Tiered and Select Physician Networks

Since the American Academy of Family Physicians (AAFP) supports quality improvement activities that focus on improving the health of patients, families and communities, it is the AAFP position that these networks must provide patients sufficient access to health care, support the physician-patient relationship, and focus on improving patient care.

The long-term value of a Patient-Centered Medical Home with patients having a personal relationship with a Family Physician will outweigh the short-term financial benefits of frequent switching of primary care physicians due to tiering. Therefore, substantial caution should be exercised when using tiering systems that may disrupt the medical home and may cause patient access issues. This would be the end result of steering patients to high quality and/or efficient-designated physicians who are already operating at their practice capacity, which will be exacerbated by any primary care physician workforce shortage. Thus, mechanism in the health insurers' program(s) must be in place to ensure patient access to a primary care physician.

Tiering methodology and policies are often proprietary and may vary among payers. However, payers’ data methodology used to rate/designate family physicians should be transparent and align with AAFP policy on Physician Performance Measurement policy.

Attributes of steering may also vary, but should maintain the continuity of existing physician patient relationships whenever possible and adhere to the AAFP policy on Performance Measures Criteria, Physician Profiling, and Transparency. Steering and tiered network programs should adhere to the following principles:

  1. Tiering should not be exclusively based on the cost-of-care delivered by the physician.
  2. Programs should provide full, adequate access to necessary physicians and non-physician providers.
  3. Quality-of-care assessments should be a prominent feature of steering programs and based on accepted national standards using evidence based medicine clinical guidelines whenever possible.
  4. Programs should provide educational and reference materials to assist patients in making informed health care decisions.
  5. Programs should fully disclose to a patient or employer the participation and availability of primary care physicians, sub-specialty physicians, and health care facilities prior to making decisions regarding a payer's steering program.
  6. Cost data used in steering programs must be accurate and specific to the identified physician.
  7. All data used to evaluate a physician should be age, sex, and severity adjusted, including adjustments for socioeconomic factors.

(2007) (2010 COD)