Using Community-Level Quality Measurement to Promote Value in Health Benefit Design

The Experience of Maine¿s State Employees Health Insurance Program

Employers or health plans may provide financial incentives to consumers in an effort to “steer” them to high quality or low cost providers, based on these tiers, through reduced deductibles or copayments.

Tiering has been applied extensively to prescription drug benefits. While not as extensive, tiering of physician and hospital services is growing. The Maine Health Management Coalition (MHMC), an alliance of employers, hospitals, health plans, and physicians, and an Aligning Forces for Quality (AF4Q) grantee, provides a useful example of how provider tiering and steering programs can be executed in the real world.

A pillar of AF4Q in the State of Maine is the development and public reporting of physician quality measures. The MHMC has worked with its employer, physician, and health plan members to develop widely supported public reporting of physician practice quality based on National Committee for Quality Assurance (NCQA) and Bridges to Excellence (BTE) metrics.

The State Employee Health Commission, which manages the health benefit plan for state employees, used the MHMC quality measurement initiative to tier providers and hospitals; the Commission also has worked with its health plan to provide incentives to consumers to seek care from high quality physician practices and hospitals. In this Research Summary, we describe the key features of the program in Maine and discuss the lessons learned through this initiative.

It has been well established that care for chronic disease in the United States is not optimal, and a variety of interventions have been proposed across the ideological spectrum to improve that care. There has been a growing interest in quality improvement interventions targeted at patients and consumers—a “consumer focused” strategy. One particular intervention which is garnering considerable attention is the concept of “tiering and steering.”

Tiering has been defined as: “the classification of health care providers (e.g., hospitals or physicians) or treatments (e.g., pharmaceuticals, durable medical equipment, physical therapy) into different groups or ‘tiers’ based on objective or subjective criteria such as measures of cost, quality, safety or value.