May 1, 2015
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:
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.