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Physician Tiering by Health Plans in Massachusetts

Wadgaonkar, Ajay D. BS; Schneider, Eric C. MD, MSc; Bhattacharyya, Timothy MD

Journal of Bone & Joint Surgery - American Volume: 15 September 2010 - Volume 92 - Issue 12 - p 2204–2209
doi: 10.2106/JBJS.I.01080
Scientific Articles
Supplementary Content

Background: Physician tiering is an emerging health-care strategy that purports to grade physicians on the basis of cost-efficiency and quality-performance measures. We investigated the consistency of tiering of orthopaedic surgeons by examining tier agreement between health plans and physician factors associated with top-tier ranking.

Methods: Health plan tier, demographic, and training data were collected on 615 licensed orthopaedic surgeons who accepted one or more of three health plans and practiced in Massachusetts. We then computed the concordance of physician tier rankings between the health plans. We further examined the factors associated with top-tier ranking, such as malpractice claims and socioeconomic conditions of the practice area.

Results: The concordance of physician tiering between health plans was poor to fair (range, 8% to 28%, κ = 0.06 to 0.25). The percentage of physicians ranked as top-tier varied widely among the health plans, from 21% to 62%. Thirty-eight percent of physicians were not rated top-tier by any of the health plans, whereas only 5.2% of physicians were rated top-tier by all three health plans. Multivariate analysis showed that board certification, accepting Medicaid, and practicing in a suburban location were the independent factors associated with being ranked in the top tier. More years in practice or fewer malpractice claims were not related to tier.

Conclusions: Current methods of physician tiering have low consistency and manifest evidence of geographic and demographic biases.

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3Clinical and Investigative Orthopaedic Surgery Section, Office of Clinical Director, NIAMS, 10 Center Drive, Bldg 10-CRC Room 4-2339, Bethesda, MD 20892. E-mail address:

Copyright 2010 by The Journal of Bone and Joint Surgery, Incorporated
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