The American Medical Association (AMA) is committed to transparency and supports the release of data that can help improve quality of care. The AMA believes that certain safeguards are needed to ensure that the public receives accurate information placed in proper context.
The AMA highly recommends that reporters consider the following concerns about the limitations of Medicare Part D claims data in developing potential stories or publications. Medicare claims data is complex and can be confusing, and the manner in which CMS is broadly releasing it, in different formats and at different times and without context, can lead to inaccuracies, misinterpretations and false conclusions.
In order to ensure that the information reported is helpful, accurate and complete, media should take into account the following:
- Treatments: The data does not account for varying strengths or dosage levels of the medications or varying patient needs. For example, a physician could prescribe a low dose of a medication and at a later time need to prescribe another, stronger dosage for the same patient if the low dose isn't meeting their need or if the patient has an adverse reaction.
- Branded vs. Generic: The data does not provide information on substitutions. State laws on generic substitutions will make it difficult to compare the filling of prescriptions of branded medications versus generic alternatives across the country. Additionally, there may be certain physicians who look like outliers in the prescription of branded medications because they treat patients for conditions where the best treatments available are still on patent and there is no generic equivalent.
- Quality: The data does not include explicit information linking treatment to the quality of care provided. It solely focuses on payment and utilization so it should not be used to evaluate care provided. The utilization part of the data may not be accurate if a patient had poor medication adherence or if the patient has an adverse reaction to a pharmaceutical and requires a prescription for an alternative treatment.
- Charges vs. Payment: The pharmaceutical cost information does not include manufacturer coupons or rebates that often help mitigate out-of-pocket costs for patients. There could also be price differences depending on where a patient gets his or her prescription.
- Patient population: The data is incomplete because it does not include instances where there were less than ten claims for a certain treatment for a particular provider (CMS has said that the main file only represents 86.8 percent of claims). Additionally, it does not include treatments paid for by private insurance plans, for patients not covered under Medicare Part D or Medicaid beneficiaries making it a limited view of the patients a physician cares for that could lead to misrepresentations and invalid calculations. The data is also not risk adjusted and fails to take into account patients' health and socioeconomic status as well as medication adherence, all of which impact prescribing practices. Furthermore, physicians do not have a way to correct the information reported.
- Provider comparisons: There is a lack of specificity in specialty descriptions and practice types in the data, which could be misleading when making comparisons between physicians. In some cases, physicians who appear to have the same specialty can serve very different types of patients, thus impacting the mix of treatments prescribed. For example, physicians who work in a hospice or palliative care setting could look like outliers in their prescription of opioids.
Additionally, some of the treatments a physician provides could be listed under their organization as opposed to their individual NPI, making their prescription levels seem lower than they are in actuality.
- Data comparisons: There are significant differences between the data sets that CMS has released over the past year that should be taken into account before making comparisons. These various releases have included data for different timeframes and Medicare populations, and have also identified physicians in multiple ways. There is also a significant concern about the accuracy of the Open Payments data since the vast majority of it has not been validated or reviewed to ensure accuracy.
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About the American Medical Association
The American Medical Association is the physicians’ powerful ally in patient care. As the only medical association that convenes 190+ state and specialty medical societies and other critical stakeholders, the AMA represents physicians with a unified voice to all key players in health care. The AMA leverages its strength by removing the obstacles that interfere with patient care, leading the charge to prevent chronic disease and confront public health crises and, driving the future of medicine to tackle the biggest challenges in health care.