Tiered and Narrowed 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 physician networks offered by payers and health systems must provide patients sufficient access to health care, support the physician-patient relationship, and focus on improving patient care.

The long-term value of patients having an ongoing relationship with a personal family physician outweighs the short-term financial benefits of frequent switching of primary care physicians due to tiering, narrowing, or terminating family physicians from networks. A substantial body of evidence demonstrates that continuity of care improves outcomes and decreases unnecessary utilization. Patients who have a higher level of continuity of care have a greater sense of trust in their physician, greater sense of security, and better communication with their physician. In addition, the ongoing relationship with a patient, when there is continuity of care, contributes to greater physician satisfaction. Therefore, substantial caution should be exercised when using systems that disrupt the ongoing patient relationship with their personal physician and cause difficulty with access to continuous and comprehensive care. Steering patients to high quality and/or efficient-designated physicians who are already operating at their practice capacity, may result in interrupted or impeded care, which could be further exacerbated by physician workforce shortages. Thus, health insurers' program must have mechanisms in place to ensure patient access to a primary care physician.

Tiering, narrowing, or executing methodologies and policies are often proprietary and may vary among payers and health systems. Any data methodology used to tier, rate, designate, or exclude family physicians should be transparent and align with AAFP policies on "Physician Performance Measurement and "Transparency."

Attributes of patient steering may also vary, but should maintain the continuity of existing physician patient relationships whenever possible and adhere to the AAFP policies on "Health Care for All," "Performance Measures Criteria," "Physician Profiling," and "Transparency." Patient steering and tiered or narrowed network programs should adhere to the following principles:

1. Networks or health systems should not be exclusively based on the cost-of-care delivered or by utilization measures attributed to the physician.
2. Programs should provide full, adequate access to necessary physicians and non-physician providers.
3. Insurers that do not have a sufficient number of skilled and proficient physicians in their network should provide coverage for the out-of-network services without additional cost to the patient.
   
4. 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.
5. Programs should provide educational and reference materials to assist patients in making informed health care decisions.
6. 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.
7. Quality and cost data used in steering programs must be accurate and specific to the identified physician.
8. All patient data used to evaluate a physician should be age, gender, and severity adjusted, including adjustments for socioeconomic factors.
9. If a physician is removed from a network, they should have sufficient opportunity to challenge the decision of the network.
   
10. Health plans should notify physicians when new plans are created so physicians have the opportunity to participate in those plans without recredentialing.

(2007) (October 2023 COD)