About the PPO Ratings


PPO Provides Recommended Care


Each year, a random sample of members from each PPO is selected and their records are reviewed to determine if their medical care meets national standards for recommended care. The PPO documents the care provided to its members in their medical charts and in other PPO records. PPO records often include information from claims for medical services and prescription drugs..

Information from the PPOs’ records are collected and scored based on standards set by the HEDIS® (Healthcare Effectiveness Data and Information Set) performance measurement system. HEDIS® is described in greater detail below.

More than thirty HEDIS® measures are combined into a set of 9 important health conditions or topics, like Heart Care and Maternity Care.The measures are used to score PPOs on providing the right care for each health condition or topic. Then, these condition and topic scores are combined to calculate a single summary rating for the PPO: ‘PPO Provides Recommended Care’.

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Patients Rate Their Experience


Each year, a sample of 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 one-third of the members who are contacted answer the survey. The report of survey results includes two summary ratings called ‘Getting Care Easily’ and ‘PPO Helps Members Get Answers.’ CAHPS® is described in greater detail below.

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Scoring and Rating Methods


PPO quality scores were built using the HEDIS® and CAHPS® quality performance systems. The individual quality scores are based on the services, care, and experiences of commercial PPO members who were enrolled in the PPO throughout 2011. The quality scores are based on information collected from medical charts, service records, and member survey findings. Some of the results are grouped into the summary scores described below.

Summary Score: ‘PPO Provides Recommended Care’ gives the percent of members who got the right care for important health conditions or topics. Scoring a health condition or topic requires several steps. :

  • First, scores are calculated for important measures of recommended medical care – for example, patients with hypertension or high blood pressure are lowering their blood pressure.
  • Second, measures that concern a similar health area like heart care are combined into a health condition or topic score. The measures are combined by giving them equal weight and calculating an average score.
  • Third, the health condition or topic scores are combined into a single 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:

  • Excellent (4 stars) means that about 8 out of 10 PPO members got the right care.
  • Good (3 stars)means that about 7 out of 10 PPO members got the right care.
  • Fair (2 stars)means that almost 6 out of 10 PPO members got the right care.
  • Poor (1 star)means that less than 6 out of 10 PPO members got the right care.

For additional information on the HEDIS® scoring methodology see this document.

The rating category called ‘Patients Rate Their Experience’ has two summary ratings:

1. Getting Care Easily is a summary rating of members’ experiences in getting appointments with doctors and other providers when needed and getting tests, treatments and other care without delay.

2. The ‘PPO Helps Members Get Answers' is a summary rating of members’ experiences with customer service help, getting accurate information about how much treatment or care will cost a member and getting accurate claim payment information.

Scores for the various CAHPS® topics are based on the percentage of members who gave high scores or answers ("always" or "usually" for most questions) to the survey question. For most questions, answers are scored using one of four possible answers ranging from the member “always” had a positive experience to the member “never” had a positive experience. For example, a member said that they “always” were able to get an appointment when needed or “usually” were able to get an appointment when needed. The answers for a set of questions about a particular topic like ‘Doctor Communications’ are combined to create a combined score for that topic.

The ratings called ‘Getting Care Easily’ and ‘PPO Helps Members Get Answers’ are summary scores calculated by adding the topic scores that are included in that summary rating. The plan is scored using one of four performance grades that are displayed as stars in the Report Card:

  • Excellent (4 stars) means that more than 9 of every 10 PPO members gave high scores/answers about their experience with the plan.
  • Good (3 stars) means that about 8 of every 10 PPO members gave high scores/answers about their experience with the plan.
  • Fair (2 stars) means that about 7 of every 10 PPO members gave high scores/answers about their experience with the plan
  • Poor (1 star) means that fewer than 7 out of 10 PPO members gave high scores/answers about their experience with the plan.

The ratings categories called ‘PPO Provides Recommended Care’ and ‘Patients Rate Their Experience’ and their associated health condition or topic-level scores include a “buffer zone” adjustment. This adjustment is needed because the formula is based on samples of members rather than all the members in a PPO. The “buffer zone” adjusts for the error that occurs in measurement and scoring. This “buffer zone” gives the benefit of the doubt to the PPO — if a score falls below a performance threshold, but within a half-point of that threshold, the PPO is assigned that next highest grade.

For additional information on the CAHPS® scoring methodology refer to this document.

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“Too Few Members” and “Did Not Report”


On the PPO rating charts, scores range from one to four stars, with four stars being the highest rating. Sometimes there is not enough information on a PPO for a star rating. In those cases, you will see one of the following:

  • Too Few Members: This means that the PPO did not have enough surveyed members (less than 100) to be scored.
  • Did Not Report: This means that the PPO would not report its results. This usually means that the PPO did not do well.

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How Reliable Are the Scores?


To get a clear picture of how well each PPO provides care and service to its members, information is collected from medical charts and member surveys. The ratings in the California Health Care Quality Report Card are based on information from PPO members who got 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, Healthy Families, or Medicare.

The rating called ‘PPO Provides Recommended Care” tells an important story about how well the PPO 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 a particular set of health conditions and topics and do not cover all aspects of medical care

The ratings in ‘Patients Rate Their Experience’ are based on survey data that is collected in a way to show the usual experience of PPO members. Surveys were sent to adults who were randomly drawn from the PPO's full list of commercial members in 2011. The survey questions ask the member about their different experiences with health plan services, doctors and staff.

We recognize that it is possible that your experience with the PPO and its doctors or other providers/staff may differ from the ratings reported in the Report Card.

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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 physician organizations (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.

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 PPO gives information about whether or not the member got a particular service or the results of a test for that member. PPOs gather this information from the member’s medical chart and/or other records. 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, 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 PPOs collected and reported the rotated measures information this year while others plans reported results for the past year. The OPA Health Care Quality Report Card uses the results from either year because generally results do not vary much from year to year.

To get information about members’ experiences with their PPO, randomly selected members of the PPO 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 PPO and its doctors. Some members got follow-up phone interviews when they did not respond by mail. A research firm collected the survey responses and independent researchers scored the answers. The CAHPS® score usually is 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

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