Tiered Ratings for Physicians and Hospitals – What do they mean?

November 28, 2011 in Member Stories

My family has just gone through the annual open enrollment process for health care.  Although I am a pediatrician, we get our health insurance through my husband’s company.  This year they were offering premiums at approximately half price if we signed up for the plans which base co-pays and deductibles on whichever tier the physician or hospital is rated.  Intriguing.

Approaching my decision from a health care consumer standpoint, I started my research with three basic questions in mind: What tier(s) are the primary care physicians, specialists and hospitals that my family has used?  What would happen if different physicians within the same office were rated differently?  Would this “half” priced premium save me money over the year?  After over 8 hours of internet research and conversations with the Human Resources Department at my husband’s company, I was left with more questions than answers.

The information was difficult to find, incomplete and seemingly meaningless.  We were offered the choice of four different insurance companies.  In order to find out about tiering levels, I had to visit each of the four company’s web sites-there was not a central location to plug in a specific  name and get the tiering level for each physician/hospital. So now I have many more questions: If my primary care physician is rated Tier 1 for one company, Tier 2 for another, Tier 3 for a third (and the fourth company did not seem to post their ratings) what could these tiers possibly mean?  The ratings for hospitals was similarly varied.  On what are the ratings based?  I could only assume that each company was using different measures to rate the physicians – so how am I to know which doctors are most cost efficient?  Does cost efficiency have anything to do with how well a doctor will diagnose and treat my family?

As a pediatrician, I am worried about how others will interpret this information when choosing their insurance.  Despite my time consuming research I could not decipher this information in any meaningful way.  Armed with the additional knowledge that as a pediatrician I had never been given a list from any insurance company telling me what I was being measured on, I had to conclude that that it is too premature and risky to choose one of these new options.  I would be thrilled to know if you have any answers to my questions or if anyone else has any other insights.

5 responses to Tiered Ratings for Physicians and Hospitals – What do they mean?

  1. Hi Sarah – this does seem like a challenging task. I called the state’s three largest insurance companies to get info about their tiered plans. So far, I have links to the Blue Cross guides for members which I’ll paste below. But I imagine you’ve already seen these items. Did you have a Blue Cross option that tiered doctors and their co-pays as well? I’ll have to look into that.

    The main criteria for rating hospitals in the Blue Cross plan seems to be the cost the hospital charges Blue Cross for services. I will look to see how the rankings vary between plans. For now, here are the links I got from Blue Cross:

    This is where people can go to learn more about Blue Options tiered plans: http://www.bluecrossma.com/plan-education/medical/blue-options/index.html . This is where they can find the list of hospitals for 2012 and the basic explanation of how tiering works (see top of page) http://www.bluecrossma.com/common/en_US/pdfs/New_SOB/55-0245_2012_Blue_Options_Hospital_List.pdf

    This is where people can go to learn more about the Hospital Choice Cost Share tiered plans: http://www.bluecrossma.com/plan-education/medical/hccs/index.html . This is where people can get the Hospital Choice Cost Share tiering list for 2012: http://www.bluecrossma.com/common/en_US/pdfs/New_SOB/55-0248_2012_HCCS_Hospital_List.pdf

  2. Thanks, Martha. The BC/BS website links were helpful. I had visited those websites before and was very curious to note that the information had changed since I last was at the website. When I first looked at the site, it looked like my pcp had met both the quality and cost benchmarks but was still rated at the “basic” (most expensive level) so I was very confused. Now the webiste says he met the quality benchmark but not the cost benchmark, so I understand that “basic” rating better (although it seems unfair to meet one benchmark and miss one benchmark and not be at the middle tier). I am still curious to know what are the exact criteria to meet a benchmark and how does tha compare to other insurance companies?

  3. I was recently hospitalized and was very conscious about making sure my physicians were part of my insurance network for coverage purposes. What they didn’t tell me was which physician was a Tier 1 vs. a Tier 2. Blue Cross Blue Shield Insurance does not pay as much on Tier 2 physician’s with my plan and my bills were much higher as a result. This needs to be made aware to all consumers so we are not left with enormous costs!!! As an RN I really thought I understood my benefits and treatments within my plan. Never did anyone mention the costs or differences with a Tier 1 or Tier 2 physician. It was a $4,000.00 bill/mistake that I will now advocate for so patients understand.

    • Hi Joanie – thanks for the warning. Might you be able to write a short summary or a few tips to share with patients? I agree that the costs associated with doctors or hospitals in different tiers is taking patients by surprise. If you have time to write a brief summary or some tips, we can put your story up as a separate post. Alternatively, we can put your comment up as is. Let me know.

  4. I’ve worked in the medical field 25+ years, and each hospital has a tier rating on employees on who can be hired
    and who can’t. How do I find out if I’m on one of those tiers ratings. Everytime I apply for a position which I’m very much
    qualified, I get the same response, we’ve hihihired with the hospital. You can post my

Leave a reply

You must be logged in to post a comment.