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Physician Tiering by Health Plans in Massachusetts
Ajay D. Wadgaonkar, BS1; Eric C. Schneider, MD, MSc2; Timothy Bhattacharyya, MD3
1 950 25th Street N.W., Apartment 707 South, Washington, DC 20037
2 RAND Boston, 20 Park Plaza 7th Floor, Suite 720, Boston, MA 02116
3 Clinical 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: Timothy.bhattacharyya@nih.gov
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from commercial entities (Stryker, AO North America, and Best Doctors, Inc.).

Investigation performed at the National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Sep 15;92(12):2204-2209. doi: 10.2106/JBJS.I.01080
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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.


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.


The concordance of physician tiering between health plans was poor to fair (range, 8% to 28%, ? = 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.


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

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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