Physician Tiering

 

Ideally, tiering physicians should enable patients to make educated choices about which clinician to visit, while at the same time encourage clinicians to strive for higher rankings. To date, ranking clinicians based on their performance has been used in a wide variety of programs. Top tier clinicians with high rankings according to a third party payer could have low patient copays (e.g. $10), whereas bottom tier clinicians who ranked poorly may have high copays (e.g. $50) Thus, in an effort for patients to save money, they are incentivized to see a physician with a smaller copay. Rankings may also be used to determine which clinicians are considered in or out of network. In this way, clinician ranking uses market forces to drive quality improvement.

The most controversial aspect of clinician tiering is ranking based on “cost-effectiveness” and “efficiency”. In fact, most of the literature in the past three years surrounds legal action taken against tiering systems based solely on cost (69, 71, 74, 75, 76, 160, 161). Legal action in some states (e.g. Massachusetts and New York) has resulted in more transparent tiering systems such that insurers ranking clinicians based solely on cost must make that apparent to patients. It is important to note that tiering clinicians based on cost is legal, so long as the basis for the rankings is not misrepresented to patients.

There may be a legitimate role for clinician tiering based on sophisticated efficiency measures that acknowledge clinicians achieving similar outcomes in similar patient populations but at less cost as compared to their peers. Indeed, Krasner (13) suggests that tiering is part of the solution to rising health care costs.

This section reflects the highly politicized and controversial elements of clinician tiering. Glendinning and Allen (10, 272) explore additional benefits and burdens including the quality improvement potential for clinicians given proper feedback, and the conflict of interest for insurers who design the very measures they stand to gain from financially.

 

Physician Tiering Literature

 

(10) Glendinning D. MedPAC explores physician comparisons. American Medical News. May 16, 2005.

Link: http://www.ama-assn.org/amednews/2005/05/16/gvsc0516.htm

Summary:

  • Data for comparing physicians will need to incorporate other factors in care, not just P4P measures.
  • Physicians will listen to feedback about their care when it is clear and succinct.
  • Comparison data should be standardized.

Significance to Literature:

The idea of physician comparisons is examined in a political context.

 

(13) Krasner J. Plan would tie copayments to doctors’ rankings. The Boston Globe. Jan. 27, 2006.

Link: http://www.boston.com/news/local/massachusetts/articles/2006/01/27/plan_...

Summary:

  • Article outlines physician tiering as one solution to rising costs in healthcare.
  • The market is driving an increase in physician rankings/tierings.

Significance to Literature:

Early commentary on movement towards tiering in New England.

 

(69) Berry E. Fight over physician quality ratings moves to Massachusetts. American Medical News. December, 24/31, 2007.

Link: http://www.ama-assn.org/amednews/2007/12/24/bisb1224.htm

Summary:

  • Article addresses physician quality rating systems in New York and Massachusetts.
  • Many physicians feel insurance companies rank them largely on costs.
  • Attorney General of New York signed a deal pledging that they would use independently derived quality measures to establish tiered networks.

Significance to Literature:

Massachusetts is facing the same legal battle over physician ranking as New York.

 

(71) Putting the Quality in Rankings. American Medical News Opinion. December 3, 2007.

Link: http://www.ama-assn.org/amednews/2007/12/03/edsa1203.htm

Summary:

  • New York State and Cigna reached an agreement that calls for Cigna to use independently developed quality criteria.
  • Cigna is prohibited from using cost data to rank doctors.
  • Requires Cigna to pay for a third party ratings examiner.
  • Physicians will be able to appeal these ratings.

Significance to Literature:

New York State requires insurers’ rating of physicians to be independent, transparent, and not based on cost data.

 

(74) Gugliemo WJ. Ranking plans face legal scrutiny. Medical Economics. November 16, 2007.

Summary:

  • Many doctors are pleased with legal actions against financially driven ranking systems.
  • The managed care industry is becoming more cautious to move towards tiered networks.

Significance to Literature:

Insurers must increase transparency in their rating systems as mandated by the New York Attorney General in October, 2007.

 

(75) Sorrel AL. Resistance builds against insurers’ tiered networks. American Medical News. September 17, 2007.

Link: http://www.ama-assn.org/amednews/2007/09/17/prl20917.htm

Summary:

  • Physicians speak out against tiered rankings based on claims data.
  • “Patients want best care, not cheapest.”
  • Describes various legal actions against insurers for unfair tiering.

Significance to Literature:

Physician rankings are controversial, especially within P4P.

 

(76) Berry E. More health plans agree to NY model for physician rankings. American Medical News. December 10, 2007.

Link: http://www.ama-assn.org/amednews/2007/12/10/bisb1210.htm

Summary:

  • Final three remaining health insurance companies in New York agreed to adopt better accuracy and transparency for tiered ranking standards and submit to outside oversight.

Significance to Literature:

New York legislators and insurers agree that physician tiering cannot be based solely on cost; legislation to follow.

 

(160) Sorrel AL. Massachusetts doctors sue, saying ranking program is flawed. American Medical News. July 7, 2008.

Link: http://www.ama-assn.org/amednews/2008/07/07/prsa0707.htm

Summary:

  • Doctors in Massachusetts sued the Group Insurance Commission for their ranking system that “put cost ahead of quality patient care.”
  • Doctors pointed to inaccurate records from claims data and computer tools used to arbitrarily rank physicians.
  • Doctors also complained of never knowing what the quality measures were.

Significance to Literature:

Example of legal action taken by doctors in response to inaccurate ranking/tiering by insurance companies.

 

(161) Trapp D. Colo. Adopts doctor rating standards, health system reforms. American Medical News. July 7, 2008.

Link: http://www.ama-assn.org/amednews/2008/07/07/gvsb0707.htm

Summary:

  • Colorado signed a new law enabling physicians to review and contest health plan rating systems.
  • Physicians will have prior notice of the ratings, and a chance to correct or appeal them.

Significance to Literature:

Example of changing laws in response to inappropriate tiering of physicians.

 

(272) Allen D. Health Plan “Tiering” of Providers: “Tiering” Innovative or Ill-Advised? Metro Doctors. October/September 2005.

Summary:

  • Article outlines physician tiering systems in Minnesota, and what both consumers and providers can expect in the future.
  • The four principle issues facing tiering are:
    • Incompleteness: "only a narrow range of health services are being measured."
    • Data may reflect populations served, not the care itself
    • Uncertain profundity: "Its unclear which indicators are meaningful, and which are trivial."
    • Vulnerable to manipulation

Significance to Literature:

Tiering is another incentive that can be used to encourage increased quality of care, and like P4P it too has challenges.