How Insurers Rate Or Tier Doctors And Hospitals

Here are a few general differences and similarities in the way insurers design tiered plans:

Tufts Health Plan:
1) tiers doctors and the hospitals they use together, as one system
2) quality is main consideration – providers are automatically the lowest tier (3) unless they meet quality standards (see the chart below)
3) providers who pass the quality test are assigned a tier based on cost

Harvard Pilgrim Health Care:
1) tiers doctors based on the performance of their group, not as individuals. The groups do not include hospitals
2) quality is the first consideration, then cost

Blue Cross Blue Shield of Massachusetts
1) only tiers primary care doctors (PCPs). Tiering does not apply to specialists
2) All PCPs and hospitals begin in the middle tier and move up or down based on their quality and cost measures

Cost And Quality Measures

Physician quality measures Physician cost measures Hospital quality measures Hospital cost measures
Blue Cross Blue Shield MA 23 measures  total cost of group’s patients  21 measures in & outpatient rates compared to regional BCBS rates
Harvard Pilgrim Health Care 16 measures PMPM cost of group’s patients six  (composite) measures in % outpatient rates compared to all HP hospital rates
Tufts Health Plan 26 HEDIS measures two measures  use criteria from  three sources two measures

Thanks to Aayesha Siddiqui for help with this chart.

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