The American Academy of Family Physicians (AAFP) supports quality improvement activities that focus on improving the health of patients, families and communities. Some insurers or payers are segregating physicians into a tiered or select network based upon the payers’ performance program ratings. 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 Medical Home with a Family Physician serving as the Primary Care Physician will usually 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 or the physician-patient relationship.
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 adhere to the AAFP policy on Performance Measures Criteria and Physician Profiling.
In addition, tiering programs should adhere to the following principles:
Tiered and Select Physician Networks
- Tiering should not be exclusively based on the cost-of-care delivered by the physician.
- Cost data for a specific physician’s patient population must be accurate and specifically attributable to the identified physician and should be age, sex and severity adjusted.
- The sample size used for evaluating a specific physicians’ performance must provide statistically significant results.
- Inpatient cost data should not be the primary basis for evaluating family physicians that only practice in an outpatient setting.
- Claims and utilization data alone should not be the basis for quality assessments.
- Quality assessments should be based on accepted national standards using evidence based medicine whenever possible.
- Physicians that meet quality standards should be identified separately from their cost assessment.
- Before payers publicly release physician performance data/rating an appropriate appeals process should be in place with adequate time provided for physicians to appeal their designation.
Attributes of steering may also vary, but should maintain the continuity of existing physician patient relationships whenever possible. Steering programs should adhere to the following principles:
- Steering programs may require higher out-of-pocket expense to utilize certain providers, but access to these providers should still be available.
- Quality-of-care assessments should be a prominent feature of steering programs.
- Patient and payer resources should include educational materials and reference materials to assist in making informed health care decisions.
- Participation and availability of primary care physicians, sub-specialty physicians, and health care facilities should be fully disclosed to a patient or employer prior to making decisions regarding providers in a steering program.
- Cost data used in steering programs must be accurate and specific to the identified physician.
- All data used to evaluate a physician should be age, sex, and severity adjusted. (2007)
