About the Medical Group Medicare Ratings


Medicare Medical Group Uses Treatments Proven To Be Effective and Individual Measure Ratings


Each year, all of the participating medical groups who have Medicare HMO health plan members are reviewed to determine if the medical care provided meets national standards for using treatments proven to be effective. The care provided to the medical group’s Medicare Advantage plan members during 2015 is documented in data submitted to the Integrated Healthcare Association (IHA) by health plans and the medical groups.

Health plan-submitted rates are aggregated for a medical group across all contracted plans that participate in the Medicare Advantage measurement program: Anthem Blue Cross, Blue Shield of California, Health Net, Humana, SCAN Health Plan, and UnitedHealthcare. The Kaiser Permanente medical groups are also included. If there is an aggregated health plan-submitted rate and a group-submitted rate for a measure, the official reported rate is the better rate. There must be at least 30 eligible patients included in the reported rate. The methods described below for determining the star ratings and scores for the Medical Group Medicare Report Card are based on requirements developed by the US Centers for Medicare and Medicaid Services (CMS).

The Medicare Medical Group Uses Treatments Proven To Be Effective rating is a summary clinical rating developed from 13 different health care quality measures. A medical group must have rates for at least seven of the quality measure to have the summary clinical quality rating. The scoring methodology to assign the star ratings for the summary rating uses the same cut-points that CMS uses to rate Medicare Advantage health plans.

The overall rating is calculated by taking an average of the measure-level star ratings that are available for a medical group. Outcome measures such as Controlling Blood Sugar for Patients with Diabetes are given three times the weight of process measures such as Colon Cancer Screening.

The medical groups are rated using one of five performance grades that are displayed as stars in the Report Card: .

Star Rating Category Score: Performance scores vary for each of the 13 quality ratings reported – all are based on comparison to the average scores across the U.S. for each specified quality measure. The following describes the distribution of the overall “Medicare Medical Group Uses Treatment Proven To Be Effective” rating:
Poor 3 percent (6 medical groups) received this overall rating for the 2016-17 Edition of the Medical Group Medicare Report Card.
Excellent 52 percent (97 medical groups) received this overall rating for the 2016-17 Edition of the Medical Group Medicare Report Card.
Good 29 percent (54 medical groups) received this overall rating for the 2016-17 Edition of the Medical Group Medicare Report Card.
Fair 9 percent (17 medical groups) received this overall rating for the 2016-17 Edition of the Medical Group Medicare Report Card.
Poor No medical groups received this overall rating for the 2016-17 Edition of the Medical Group Medicare Report Card.
No Rating 6 percent (12 medical groups) did not have sufficient data to be scored reliably and are listed without an overall star rating.

The scores and star ratings for each of the 13 clinical care measures are calculated for all members who are eligible based on their age, gender and/or a particular health condition they have. A quality measure gives the percent of Medicare Advantage patients who got the right care for an important health care goal. These goals were set to make sure that medical group patients are getting quality preventive care and treatment services.

For example, the Colon Cancer Screening measure assesses all Medicare members aged 50 to 75. The score is the percent of these members whose records indicate that they had appropriate screening for colorectal cancer. The scoring methodology to assign star ratings for the individual measures uses the same cut-points that the CMS uses to rate Medicare Advantage health plans.

There are times when a medical group does not have enough patients to calculate a score for a quality measure or other reasons why a score is not shown. In these cases, the medical group does not receive a score for that quality measure.

To understand how data is reported in these situations see explanations for the following labels: “Not enough data to score reliably”, “Not willing to report”.

For more detailed information on the CMS scoring methodology for the ‘Medicare Medical Group Uses Treatments Proven To Be Effective’ measure, see: Medical Group Medicare Report Card, 2016-17 Edition Scoring Documentation for Public Reporting on Clinical Care document.

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“Not Enough Data to Score Reliably” and “Not Willing to Report”


On the Medical Group Medicare Report Card, scores range from one to five stars, with five stars being the highest rating. For some medical groups you may see a brief note indicating that the group does not have a score. In those cases, you will see one of the following labels:

  • Not enough data to score reliably: This means that the medical group results were not reported because the data available were not complete or reliable enough to score.
  • Not willing to report: This means that the medical group would not agree to report its results.

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How Reliable Are the Scores?


Enough patient records were checked to give a clear picture of how well each medical group is doing. However, your experiences with a medical group may be the same as or different from the ratings shown here.

The rating Medicare Medical Group Uses Treatments Proven To Be Effective tells an important story about how well the medical group and its doctors do in meeting national standards for good care. This includes ensuring patients 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.

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Medical Group Medicare, Medical Group and HMO and PPO Ratings are not comparable


HMOs and PPOs are types of health insurance. The medical groups in the Medical Group Report Card are groups of doctors who work with the HMOs listed in the HMO Report Card as well as other health plans to give medical care to patients. The medical groups in the Medical Group Medicare Report Card are most of the same groups as in the Medical Group Report Card but are a smaller subset of the patients who are in Medicare Advantage health plans. The ratings for HMOs, PPOs and medical groups cannot be compared because:

  • The quality of the care of HMOs, PPOs and medical groups are measured and rated in different ways.
  • HMOs, PPOs and medical groups keep different kinds of records. This means that the information we get from them is different.
  • We did not look at the same members when we looked at information from medical groups, HMOs and PPOs, even when we were looking at medical care for the same health topic. For example, a person whose diabetes care was reviewed for her medical group may not have had her diabetes care reviewed for her HMO.

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Where did the data for the Medical Group Medicare Report Card come from?

Integrated Healthcare Association (IHA)


The Integrated Healthcare Association (IHA) is a non-profit, multi-stakeholder leadership group that promotes healthcare quality improvement, accountability, and affordability for the benefit of all Californians. As a regional healthcare improvement collaborative, IHA convenes diverse, cross-sector organizations to collaborate on challenging healthcare issues. IHA membership includes industry-leading health plans, physician groups, and hospital systems, plus academic, consumer, purchaser, pharmaceutical and technology representatives. Principal projects and activities include the California Value Based Pay for Performance (P4P) Program, performance measurement, payment innovation, administrative simplification, and promoting the use of health information technology and integrated care delivery. The P4P program generates the clinical performance measures used in the ‘Medicare Medical Group Uses Treatments Proven To Be Effective’ ratings.

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