Transparency in Action: “The Imperfect Is Our Paradise”
Authors: Eli Y. Adashi
Journal: JAMA (2014)

Just6monthsago,onApril9, 2014, the Centers forMedicare &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 2012weremore than 880 000Medicare-participatinghealthcare providers. This release of CMS data capped a 35year legal saga that beganwhen 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 aboutMedicarepayments to individualphysicians 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 riskadjust the data to reflect the relevant case mix or to furnish metrics that indicate the quality of care provided by an individual. Moreover, the informationprovideddidnot 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-sectorpayers (adeficiency that cannot be helped because the proprietary information inquestion isnot in thepublicdomain). 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 userfr iendly. 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 userfriendly 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 procedurehasbeenstruggling to identifyan 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 toguessworkor to a poorly conducted poll. It follows that whatever conclusions are ultimately reached, they have everything to do with hearsay andnothing todowith facts. This is hardly theplace tobewhenyourhealth ison the line. It need not be this way. Unfortunately, though, most surgeons are not in the habit of listing and sharing their case volumes (howoften theyperformagivenprocedure in a year) and patient outcomes. Enter health care data transparency. It took my colleague all of 10 minutes using a searchableversionof thepublic-usedata file releasedbyCMStogeneratea listingofhighvolume local surgeons.Althoughhardly synonymouswith good outcomes, high procedural volumes are predictive of such. A surgeonwho frequentlyperformsaparticular procedure is more likely to have better outcomes than one who does not. My colleague’s experience would not havebeenpossiblebeforeApril9,2014. I call this progress.