Physician Tiering by Health Plans in Massachusetts

Abstract

Background: Physician tiering is an emerging health-care strategy that purports to grade physicians on the basis of cost-

Acuity, outcomes, and trends in the transfer of surgical patients: a national study

“…Even controlling for case mix and patient factors, transferred surgery patients appear to have worse outcomes compared to non-transferred patients in institutional studies [2,3]. North Carolina is the first state where insurance companies have started tiering surgeons and determining co-payments depending on the tier of the surgeon [10]; for example, a patient going to a ''tier two'' surgeon as determined by insurance will have to pay significantly more out of pocket expenses than if they are taken care of by a ''tier one'' surgeon [10][11][12]. Unfortunately, current tiering methods do not take patient comorbidities into account [13].…”

Public Reporting of Cost and Quality Information in Orthopaedics

“…This standard set of metrics would also include the development and use of comparative effectiveness research results for musculoskeletal care, the identification of methods necessary for risk-adjusting the data to achieve fair comparisons as well as the formulation of strategies to tailor and disseminate reports to specific target audiences. Efforts to create a standard set of reportable metrics for orthopaedics have highlighted the difficulties in collecting data that is accurate [7], and that effectively ensures both appropriate attribution of beneficiaries to providers, and accurate assignment of costs among providers [46]. These efforts have also highlighted the challenges associated with creating readily usable performance measures that can be applied toward improving practice [8].…”

“…The steps required to achieve sufficient volume and accurate attribution are made more difficult by the existing team-based structures of healthcare delivery. It is challenging (and perhaps inappropriate with a risk of undermining team function) to report individual provider concerns about variation in patient risk at the individual provider level, as well as limited data for appropriate risk adjustment at this level and a small patient sample size render it difficult to ensure that a physician's practice profile primarily reflects their individual performance [46]. For example, Scholle et al [42] have reported that results based on the denominator of patients for a single physician are performance metrics or to implement the use of episode-based cost payment with physician attribution allotted if x% of a physician's own costs is in the profile.…”

Measuring Changes in the Economics of Medical Practice

“…The role of the primary care physician in care received by patients varies substantially from setting to setting, 26,27 and patient attribution and severity adjustment pose daunting challenges to population based metrics of physician output. [28][29][30] Thus, there may be no one metric for the output of physician work that can be applied to all physicians in all settings. For example, while work RVUs might be an effective way to capture the daily work of a radiologist or an interventional cardiologist, the lack of RVUs for care coordination or advanced access (such as telephone or email communication) render them of limited value in measuring outputs for a family physician or a cardiologist managing heart failure patients.…”