Summary Rating: HMO/PPO Uses Treatments Proven to be Effective

Each year, a random sample of members from each HMO and PPO is selected and their records are reviewed to determine if their medical care meets national standards for care and treatments proven to be effective. The health plan keeps track of the care provided to its members in their medical charts and in health plan billing records for medical services and prescription drugs.

Information from the health plan’s records were collected and scored based on standards for quality of care set by the HEDIS® (Healthcare Effectiveness Data and Information Set) performance measurement system to make sure that health plans were offering quality care and service to members.

More than 41 HEDIS® quality care measures are sorted into 9 important health topics, like 'Heart Care' and 'Maternity Care'. The measures and topics are used to rate health plans on how well the plan and its doctors make sure that members get the right care for each health condition or topic and that they do not receive unnecessary care or services. Then, these health and topic ratings are combined to calculate one summary rating for the plan: ‘HMO or PPO Uses Treatments Proven to be Effective.’

Rating a health condition or topic requires several steps.

• First, scores are calculated for important measures of recommended medical care. For example, making sure that patients under age 60 have a blood pressure below 140/90.
• Second, measures related to a similar health area like heart care are combined into a health condition or topic rating. The measures are combined by giving them equal weight and calculating an average score that is converted into a star rating.
• Third, all 9 health topic scores are combined into one summary rating using the same equal weight and average score formula.

The health plan is scored using one of four performance grades that are displayed as stars in the Report Card:

Rating Category and Number of Stars	Score*: Performance marks for ‘Quality of Medical Care’ are based on a comparison to the average ratings across all health plans nationally
	Comparable to the top 10 percent of ratings across all health plans nationally
	Comparable to ratings between 35 percent and 64 percent across all health plans nationally
	Comparable to ratings between 11 percent and 34 percent across all health plans nationally
	Comparable to the bottom 10 percent of ratings across all health plans nationally

*The percentages in each rating category are rounded up to account for health plans whose score falls just below a performance mark.

For additional information on OPA's scoring methodology for HEDIS® quality measures, see HMO and PPO Report Cards, 2016-17 Edition Scoring Documentation for Public Reporting on Clinical Care document.

Summary Ratings: Patients Rate Their Experience

Each year, a sample of HMO and PPO members is contacted by mail or phone to complete a survey called CAHPS® (Consumer Assessment of Healthcare Providers and Systems). This survey asks members about their experience with the care and services offered by the health plan. Usually, about 33% of members who are contacted complete the survey. This survey is described in greater detail below. These patient experience ratings are presented in one overall category rating called 'Patients Rate Their Experience', which is made up of three topic summary ratings called 'Getting Care Easily', 'Satisfaction with Plan Services' and 'Satisfaction with Plan Doctors'.

• 'Getting Care Easily' is a topic summary rating of members' experiences in getting appointments with doctors and other providers and getting tests, treatments and other care without delay.
• 'Satisfaction with Plan Services' is a topic summary of member ratings of customer service, getting correct information about the cost of treatment or care, and getting correct claims payment information.
• 'Satisfaction with Plan Doctors' is a topic summary of member ratings of their doctors or specialists and overall satisfaction with their health care.

Scores for the CAHPS® topics are based on the percentage of members who gave high scores or the most positive answers ("always" or "usually" for most questions) to the survey question. For most questions, answers are scored using one of four possible choices ranging from the member “always” had a positive experience to the member “never” had a positive experience.

For more detailed information on OPA's scoring methods for CAHPS, see: HMO and PPO Report Cards, 2016-17 Edition Scoring Documentation for Public Reporting on CAHPS document.

“Too Few Members” and “Not enough data to score reliably”

On the HMO and PPO Report Cards sometimes there is not enough information on a health plan for a star rating or a bar chart score. In those cases, you will see one of these labels:

• Too Few Members: This means that the HMO/PPO did not have enough members in the measure to be scored (less than 100 for clinical scores, less than 30 for patient experience scores).
• Not enough data to score reliably: This means that the HMO/PPO results were not reported because the data available were not complete or reliable enough to score.

How Reliable Are the Scores?

To get a clear picture of how well each health plan provides care and service to its members, information is collected from medical charts and member surveys. The ratings in the HMO and PPO Health Care Quality Report Cards are based on information from members who got commercial/private health insurance through their job or purchased health insurance themselves. These ratings do not include information on members with health care coverage through Medi-Cal or Medicare.

The rating called ‘HMO or PPO Uses Treatments Proven to be Effective’ tells an important story about how well the health plan and its doctors do in meeting national standards for good care, which includes ensuring that members get the right care and that they don’t receive unnecessary care or services. These ratings cover only certain health conditions and topics and do not cover all aspects of medical care. Information is only reported when enough patient records were checked to give a clear picture of how well each health plan is doing.

The ratings in ‘Patients Rate Their Experience’ are based on survey data that is collected to show the typical experience of health plan members. Surveys were sent to adults who were randomly drawn from the health plan's full list of commercial members in 2015. The survey questions ask the member about their different experiences with their health plan’s services, doctors and staff. It is possible that your experience with a health plan and its doctors or other providers/staff may differ from the ratings reported in the Report Cards.

Medical Group and HMO/PPO Ratings are not comparable

An HMO or a PPO is a type of health insurance product. A medical group is a group of doctors who work with health plans to give medical care to the plan’s members. The ratings for HMOs, PPOs and medical groups are not comparable because:

• The quality of the care of health plans (HMOs and PPOs) and medical groups is measured in different ways.
• HMOs and medical groups keep different kinds of records. The information from these records is different.
• We did not look at information from the same members for the 3 Report Cards: Medical Groups - Commercial, HMOs and PPOs. For example, a person whose diabetes care was reviewed for her medical group may not have had her diabetes care reviewed for her HMO.

Where did the data for the HMO and PPO Report Cards come from?

HEDIS®, CAHPS®, and the National Committee for Quality Assurance (NCQA)

HEDIS® and CAHPS® measures are important parts of a national system of accreditation of health plans and some medical groups. These measures are administered by the National Committee for Quality Assurance (NCQA). NCQA is “a private, not-for-profit organization dedicated to improving health care quality everywhere.” The NCQA-sponsored accreditation process is voluntary but many health plans participate.

The scores and ratings for HEDIS® measures are based on randomly selected lists of members with a particular condition or need, like members who have had a heart attack or members who are children. The health plan gives information about whether or not the member got a particular service or the results of a test for that member. Health plans gather this information from administrative records. For some measures, health plans have the option to use either administrative records or patient medical records to collect the information. The accuracy of this information is independently checked. The score usually is the percentage of members whose records show that they got a particular service or test result.

Most HEDIS® measures are collected once a year from the health plan members’ experiences in the previous year(s). However, HMOs and PPOs are allowed to report on some HEDIS® measures every other year because the results do not change greatly over the span of just one year and collecting the HEDIS® data is expensive. A HEDIS® measure that can be reported every other year is known as a “rotated” measure. Some health plans collected and reported the rotated measures information this year while others plans reported results for the past year. The HMO and PPO Report Cards use the results from either year because generally results do not vary much from year to year.

To get information about members’ experiences with their HMO or PPO, randomly selected members of the health plan are asked to complete the CAHPS® survey. These members were mailed a copy of the CAHPS® survey and asked to report about their experiences with the HMO or PPO and its doctors. Some members got follow-up phone interviews when they did not respond by mail. A research firm collects the survey responses and independent researchers score the answers. The CAHPS® scores usually are the percentage of members who answered the survey about a particular experience—like the helpfulness of plans' customer service staff. For more information about HEDIS®, CAHPS®, or NCQA visit www.ncqa.org

The data source for data for the Report Cards is Quality Compass® 2024 and is used with the permission of the National Committee for Quality Assurance (NCQA). Quality Compass® 2024 includes Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) data. Any data display, analysis, interpretation, or conclusion based on these data is solely that of the authors. NCQA specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion. Quality Compass and HEDIS are registered trademarks of NCQA. CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Users of the data shall not have the right to alter, enhance, or otherwise modify the data. Anyone who wants to use or reproduce the data without modification for a noncommercial purpose may do so without obtaining any approval from NCQA. All commercial uses must be approved by NCQA and are subject to a license at the discretion of NCQA. Use by healthcare providers in connection with their own practices is not commercial use. A "commercial use" refers to any sale, license, or distribution of the data for commercial gain, or incorporation of the data into any product or service that is sold, licensed, or distributed for commercial gain, even if there is no actual charge for inclusion of the data. ©2004-2024 National Committee for Quality Assurance, all rights reserved.