NCQA PRESIDENT OUTLINES PROSPECTS FOR TIERED NETWORKS

NCQA President Margaret E. O’Kane recently commented on efforts by the Massachusetts Group Insurance Commission (GIC) to experiment with tiered provider networks, advancing the on-going national discussion on creating a value-based health care system. O’Kane’s editorial appeared in the latest issue of the American Journal of Managed Care

Tiered networks are an important part of the value agenda because they allow consumers to choose physicians in a higher performing tier while encouraging those in lower performing ones to improve their performance.

 A recent study in the American Journal of Managed Care analyzed consumer awareness, use and trust of a tiered provider network. The study showed that using tiered networks to help consumers choose physicians requires increased consumer education. O’Kane noted that the report provided a useful analysis of health plan members’ reaction to the GIC, and in response offers further suggestions and insight for advancing value and quality in tiered networks:   

• The GIC project builds on the PPO concept: The GIC project goes beyond the traditional design of a PPO, which excludes quality and cost criteria for network inclusion, to one based on quality criteria and episode-based costs. 
• Consumers don’t trust tiers: According to the study, a large portion of consumers don’t trust tiers to tell them which doctors are better than others. The lack of trust possibly relates to the novelty of the plan design. Trust can be enhanced through experience and by continuing to inform patients of how tier 1 doctors are selected. 
• Involve primary care physicians: Although the current GIC project focused heavily on specialists (most plans did not tier primary care physicians), a strategy enlisting the cooperation of willing physicians could generate a less controversial path to cost savings.
• Engage patients through incentives: Applying a more vigorous strategy to engage patients can bring programs like the GIC to their maximum potential. Programs should incorporate patient education and incentives.
• Create consumer awareness: O’Kane states that as the insurance market evolves, enrollees need to be a part of the changes. Tiering networks can and should create consumer awareness and education only if consumer choices and incentives are structured to drive value in the future.

To view the full editorial in the American Journal of Managed Care, click here. To view the study, click here.