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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.
This program aired on January 17, 2012. The audio for this program is not available.