Profiling is done via "grouper" software...no this is not the fish...everything relative to one diagnosis is grouped together...physicians argue that claim data does not reflect clinical outcomes as well....and what do you do as a physician when you are at the bottom of the list? Those payers that do not have tiered plans will more than likely employ them down the road...when looking a profile for a physician, see who created the list...and realize that sometimes information can be skewed to reflect costs and not necessarily better care...BD
Family physician Kevin B. Martin, MD, offers his patients top-tier medical care in Auburn, Wash. Or maybe he doesn't. Or maybe he didn't at one time, but he does now. It all depends on which health plan you ask - and when.
Martin is one of many doctors who have come away shaking their heads after payers have rated the efficiency and quality of their practices based only on claims data and then have shared the results with patients. The goal of the approach, which some call "tiering and steering," is to cut costs and encourage quality. Martin just calls it frustrating. "I am the same doctor," Martin says. "I give the same care with the same instruments and the same hands in the same rooms regardless of the payer. I'm not a good doc one day on one plan and the dregs another day on another plan."
Aetna, CIGNA, Humana and United Healthcare all have tiered networks. They are called Aetna Aexcel, CIGNA Care Network, Humana Preferred and UnitedHealth Premium. Currently, the only payers that tier family physicians are United and Humana. United has stated that it will not allow employers to use benefit design incentives based on family physicians' tiers to steer their employees. United does exempt physicians in the highest tiers from its required notification program for radiology procedures. Aetna and CIGNA do not rate and tier family physicians but likely will at some point in the future.
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