The Impact of Health Plan Physician-Tiering on Access to Care

In an attempt to improve quality and control costs, health plans are creating tiered products that encourage enrollees to seek care from “high-value” physicians. However, tiered products may limit access to care because patients may have to travel unreasonable distances to visit the nearest high-value physician.

To assess geographic access to high-value physicians, particularly for disadvantaged populations.

Cross-sectional observational study.

Physicians and adult patients in Massachusetts.

Travel time from census block centroid to nearest physician address under two scenarios: patients can see (1) any physician or (2) only high-value physicians.

Among the physicians, 768 (20.9%) primary care physicians (PCPs), 225 (26.6%) obstetricians/gynecologists, 69 (10.3%) cardiologists, and 31 (6.0%) general surgeons met the definition of high-value. Statewide mean travel times to the nearest PCP, obstetrician/gynecologist, cardiologist, or general surgeon under the two scenarios (any physician vs. only high-value physicians) were 2.8 vs. 4.8, 6.0 vs. 7.2, 7.0 vs. 12.4, and 6.6 vs. 14.8 minutes, respectively. Across the four specialties, between 89.4%–99.4% of the population lived within 30 minutes of the nearest high-value physician. Rural populations had considerably longer travel times to see high-value physicians, but other disadvantaged populations generally had shorter travel times than comparison groups.

Most patients in Massachusetts are likely to have reasonable geographic access to high-value physicians in tiered health plans. However, local demographics, especially rural residence, should be taken into consideration when applying tiered health plans broadly. Future work should investigate whether patients can and will switch to receive care from high-value physicians.