Plans drive doctors to tiers

Insurers should not use economic criteria to rate physicians.

Editorial. Jan. 1/8, 2007.

It was a victory for doctors and patients when Regence BlueShield in Washington a few weeks ago called off a flawed plan to use economic incentives to steer PPO patients to a newly created network within a network.

Physicians there rejected Regence's claims that valid measures of quality and efficiency were the deciding factors in how doctors were grouped. They suspected that the top priority of the program -- which reviewed claims, not medical records -- was to reduce Regence's costs.

In other parts of the country, physicians are complaining of health plans using economic profiling to direct patients to a specific subset of PPO-network doctors, a phenomenon that became known as tiered networks. It's similar to efforts by health insurers for the past few years to promote drug and hospital savings.

Patients pay less out of pocket to see the plan's tier of "preferred" physicians. Those savings, however, can come at the price of the patients not seeing the trusted doctor they'd prefer to see. At the same time, the tiers are an unsubtle message to physicians not to cost the plan too much money. Doctors see it as a divide-and-conquer tactic to pit patient against physician -- with health plans picking up the spoils.

In the case of Regence, the plan called off its "Select Network" plan in the face of a lawsuit filed by six physicians and the Washington State Medical Assn. The Regence announcement came just days after the American Medical Association/State Medical Societies Litigation Center joined the case.