What Patients Should Know About Physician Tiering and the GIC's Clinical Performance Improvement Initiative

If you, or someone in your family, is employed by the state, you may have obtained your health insurance through the state agency the Group Insurance Commission. If so, you will see that your health plan has placed your doctors in a "tier." The tier that your doctor is in determines your co-pay.

What does this mean?

1) The health plans say that the tiers tell you whether your doctor provides high quality care, at a reasonable cost. We do not believe this is true.

2) Doctors are telling us that the tiers do not accurately reflect the care that they provide.  The Massachusetts Medical Society has found that:

  • Doctors have been rated on procedures they have never done.
  • They have been rated on patients they have never seen.
  • The same doctor may be ranked different ways by different health plans. Which health plan's ranking is more accurate? No one knows - maybe none of them.

3) Who pays the price? You do. Your co-payments may be needlessly higher, based on a ranking that isn't accurate or fair. You are also being encouraged to change doctors based a system that isn't fair or accurate.

4) Doctors are trying to fix this. We support sharing good cost and quality information with you. But this system is neither accurate nor fair. Doctors have repeatedly pointed out all of these issues, but the Group Insurance Commission has refused to make the changes needed to fix the problem.

5) What you can do: If your doctor has been placed in a lower tier, talk to him or her about it. Find out what is accurate and what's not. Also, talk to your employer and explain what's not working. Your employer must understand that you're the one paying the price for a system that doesn't work.

6) If you're selecting a doctor, don't rely on the GIC's tiering program to make your choice. Read "How to Choose a Doctor" at www.massmed.org/chooseMD. This document provides a balanced guide on how to choose a doctor that's right for you. It's been endorsed by the Massachusetts Health Quality Partners and other health care organizations in Massachusetts.

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