Questioning the Trend Towards Physician Tiering

Hi Will:

I wanted to write to you about what I consider a disturbing trend in the medical insurance industry. A number of health plans are placing physicians into tiers based one mostly there cost to treat a particular common diagnosis. The plans are supposed to include quality of care as well but have not because there are no good measures as of yet. The purpose of tiering is to have patients have higher co-pays (and eventually deductibles) to see physicians that cost more to the insurance company.

This is a way of steering patients away from physician choice based on a financial incentive. Interestingly, it is illegal for us as physicians to waive a co-pay because it is considered enticing patients to come to your practice based on financial incentives.

More importantly, it is inherently more costly for a children to be seen at a teaching hospital on an average basis because of the complexity of the ilnesses. For example, if they want to know how much it costs me to place ear tubes in a child compared to the community (a common procedure for a common diagnosis), on average it will be higher for me because I take care of the child with Down syndrome, cancer who is immunocompromised, cardiac transplant patient etc.. All of these patients need special evaluations and postoperative care because of their co-morbidities and not the common procedure they are having for a common problem. I would classified as tier 3 (the highest) and when those patients come to see me they need to pay (example) $40 as opposed to seeing a tier 1 physician (example) $20. The Tier 1 physician is inherently cheaper because they tend to work in hospitals that do not have the resources to care for the sicker child and infact, refer them to me for care.

This has the following problems as I see them:

Patients and families of children who are very sick and may only be cared for at specialty facilities will be forced to pay more (co-pays) and eventually deductibles. This is a burden on families who already have the emotional and financial stress of taking care of a sick child (missing work for example).

Families with lower incomes (not including masshealth) may not be able to afford to see a physician they want even though they are in the same plan as other subscribers who may have more money. They now have the burden of deciding there childs care patially on a financial basis.

There is a huge number of families with children in the down syndrome clinics who see multiple physicians (cardiology, genetics, otolaryngology etc) who will see an increase in there co-pays while other families with children not relying on these services may not.

I would guess that if one of the large groups (cystic fibrosis, down syndrome etc) knew about this discrepency it would not go over well.

Click herefor the tufts health care information about tiering: they state in there that though they want to include quality as a measure that they do not. It is financially based. Specifically read the first two paragraphs on page 3.

Thank you for listening. As physicians we are not allowed to forgo a co-pay as stated above so I feel the same should be for the insurance company. In fact, if I have a patient who lost a job or has financial hardship I waive the whole bill (which is legal) so that the child ca continue to receive the care they need.

I would appreciate it if you could talk to someone in the house who may know or be involved with the insurance companies to get their take on this and the legality.

I think that there could be a large contingency of families with children with special needs that would see this policy as inherently unfair to the child and limit families who can have health insurance but not extra money to spend on larger co-pays.

I am not representing any hospital but only myself on this matter.

Respectfully yours


Below is right from their website on how to choose a doctor. Notice that no mention is made of differences in co-pay although clearly the differential in co-pays is the intent to influence physician choice for families.

What You Should Know About Choosing a Doctor [] <>
The Agency for Healthcare Research and Quality (AHRQ) suggests you determine the following when selecting a physician:

*   Make a list of what you’re looking for in a doctor (location, male/female, specialty, language spoken, health plan and hospital affiliations, etc.)
*   Ask for referrals from family, friends, health practitioners, and hospitals and determine which doctors you’d like to learn more about
*   Research the doctor’s qualifications, training, background, and quality of care through trusted sources such as those below
*   Call the doctor’s office and inquire about office hours (do they have evening and weekend appointments, is the doctor accepting new patients, who are the other practitioners in the practice, how long does it take to schedule a routine appointment)
*   Once you’ve narrowed down your choice, make an appointment with your prospective doctor to discuss your needs and determine if you’ll be comfortable with he or she as your personal doctor.

Researching Your Doctor

To help get you started, use the tools below to explore and comparison shop.

*   Massachusetts Board of Registration in Medicine
<>Provides profiles on every licensed physician in the Commonwealth about his or her education, training, specialties, insurance and hospital affiliations, translation services, malpractice claims, disciplinary actions and more!
*   Clinical Quality Report (Quality Insights)<>
Compare how well Massachusetts medical groups provide preventive services and take care of patients with chronic diseases (by Massachusetts Health Quality Partners (MHQP)
*   Patient Experience Survey:<>
Statewide survey results of patients experiences with their Primary Care Providers for over 400 Massachusetts doctors offices (by MHQP)
*   NCQA’s<> Physician Recognition Directory <>
Search for NCQA-Recognized physicians that have met the highest standards of quality care in the areas of heart/stroke care, diabetes care and systematic processes.

One reply on “Questioning the Trend Towards Physician Tiering”

  1. This is a very deep issue that recurs in every field where people are trying to introduce accountability measures — from teaching to substance abuse treatment to specialist medicine. I spent a year working with a national panel on this issue in substance abuse treatment.

    My bottom line on it is that, yes, no measure is perfect, but they have to do something. I basically support physician tiering. I read through the whole document that you attached and they do drop the outlier cases, so the most difficult cases in the Tufts population are not counted against you. That will not totally mitigate your concerns, but it may help a little.

    I know this isn’t a satisfying answer. Happy to discuss it further.

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