Massachusetts state agency creates tiered doctor networks

Physicians question the merits of the plan, particularly because it would result in a jumble of different ratings systems.

By Jonathan G. Bethely — Posted Feb. 27, 2006

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The Massachusetts state agency that oversees health insurance for 144,000 public workers plans to launch a program that would lower co-payments for patients who receive care from doctors it considers highly rated.

The Group Insurance Commission's effort is an expansion of a similar program already in place for hospitals for the last two years.

Under the commission's physician program, its contracted health plans use commission data gathered from 2002-04 comparing physicians' claims with specialists treating like conditions as a basis for putting doctors in two tiers. The rating system is comprised of several factors, including physicians fees, the number of procedures requested and quality measures outlined by the plan.

Patients would pay a smaller co-pay to doctors in the higher tier, and a larger co-pay for physicians in the lower tier. Actual physician reimbursement would not differ.

The data should be available to state employees during their open enrollment in April and May, said Delores L. Mitchell, executive director for the Group Insurance Commission.

Mitchell said the program's aim was to help cut health care costs and increase quality to members. "I do not claim it's perfect, but my claim is, let's do something," she said.

Physicians are skeptical, based on two major factors. One is that the program is using data that are, at best, two years old. Another is how confusing the program could become. When individual health plans, using the same data, are allowed to set up their own standards for tiers, even Mitchell acknowledges that a physician could be in the higher tier in one plan, but be in the lower tier in another.

"GIC has a big project here that they need to get out and explain how this information is accurate, reliable and clinically meaningful information," said Alan M. Harvey, MD, a Boston anesthesiologist and president of the Massachusetts Medical Society. "This is based on two-year-old information, and physicians don't know how they are going to upgrade their rating. Far more can be done to control costs to make sure we have a system that meets patients needs."

Dr. Harvey said physicians fear both patients and doctors will have a difficult time comprehending the pricing structures. Instead of a tiered system, he said, efforts should be made to better coordinate care between patients and their primary care doctors.

In the future, Mitchell said, the commission will look at financial rewards for highly rated physicians, but details have not been discussed.

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