insurance carriers may restrict patients in certain plans
to receiving care from providers in a specific tier. In this
case, patients who are restricted to physicians in Tier
1 would be restricted to the three general surgeons in
that tier in order to receive full coverage.
ACS policy on tiered/narrow networks
The American College of Surgeons (ACS) Statement
on Physician Tiering and Narrow Network Programs
provides guidance for surgeons seeking to address problems with tiering and narrow network programs and
emphasizes that these programs should be based on
quality metrics, not cost. 1
However, the College is aware that many narrow
and tiered health care networks rank physicians based
solely on cost. These protocols often are implemented
improperly, rely on faulty data, use inappropriate cost
measures, lack transparency, and lead to the misclassification of physicians. The ACS regards the provision
of high-quality surgical care—particularly with the
increased emphasis on performance measurement in
health care today—as a top priority and urges federal
or state agencies, hospitals, health care organizations,
insurance companies, and other interested parties to
develop policies to ensure patients receive optimal surgical care.
Although the ACS supports efforts that result in
the efficient delivery of care, these protocols should
be based solely on quality until reliable and valid
methods are available to evaluate both cost and
quality. As noted in the ACS statement, “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.” 1
The College supports physician tiering and
narrow network programs that meet the following criteria: 1
•Use transparent methods and are rooted in logic
that patients, physicians, and other stakeholders can
•Use quality measures that meet nationally accepted
standards based on importance, scientific acceptability,
feasibility, and usefulness. Composite measures that
account for both quality and cost should be held to the
same standards and should include regular audits for
reliability and validity.
• Have metrics that incorporate care from all appropriate
providers and that comply with nationally recognized
standards. Health care outcomes are the result of the
actions of many individuals and the systems that support them.
•Incorporate accepted risk adjustments for outcomes
and socioeconomic status to ensure ongoing access for
patients who are at higher risk of complications and poor
•Involve physicians and physician organizations in the
development and implementation of any protocol.
• Use reasons other than just cost for tiering or removing
physicians from health care networks. Payors should
rely on nationally validated and reliable quality metrics, and even though cost data should be transparently
available to patients, these data should not affect network decisions.
• Set appropriate benchmarks that incentivize physicians
to achieve optimal clinical outcomes and provide high-value care.
•Impose minimal burdens on physicians to avoid impeding the provision of care or patient access to care.
• Provide an opportunity for patients, physicians, or other
stakeholders in the delivery system to appeal any classification of the physician in the program.
According to the statement, to the best of the College’s knowledge, none of the tiering or narrow network
programs meet all of these criteria at present. This gap is
likely due, in part, to the lack of transparency associated
with these programs. The ACS recommends that payors