An Assessment of Legal Issues Raised in "High Performing" Health Plan Quality and Efficiency Tiering Arrangements: Can the Patient Be Saved?

Publication Date: October 2007

Publisher: Robert Wood Johnson Foundation; The George Washington University School of Public Health and Health Services

Author(s): P.C. Borzi; S. Kornblet; S. Rosenbaum

Research Area: Health

Type: Report

Abstract:

A legal analysis released by The George Washington University School of Public Health and Health Services and the Robert Wood Johnson Foundation affirms the legality under federal and state law of physician ranking systems used by health plan provider networks. This analysis examines seven types of possible legal allegations against physicians tiering, concluding how the approach is undertaken plays a significant role in determining legal backlash.

Key findings:

* Successful transparency efforts include an open process that outlines clear development of standards and methods to identify and correct errors.
* All affected groups should be involved in developing the transparency process from the start and weigh in on key governance issues, including approved uses and access to data, disclosure issues and due process rights to challenge data, and performance evaluations.
* Government entities (i.e., state insurance regulators, the Centers for Medicare and Medicaid Services or the United States Department of Labor) could assist the process by developing common standards to establish scientific methodology of tiering.