The following statement was developed by the American College of Surgeons (ACS) Health Policy and Advocacy Group and was approved by the ACS Board of Regents at its February 2015 meeting.
As health care plans create incentives to improve quality and reduce costs, many entities have started using physician-tiering protocols directing patients to choose certain physicians; or they are offering a narrow network, reducing the number of available providers. Both of these protocols rank physicians based on cost, and some networks rank providers based on quality, as well. These protocols are often improperly implemented, rely on faulty data, use inappropriate cost measures, lack transparency, and lead to the misclassification of physicians. The College regards the provision of high-quality surgical care as a top priority and strongly urges that federal or state government agencies, hospitals, health care organizations, insurance companies, or other interested parties develop policies to ensure that every consideration be given to patients so they receive the highest quality surgical care.
Given the current state of performance measurement in health care, the ACS believes that tiering or narrowing accessibility of out-of-network physicians should be based on quality of care rather than cost of care. Although the ACS agrees with efforts that appropriately lead to the efficient delivery of care, we believe that such protocols should be based solely on quality until reliable and valid methods evaluating both cost and quality are available, ensuring the smallest potential risk of misguiding patients who are seeking surgical care. Cost alone should never be considered an adequate metric, and patients should understand that access to reasonable care may be limited when such payor-based programs are imposed on plan benefits without regard to quality.
The ACS supports the following physician tiering and narrow network programs:
- Programs that use transparent methods and are rooted in logic that patients, physicians, and other stakeholders in the delivery system can comprehend.
- Programs that use quality measures that meet nationally accepted standards for quality based on importance, scientific acceptability, feasibility, and usefulness. Composite measures that combine quality and cost should be held to the same high standards and should include regular audits for reliability and validity.
- Programs that have metrics that incorporate care from all appropriate providers and are in accordance with nationally recognized standards. Health care delivery is an outcome of the actions of many individuals and the systems that support them.
- Programs that incorporate accepted risk adjustments for outcomes and socioeconomic status to ensure ongoing access for patients who are at higher risk for complications and poor outcomes.
- Programs that involve physicians and physician organizations in the development and implementation of any protocol.
- Programs that never tier physicians or remove physicians from health plan networks based on cost alone. Payors should rely on nationally validated and reliable quality metrics, and while cost data should be transparently available to patients to allow them to apply cost information independently in the decision-making process, these data should not be used to make network decisions.
- Programs that set appropriate benchmarks that incentivize all physicians to achieve optimal clinical outcomes and high-value care.
- Programs that impose minimal burdens on physicians so as to avoid impeding the provision of care or patient access to care.
- Programs that provide an opportunity for patients, physicians, or other stakeholders in the delivery system to appeal any classification of the physician in the program.
The ACS is not aware of any physician tiering or narrow network programs that meet these criteria. This gap is likely due, in part, to the lack of transparency associated with these program. The ACS recommends that payors discontinue such programs and direct their efforts toward quality measures currently available to encourage providers to participate in learning health systems and quality improvement efforts. However, if measures of both quality and cost are used for these programs, the metrics used must be explicitly stated. This transparency is necessary so that patients can understand that access to care may be limited when such programs impose restrictions without regard to quality. Entities should partner with physician stakeholders if they are interested in developing reliable resource-use measures that do not run the risk of denying patients access to quality care.