What we know and do not know about tiered provider networks

Area of Science:

• Health Services Research
• Healthcare Management
• Health Economics

Background:

• Rising healthcare costs and variable quality necessitate innovative health plan strategies.
• Tiered provider networks (TPNs) are emerging as a response to these concerns.
• Limited understanding exists regarding TPN structure, implementation, and operational dynamics.

Purpose of the Study:

• To investigate the characteristics of tiered provider networks.
• To understand how health plans are structuring and implementing TPNs.
• To gather insights from health plan executives, employers, and providers on TPNs.

Main Methods:

• A national survey of health plans was conducted.
• Interviews were held with health plan executives.
• Interviews were also conducted with employer clients and network providers.

Main Results:

• Findings on the structure and implementation of TPNs were developed.
• Insights into the operational aspects of TPNs were gathered.
• Data from diverse stakeholders provide a comprehensive overview.

Conclusions:

• TPNs represent a significant shift in health plan network design.
• Further research is needed to fully understand TPN impact and effectiveness.
• This study provides foundational knowledge on TPNs for stakeholders.