New UnitedHealth Premium program designation and updates
Select Premium Care Physicians are now Tier 1.
The UnitedHealth Premium® program provides physician designations based on clinical quality criteria to help members make more informed choices about their medical care. UnitedHealth Premium designation updates take place prior to open enrollment to allow members to verify a physician’s premium status in the upcoming calendar year before enrolling in a benefit plan.
For plan year 2024, Version 16, the primary focus is on enhancing the consumer experience to increase the trust and usability of the program. Enhancements include simplifying the designation and making analytic changes that provide a greater emphasis on quality rather than cost.
Simplifying the four Premium designations to one designation
Feedback from consumers reveals that they value clinical quality information and are less trusting of cost evaluations. Purchasers have communicated there is a desire for more emphasis on quality and believe that increased use of high-quality physicians results in more affordable care and a better care experience for their employees and their families.
There is now one designation – Premium Care Physician – defined as those who meet the UnitedHealth Premium quality criteria for safe, timely, effective and efficient care.
Enhancing the methodology to provide a greater emphasis on quality rather than cost
To be designated, physicians must continue to first meet the current quality care criteria. If quality is met, physicians receive the Premium Care Physician designation if they are statistically low cost or statistically not different cost (below or not different than the 75th percentile cost efficiency performance) or do not have enough data to evaluate cost efficiency. Previously, physicians must have been statistically low cost to be designated. Physicians who are not designated are those who do not meet the quality criteria, do not have enough data to evaluate quality or are statistically high cost.
The Premium program evaluates 16 specialties, representing 46 credentialed specialties.
Assigning Tier 1 status to a subset of Premium Care Physicians
To maintain Tier 1 savings, a higher cost efficiency rating is required for Tier 1 status than for Premium Care Physician designation. A subset of Premium Care Physicians will receive Tier 1 status. Premium Care Physicians with statistically lower cost and those who do not have enough data to evaluate cost efficiency will be given Tier 1 status.
Members in a tiered benefit plan continue to leverage the Tier 1 icon to identify providers that provide the best benefit for their plan.
Member access to a Tier 1 physician in each specialty within the applicable mileage criteria will remain at 99%. Tier 1 physicians will now have an 8.91% lower total cost of care than non-Tier 1 physicians, as compared to 7.75% previously. A total of 57% of current Tier 1 physicians will retain their Tier 1 status nationally, with primary care and specialist member disruption at 20% and 16.9%. This higher than historical disruption is due primarily to the removal of the temporary accommodations applied during the COVID-19 pandemic to minimize disruption.
For more information, visit the Premium program page or contact your UnitedHealthcare representative.