title: Physician tiering by health plans in Massachusetts.
abstract: 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.
authors.affiliation: National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA.
authors.forename: Ajay D
authors.initials: AD
authors.lastname: Wadgaonkar
authors.forename: Eric C
authors.initials: EC
authors.lastname: Schneider
authors.forename: Timothy
authors.initials: T
authors.lastname: Bhattacharyya
mesh_terms: D002983:Clinical Competence; D003406:Credentialing / Q000191:economics*; D005260:Female; D006801:Humans; D007348:Insurance, Health / Q000191:economics*; D008297:Male; D008404:Massachusetts; D009985:Orthopedics / Q000191:economics* / Q000592:standards*; D010820:Physicians; D011787:Quality of Health Care; D012052:Reimbursement, Incentive