UnitedHealthcare Alters Policy on Benefit Tiering

After listening to Academy concerns about its designation pilot programs, UnitedHealthcare's EVP of Clinical Strategies and Policy, Lewis Sandy, M.D., told AAFP leaders UHC will not support benefit tiering around primary care in its new UnitedHealth Premium(SM) Designation Program.

UHC's stance means patients won't be tempted to choose a primary care physician based on the amount of the patient's copay for an office visit to that physician. According to Sandy, who met with Academy leaders Jan. 4 at AAFP headquarters in Leawood, Kan., under a tiered benefit plan, the patient shoulders more cost -- perhaps a $40 copay versus a $10 co-pay -- when seen by a nondesignated physician.

The UHC program, which is rolling out in markets across the country, rewards physicians with a special designation when they achieve certain quality and efficiency markers set by the insurer.

Representatives from UHC requested the meeting and came ready to discuss a variety of physician payment issues with AAFP President-elect Rick Kellerman, M.D., of Wichita, Kan.; EVP Douglas Henley, M.D.; and selected Academy staff members.

"It was a good back-and-forth discussion," said Kellerman after the meeting. "We laid the groundwork for continued work with them. The meeting also "set a template for future meetings with other insurance companies about similar concerns and complaints that our members have," he said.

In an interview following the meeting, Sandy praised Academy leaders and members for feedback that led to UHC's decision. He said UHC pilot programs that launched in some markets in 2005 included benefit differentials between designated and nondesignated primary care physicians.

"As we looked at that experience and heard from the Academy about concerns related to disruption of primary care relationships and continuity of care, we laid out 'rules of the road' relating to benefit designs around these designations," Sandy said.

Sandy said UHC supports, at the request of its customers, the creation of benefit differentials around designated subspecialists, such as cardiologists, because those physician contacts usually are referrals. In addition, subspecialists have fewer concerns about continuity of care. Currently, no UHC customers are requesting differential copays for primary care physicians, he added.

Other meeting outcomes included an airing of AAFP concerns about the UHC designation program's methodology and inaccuracies in UHC letters to physicians regarding quality measurements.

"This is an ongoing process of engagement and collaboration that I hope will deepen and strengthen over time," said Sandy. "We (UHC and the Academy) have very similar goals to improve the quality and efficiency of patient care, and we both want to do so in ways that support the physician-patient relationship."

Kellerman said he came out of the meeting with a "gut feeling that they were really listening." In addition, he said the Academy learned it could work more effectively to resolve physician complaints by collecting hard data and evidence to submit to insurers. "We can't just work off of anecdotes," he said.

"There are always going to be conflicts between insurance companies and physicians -- it's not going to be Nirvana -- but if they can listen and make some changes, that's to our benefit," said Kellerman.