part to the Hospital Readmissions Reduction Program, the Partnership for Patients Initiative, and other efforts. The Partnership for Patients Initiative continues to invest in sharing best practices and solutions for reducing hospital-acquired conditions, readmissions, and harm across hospitals nationwide. As of 2015, there have been 1.3 million fewer hospital acquired conditions and 50,000 patient deaths avoided, leading to an estimated $12 billion in health care costs saved. This translates into a 17 percent reduction in patient harm nationally over the 3-year period.

In 2012, we implemented Hospital Readmissions Reduction Program, which ties Medicare payment for hospitals to readmission rates for certain conditions (i.e., the percentage of patients that have to return to the hospital within 30 days of being discharged). After holding constant at 19 percent from 2007 to 2011 and decreasing to 18.5 percent in 2012, the Medicare all-cause 30-day readmission rate further decreased to approximately 17.5 percent in 2013. This translates into an 8 percent overall reduction in the rate and an estimated 150,000 fewer hospital readmissions among Medicare beneficiaries between January 2012 and December 2013.

Providers are engaged

The Innovation Center in the Centers for Medicare & Medicaid Services (CMS) is charged with testing innovative payment and service delivery models to reduce expenditures in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) while preserving or enhancing the quality of care.

The Innovation Center has engaged more than 60,000 health care providers in various payment and service delivery models to improve care, which has impacted an estimated 2.5 million Medicare, Medicaid, and CHIP beneficiaries.

Accountable Care Organizations: In 2012, Medicare Accountable Care Organizations (ACOs) began participating in the Medicare Shared Savings Program (MSSP) and the Pioneer ACO model. These ACO initiatives encourage providers to invest in redesigning care for higher quality and more efficient service delivery, without restricting patients’ freedom to go to the Medicare provider of their choice.

As of August 2015, over 420 ACOs currently participate in the MSSP and Pioneer ACO program, serving over 7.8 million beneficiaries. Results released earlier this year  indicated the Medicare ACOs continue improve quality of care for beneficiaries, as Shared Savings Program ACOs that reported quality measures in 2013 and 2014 improved on 27 of  33 quality measures. Pioneer ACOs showed improvement in 28 of 33 quality measures and experienced average improvements of 3.6 percent across all quality all quality measures in their third performance year.

Overall, in performance year 2014, Medicare ACOs in Pioneer and MSSP have resulted in combined total net savings of $411 million. The results show that ACOs with more experience in the program tend to perform better over time. Savings in the Pioneer ACO program coupled with improved quality of care led the independent CMS actuary to certify that it can be scaled across Medicare programs at large. The Pioneer model shaped the new MSSP Track 3 that was announced earlier this year.

Medicare beneficiaries are shopping for coverage according to quality

Medicare Advantage plans’ payments are now tied to the quality ratings of the coverage they offer. Since those payment changes have been in effect, more seniors are able to choose from a broader range of higher quality Medicare Advantage plans, and more seniors have enrolled in these higher quality plans as well.

Approximately 65 percent of Medicare Advantage enrollees are currently enrolled in plans with four or more stars for 2016, a significant increase from an estimated 17 percent of enrollees in such plans in 2009.

Below are additional specific examples of reforms and investments that are helping build a health care delivery system that better serves all Americans.

INCENTIVES:  PAYING FOR VALUE

• Hospitals. Three important programs that reward hospitals based on the quality of care they provide to patients began in 2012, and a third was initiated in 2014.
  • Hospital Value-Based Purchasing Program. This program links a portion of hospitals’ Medicare payments for inpatient acute care to their performance on important quality measures. Examples of measures include whether a patient received an antibiotic before surgery and how well doctors and nurses communicate with patients. For fiscal year 2015, as directed by the law, CMS increased the applicable percent reduction, the portion of Medicare payments available to fund the value-based incentive payments under the program, from 1.25 to 1.5 percent of the base operating DRG payment amounts to all participating hospitals.  
  • Hospital Readmissions Reduction Program. This program reduces Medicare payments to hospitals with excess readmissions beginning October 2012 to encourage patient safety and care quality. In fiscal year 2015, the maximum reduction in payments under the Hospital Readmissions Reduction Program increased from 2 to 3 percent of base discharge amounts, as required by law. CMS will assess hospitals’ readmissions penalties using five readmissions measures endorsed by the National Quality Forum.  
  • Hospital-Acquired Condition Reduction Program. This program began in October 2014 and reduces Medicare payments for hospitals that rank in the lowest performing quartile with respect to hospital-acquired conditions, which is determined based on the hospital’s performance on three quality measures (Patient Safety Indicator 90 composite, central-line associated bloodstream infection, and catheter associated urinary tract infection). Additional safety measures, such as surgical site infections and methicillin resistant staph aureus infections, have been added to the program for future years.
• Dialysis Facilities. The End-Stage Renal Disease (ESRD) Quality Incentive Program ties Medicare payments directly to facility performance on quality measures, resulting in better care at lower cost for over 503,000 Medicare beneficiaries with end stage renal disease. Through the Comprehensive ESRD Care initiative, CMS will partner with health care providers and suppliers to test the effectiveness of a new payment and service delivery model in providing beneficiaries with patient-centered, high-quality care.
• Testing Payment Models: The Innovation Center is testing innovative payment and service delivery models.
  • Bundled Payments for Care Improvement Initiative. Bundling payment for services that patients receive across a single episode of care is one way to encourage doctors, hospitals and other health care providers to work together to better coordinate care for patients, both when they are in the hospital and after they are discharged. Over 2,100 acute care hospitals, skilled nursing facilities, physician group practices, long-term care hospitals, inpatient rehabilitation facilities, and home health agencies have transitioned from a preparatory period to a risk-bearing implementation period in which they assumed financial risk for episodes of care. Additionally, 360 organizations have entered into agreements to participate in the Bundled Payments for Care Improvement initiative and an additional 1,755 providers who have partnered with those organizations.
  • Medicare Advantage Value-Based Insurance Design Model. In September 2015, CMS announced a model intended to improve outcomes and reduce costs by giving health plans the flexibility to provide new supplemental benefits specifically tailored to the enrollees’ clinical needs. The Medicare Advantage Value-Based Insurance Design Model focuses on Medicare Advantage enrollees with the chronic conditions of diabetes, congestive heart failure, chronic obstructive pulmonary disease, past stroke, hypertension, coronary artery disease, mood disorders, and combinations of these categories.
  • Home Health Value-Based Purchasing Model. In July 2015, CMS proposed a new model to test whether incentives for better care can improve outcomes in the delivery of home health services. The model leverages the successes of and lessons learned from other value-based purchasing programs and demonstrations – including the Hospital Value-Based Purchasing Program and the Home Health Pay-for-Performance Demonstration – and is the first payment model to exclusively focus on home health agencies.
  • Comprehensive Care for Joint Replacement Model. In July 2015, CMS proposed a bundled payment and quality measurement model for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery. Depending on the hospital’s quality and cost performance during the episode, the hospital may receive an additional payment or be required to repay Medicare for a portion of the episode costs. This model aims to ensure beneficiaries get the coordinated care they need, with the goal of reducing avoidable hospitalizations and complications.
  • Pioneer Accountable Care Organization Model. Pioneer ACOs are early adopters of coordinated care and tend to be more experienced, have an established care coordination infrastructure, and assume greater performance-based financial risk. These ACOs showed continued strong performance and improvement across financial, quality of care, and patient experience measures. The 20 Pioneer ACOs participating in 2014 (performance year 3) were accountable for 622,265 beneficiaries, a 2 percent increase from 607,945 beneficiaries in 2013 (performance year 2). During this same time period, these Pioneer ACOs generated total model savings of $120 million and improved the average performance score for patient and caregiver experience in 5 out of 7 measures compared to Performance Year 2, suggesting that Medicare beneficiaries who obtain care from a provider participating in a Pioneer ACO continue to report a positive experience.
  • Next Generation ACO Model. Building upon experience from the Pioneer ACO Model and the Medicare Shared Savings Program, the Next Generation ACO Model offers a new opportunity in accountable care—one that sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care.  This model encourages greater coordination and closer care relationships between ACO providers and beneficiaries.
  • The ACO Investment Model. This model is a model of pre-paid shared savings that builds on the experience with the Advance Payment Model. This model will test the use of pre-paid shared savings to encourage new ACOs to form in rural and underserved areas and to encourage current Medicare Shared Savings Program ACOs to transition to arrangements with greater financial risk.
  • Oncology Care Model. This model is a new multi-payer payment and care delivery model designed to provide enhanced services and better care coordination for cancer care as part of the Department’s ongoing efforts to improve the quality of care patients receive and spend health care dollars more wisely, contributing to healthier communities. The initiative will include 24-hour access to practitioners for beneficiaries undergoing treatment and an emphasis on coordinated, patient-centered care, aimed at rewarding high value care, rather than volume. The model encourages participating practices to improve care and lower costs through episode-based, performance-based payments that financially incentivize high-quality, coordinated care.  
• Health Care Innovation Awards. Almost 150 Health Care Innovation Awards were provided in 2 rounds in 2012 and in 2014. These awards were designed to engage a broad set of innovation partners to identify and test new care delivery and payment models that originate in the field and that produce better care, better health, and reduced cost through improvement for identified target populations. New workforce development and payment models were identified, and innovators were supported to rapidly deploy care improvement models through new ventures or expansion of existing efforts to new populations of patients, in conjunction (where possible) with other public and private sector partners.

CARE DELIVERY: PROMOTING BETTER CARE AND PROTECTING PATIENT SAFETY

• Transforming Clinical Practices: In September 2015, CMS awarded $685 million to 39 national and regional health care networks and supporting organizations to provide technical assistance support to help equip more than 140,000 clinicians with the tools and support needed to improve quality of care, increase patients’ access to information, and spend dollars more wisely. The Transforming Clinical Practice Initiative is one of the largest federal investments designed to support doctors and other clinicians in all 50 states through collaborative and peer-based learning networks.
• Comprehensive Primary Care Initiative. The Comprehensive Primary Care (CPC) Initiative is a multi-payer partnership between Medicare, other public and private payers, and primary care practices in four states (Arkansas, Colorado, New Jersey and Oregon) and three regions (New York’s Capital District and Hudson Valley, Ohio and Kentucky’s Cincinnati-Dayton region, and Oklahoma’s Greater Tulsa region). This initiative tests whether payment of population-based care management fees and shared savings opportunities to participating primary care practices to support their provision of a core set of comprehensive primary care functions can achieve improved care, better health and lower costs.  Participating practices perform a number of functions under the model, including providing care management for those at greatest risk, improving health care access, tracking patient experience, coordinating care with hospitals and specialists, and using health information technology to support population health. Results from the first year suggest that CPC has generated nearly enough savings in Medicare health expenditures to offset the care management fees paid by CMS, with hospital admissions decreasing by 2 percent and emergency department visits by 3 percent. Results should be interpreted cautiously as effects are emerging earlier than anticipated. Additional research is ongoing to assess how the initiative affects cost and quality of care beyond the first year.
• Multi-Payer Advanced Primary Care Demonstration. CMS is currently testing the Multi-Payer Advanced Primary Care Practice Demonstration, which is a multi-payer advanced primary care initiative in which Medicare partners with Medicaid and private health care payers. Under this demonstration, participating practices and other auxiliary supports (e.g., community health teams) receive monthly care management fees from the participating payers and additional support (e.g., data feedback, learning collaboratives, practice coaching). More than 4,000 providers, 700 practices, and 350,000 Medicare beneficiaries participated in the first year. Unlike the Comprehensive Primary Care Initiative, the five participating states (Maine, Michigan, New York, Rhode Island, and Vermont) convene participants and administer the initiatives rather than CMS. During the first year, the demonstration produced an estimated $4.2 million in savings. Also, the rate of growth in Medicare FFS health care expenditures was reduced in Vermont and Michigan, driven largely by reduced growth in inpatient expenditures.
• Partnership for Patients. The Partnership for Patients Initiative invests in sharing best practices and solutions for reducing hospital-acquired conditions, readmissions, and harm across hospitals nationwide. As of September 2015, there have been 1.3 million fewer hospital acquired conditions and 50,000 patient deaths avoided, leading to an estimated $12 billion in health care costs saved. This translates into a 17 percent reduction in patient harm nationally over the three-year period. At the core of this initiative is a three-pronged strategy to align federal programs, team with private and public partners, and provide resources to Hospital Engagement Networks (HENs). The HENs work with hospitals, engaging with health care providers and institutions, to identify best practices and solutions to reducing hospital acquired conditions and readmissions. In September 2015, CMS awarded $110 million to 17 national, regional, or state hospital associations and health system organizations to serve as the second round of Hospital Engagement Networks, which will enable us to continue to identify solutions already working to reduce healthcare acquired conditions and work to spread them to other hospitals and health care providers.  
• The Million Hearts®: Cardiovascular Disease Risk Reduction Model: This model is a randomized-controlled trial that seeks to bridge a gap in cardiovascular care by providing targeted incentives for providers to engage in individual cardiovascular disease risk calculation and population-level risk management. Instead of focusing on the individual components of risk, participating practices will engage in risk stratification across a patient panel to identify those Medicare beneficiaries at highest risk for cardiovascular disease.
• Healthy infants. The Strong Start for Mothers and Newborns initiative, announced in February 2012, aims to improve birth outcomes through two different but related initiatives. Strategy I tested a nationwide public-private partnership and awareness effort to spread the adoption of best practices to reduce the rate of early elective deliveries before 39 weeks for all populations. As part of this initiative, clinicians at some hospitals reduced their early elective deliveries to close to zero, resulting in fewer at-risk newborns and fewer admissions to the neonatal intensive care unit. Strategy II is testing the effectiveness of specific enhanced prenatal care approaches to reduce preterm births for high-risk women enrolled in Medicaid and CHIP. The enhanced services are provided in birth center care, group prenatal care, and maternity care home settings. February 2015 marked the beginning of the third year of the initiative and programs are continuing to provide enhanced prenatal services to Medicaid and CHIP beneficiaries, as well as developing sustainability plans for post award activities and services. Additionally, CMS is partnering with the Administration for Children and Families (ACF) and the Health Resources and Services Administration (HRSA) to evaluate HRSA’s Maternal, Infant, and Early Childhood Home Visiting Program, as another arm of Strategy II.
• New options of care. The Medicare Care Choices Model empowers beneficiaries, their families, and clinicians by providing them with greater flexibility when faced with life limiting illness. The Medicare Care Choices Model provides Medicare beneficiaries who qualify for coverage under the Medicare hospice benefit and dually eligible beneficiaries who qualify for the Medicaid hospice benefit who satisfy the Model’s eligibility criteria the option to elect to receive supportive care services typically provided by hospice, while continuing to receive curative services. In July 2015, over 140 Medicare-certified hospices were selected to participate in the five-year model, which will enable up to 150,000 eligible Medicare and dually eligible beneficiaries to participate.
• Better coordination of care for beneficiaries with multiple chronic conditions. The Medicare Physician Fee Schedule for calendar year 2015 now includes a chronic care management service. This separate payment for chronic care management supports physician practices in their efforts to coordinate care for Medicare beneficiaries with multiple chronic conditions. This helps improve the way care is provided by supporting clinicians coordinating care for patients, including outside of regular office visits.
• Medicaid innovation and payment reform. Through the Medicaid Innovation Accelerator Program, we are building on lessons and recommendations we have heard from our state partners for specific opportunities to advance innovation, and we are developing strategically targeted resources and technical assistance that states can leverage to accelerate Medicaid-focused innovations to transform health care. The model supports states’ efforts to accelerate new payment and service delivery reforms.
• Providing states with additional flexibility and resources to enhance care. The State Innovation Models Initiative aims to help states deliver high-quality health care, lower costs, and improve their health system performance. Together with awards through this initiative, over half of the states (34 states and three territories and the District of Columbia), representing nearly two-thirds of the population are participating in efforts to support comprehensive state-based innovation in health system transformation aimed at finding new and innovative ways to improve quality and lower costs. Seventeen states are currently implementing comprehensive state-wide health transformation plans (Arkansas, Colorado, Connecticut, Delaware, Idaho, Iowa, Maine, Massachusetts, Michigan, Minnesota, New York, Ohio, Oregon, Rhode Island, Tennessee, Vermont, and Washington).
• Integrating care for individuals enrolled in Medicare and Medicaid. Many of the ten million Medicare-Medicaid enrollees suffer from multiple or severe chronic conditions. Total annual spending for their care is approximately $300 billion. Thirteen states (California, Colorado, Illinois, Massachusetts, Michigan, Minnesota, New York, Ohio, Rhode Island, South Carolina, Texas, Virginia, and Washington) have entered into agreements with CMS to integrate care for Medicare-Medicaid enrollees. Enrollees participating in the Financial Alignment Initiative have access to coordinated services and – in some states – services that were not available outside of this demonstration, like dental, vision, and community-based behavioral health services. These demonstrations are designed to provide enrollees with person-centered, integrated care that provides a more easily navigable and seamless path to accessing and using services covered by Medicare and Medicaid.   
• Greater independence for Americans with disabilities and long-term care needs. A number of policies promote non-institutional long-term care programs that will help keep people at home and out of institutions:
  • Money Follows the Person Program. The Money Follows the Person Program helps states rebalance their long-term care systems in part by transitioning Medicaid beneficiaries from institutions to the community. As of December 2013, over 40,650 individuals with chronic conditions and disabilities have transitioned from institutions back into the community through the Money Follows the Person Program. The 44 participating States and DC have proposed to transition an additional 25,816 individuals out of institutional settings through 2016.  
  • Balancing Incentive Program. Nineteen states are participating in the Balancing Incentive Program, which gives states incentives to increase access to non-institutional long-term services and supports and provides new ways to serve more Medicaid beneficiaries in home and community-based settings.
  • Health Home State Plan Amendments. Sixteen states have approved Health Home State Plan Amendments to integrate and coordinate primary, acute, behavioral health, and long term services and supports for Medicaid beneficiaries.
  • Promoting care at home. The Independence at Home Demonstration tests whether providing chronically ill beneficiaries with primary care in the home will help them stay healthy and out of the hospital. Fifteen primary care practices are participating in the Independence at Home Demonstration.

INFORMATION: IMPROVING THE AVAILABILITY OF INFORMATION TO GUIDE DECISION-MAKING

• Electronic Health Records (EHRs). Adoption of electronic health records continues to increase among physicians, hospitals, and others serving Medicare and Medicaid beneficiaries supporting advanced clinical process and patient safety, enhanced quality measurement, and care coordination through health information exchange. The proportion of U.S. physicians using EHRs increased from 18 percent to 78 percent between 2001 and 2013, and 94 percent of hospitals now report use of certified EHRs. Electronic health records will help speed the adoption of many other delivery system reforms by making it easier for hospitals and doctors to better coordinate care and achieve improvements in quality.
• Access to Cost, Charge, and Quality Data. Cost and charge data for hundreds of services (inpatient, outpatient, and physician services) and quality scores for hundreds of thousands of hospitals, physicians, nursing homes, and other providers are now available on the Medicare website. These websites are part of an Administration-wide effort to increase the availability and accessibility of information on quality, utilization, and costs for effective, informed decision-making.
  • Physician Compare. The Physician Compare website helps consumers make informed choices about the health care they receive from Medicare physicians and other health care professionals. Currently, users have the ability to compare the general information for up to three group practices on Physician Compare. This includes names, addresses, distance from the search location, specialty, Medicare assignment, and affiliated health care professionals. The first quality measures were added to Physician Compare in February 2014, and since then, the number of groups reporting quality data through the Physician Quality Reporting System (PQRS) has doubled.  In 2015, CMS plans to expand physician compare to include quality performance results for all physician groups.
  • Hospital Compare. The Hospital Compare website helps consumers make informed choices about the health care they receive from hospitals. Hospital Compare has information about the quality of care at over 4,000 Medicare-certified hospitals across the country and includes measures such as access to timely and effective care, readmissions, and patient experience, among many others. Beneficiaries also can now find information on the incidence of serious hospital-acquired conditions in individual hospitals. In FY 2015, hospitals with high rates of hospital-acquired conditions will see their Medicare payments reduced.
  • Charge Data for Hospital and Physician Services. In May 2013, HHS released for the first time new data showing variation across the country and within communities on what hospitals charge for common inpatient services. The data posted on CMS’s website include information comparing the average hospital charges for inpatient services that may be provided in connection with the 100 most common Medicare inpatient stays. Hospitals determine what they will charge for items and services provided to patients and these “charges” are the amount the hospital generally bills for an item or service. The website also includes data on outpatient charges. In April 2014, CMS updated the hospital data and released for the first time comprehensive data on physician utilization and charges in the Medicare program.
  • Qualified Entity Program. The Qualified Entity Program, created by the Affordable Care Act and subsequently expanded by the Medicare Access and CHIP Reauthorization Act of 2015, currently allows organizations approved as qualified entities (QEs) access to standardized extracts of Medicare data for use in provider and supplier performance evaluations. The findings of these evaluations are then reported out in of public performance reports. These reports analyze private sector and/or Medicaid claims data with the Medicare data to identify which hospitals, doctors and other providers and suppliers provide the highest quality, most cost-effective care. QEs must protect the privacy and security of the Medicare claims data, and may currently only use it for purposes of the public performance reporting under the QE Program. To date, CMS has certified 12 regional QEs and one national QE. Two of the regional QEs, Q-Corp and Health Insight, released public reports using the combined Medicare and other payer data in 2014.    

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