The growing number of selective and tiered health plans has raised the concern that these plans will adversely impact access to care especially for disadvantaged sociodemographic groups. Contrary to our hypothesis we did not find any significant increase in travel time to physicians in a scenario where patients could only visit high-value physicians. It seems reasonable that patients would be willing to travel an extra 2.0 minutes to see a high-value PCP and an extra 8.2 minutes to see a high-value general surgeon. The notable exception was for rural populations, which had to travel 5.9 minutes longer to see the nearest high-value PCP and 15.1 minutes longer to see the nearest high-value general surgeon. While these travel times may still be reasonable for rural populations who are accustomed to traveling greater distances, caution should be taken when applying tiering networks to rural populations since they are most susceptible to increases in travel times to high-value physicians.
Our findings did not support that access to high-value physicians is inequitable for other disadvantaged populations. This is consistent with a study of one health plan which found minorities are fairly evenly distributed among specialists of varying efficiency performance.14
In fact, we found that poor, black, and Hispanic populations had the shortest average travel times.
We selected to study geographic access because it is the most basic level of access—if there are no physicians within a reasonable distance, patients will not be able see a physician. However, our study did not address other dimensions of access. For example, we did not directly address whether the high-value physicians have the capacity to see more patients. If we divide the number of available high-value physicians by the adult population, it is clear that the supply of high-value physicians is not sufficient for the whole population. If patients were restricted to seeing only high-value PCPs, the statewide population-physician ratio would increase from 1,318:1 to 6,308:1, which is well above the cut-off of 3,500:1 used for designation of Primary Care HPSAs.15
Similarly, the population-physician ratios would increase dramatically if patients could only see high-value obstetrician/gynecologists, cardiologists, and general surgeons. There is no single population-physician ratio used as a cut-off for insufficient access for specialist physicians.17
However, the ratios of 70,210:1 and 156,274:1 which we found for cardiologists and general surgeons, respectively, are much higher than the 9,400:1 ratio previously cited for cardiologists18,19
and 20,000:1 for general surgeons.20
Considering results from travel time analyses and population-physician ratios, it appears that access may not be an issue if only a small aspect of the population is enrolled in a selective or tiered product, but access could become critically limited if a large fraction of the population is in a tiered product.
Future work should explore this and other dimensions of access, including whether patients have transportation to the physician practice, whether physicians are accepting new patients, and whether wait times to see high-value physicians are within reason. These latter two concerns may be especially important in primary care where fewer physicians in Massachusetts are accepting new patients and where wait times continue to increase21–23
. Additionally, if patients have access, it will be important to investigate whether patients will trust physician ratings24
and actually switch from their current provider to a new, high-value physician.
Our study has several limitations. First, our data sources did not permit us to measure travel times from each individual patient's home address to their actual provider so our results are an estimation of how travel times might change in aggregate across the state. Second, we conducted our analysis in Massachusetts, which has the most physicians per capita in the U.S.25
; therefore it is unclear whether analyses in other states would find similar results. Third, travel times depend on the pool of high-value physicians and can differ if a different method for designating high-value physicians is used, although it is likely that health plans would create tiering products similar to ones presented here and assessed in our sensitivity analyses. Fourth, we assumed that the four individual health plans included in this study were distributed uniformly throughout the state and used the same profiling and tiering methods; however each health plan tends to have its own market around which it clusters and each plan uses different tiering methods so that physician and enrollee experience with tiering would vary by location.
Contrary to our hypothesis, we found that patients were within a reasonable travel time of the nearest high-value physician in adult primary care specialties and three sub-specialties in Massachusetts, and that, with the exception of rural patients, disadvantaged sociodemographic groups did not have worse access to high-value physicians.