Group Insurance Commission’s Clinical Performance Initiative

Created in 2003, the Group Insurance Commission’s Clinical Performance Initiative (CPI) was created in an effort to control costs, improve healthcare quality, and promote cost-efficiency. Using an advanced statistical model, CPII uses claims data to assess providers' adherence to quality standards, as well as cost-efficiency compared to other providers in the same specialty treating patients with similar conditions. Specialist provider tiers are based on a combination of these quality and cost-efficiency scores. Tier 1 providers receive the highest quality scores and provide the most cost-efficient care. Patients who see these doctors pay the lowest office visit copayments.

Specialties tiered by Fallon Health

Effective July 1, 2017, Fallon will tier the following specialties for both the Direct Care and Select Care plans:

  • Allergy/immunology *
  • Cardiology
  • Dermatology
  • Endocrinology
  • Gastroenterology *
  • General Surgery 
  • Hematology and Oncology *
  • Nephrology
  • Neurology
  • OB/GYN
  • Orthopedic Surgery*
  • Ophthalmalogy  
  • Otolaryngology
  • Podiatry *
  • Pulmonary disease
  • Rheumatology
  • Urology *

(*) indicates those specialties ranked by efficiency only.

The tiering works as follows:

***Tier 1 (excellent): This tier includes plan physicians practicing at an excellent level of quality and cost-efficiency. Members pay the lowest copayment when they see Tier 1 plan physicians.

**Tier 2 (good): This tier includes plan physicians practicing at a good level of quality and cost-efficiency, or a plan physician with insufficient cost-efficiency or quality data. Members pay the prevalent (mid-level) copayment when they see Tier 2 plan physicians.

*Tier 3 (standard): This tier includes plan physicians practicing at a standard level of quality and cost-efficiency. Members pay a higher copayment when they see a Tier 3 plan physicians.

Not Tiered/Insufficient Data (NT/ID): This designation includes providers that did not have sufficient data for tiering. These specialists are subject to a Tier 2 copayment.

We annually mail providers the following information:

  • Massachusetts specialists receive details of their Clinical Performance Improvement Initiative tiering designations.
  • Massachusetts Primary Care Physicians who had sufficient quality and efficiency data to be scored receive details of the Clinical Performance Improvement scoring data. Since Primary Care Physicians are not scored, they do not receive tiering designations.

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