Quality and Cost Information Available to Commercial Members

In 2010, Massachusetts health policy shifted its focus from increasing access of care to controlling the rising rate of health care spending in the Commonwealth. As a result, Chapter 288 of the Acts of 2010 was enacted to promote cost containment, transparency, and efficiency in health insurance for individuals and small businesses.

To provide the necessary tools to our members regarding providers’ cost and quality and to be compliant with Massachusetts law, Tufts Health Plan displays quality and cost indicators on its secure Provider directory.

Providers who perform in the top 25 percent ranking of Tufts Health Plan’s Massachusetts network of hospitals and physician groups, based on their overall quality performance, receive a top quality designation. For physician groups, the ranking is based on performance according to the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS) specifications and the Massachusetts Health Quality Partners’ Patient Experience Survey. Individual primary care physicians and specialists whose primary affiliation is with a physician group that is in the top 25 percent will show the Top Quality Recognition Symbol next to their individual names in the provider directory.

For hospitals, the top quality ranking is based on the performance of Massachusetts hospitals using data made available by the Centers for Medicare & Medicaid Services. Specialty hospitals and hospitals without enough data or data considered to be unsuitable for comparison are not included in Tufts Health Plan’s Top Quality Recognition.

Tufts Health Plan reviews cost efficiency data to determine the cost designation for Massachusetts hospitals, primary care physicians, specialists, and some ancillary providers. Cost efficiency is derived from two measures: relative price and total medical expense. Relative price is a calculated measure that compares different provider prices within a payer’s network to the average of all providers’ prices in that network and adjusts for case-mix. Total Medical Expense (TME) measures the total cost of care for members associated with a provider system. TME is adjusted for health status and expressed on a per member per month basis.

The cost symbol indicates Tufts Health Plan's assessment of provider cost ($–$$$$), where fewer dollar signs indicates higher cost efficiency. Hospital cost efficiency is based on relative price at the individual hospital level. Physician cost efficiency is based on both relative price and total medical expense, and is calculated at the provider system level. For provider systems with fewer than 36,000 member months per year, cost efficiency is determined based solely on relative price. If there is no cost designation symbol listed for a provider, there are not enough data to review cost efficiency. Ancillary and mental health providers are assigned a cost designation based on the provider’s system affiliation and/or cost position.

All registered members of certain Tufts Health Plan commercial products can view this cost and quality information on the secure online Provider Search at tuftshealthplan.com. It is important to Tufts Health Plan that our members (your patients) have the tools to make an informed choice about where to receive their care. We want you to be aware that these tools are available to them. Please encourage them to register as a user to view the available cost and quality data.

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