About the Medical Group Ratings

Summary Rating: Quality of Medical Care

Each year, all of the participating medical groups who have commercial HMO health plan members are measured by the Integrated Healthcare Association (IHA) 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 HMO member’s during calendar year 2021 is documented in medical charts and in HMO billing records for medical services and prescription drugs.

The ‘Quality of Medical Care’ rating is a summary clinical rating developed from the average of most clinical quality measures displayed on the Medical Group Report Card. For example, the quality measures "Immunizations for Children", "Immunizations for Early Teens", and “Treating Children with Throat Infections” make up the health topic called ‘Treating Children: Getting the Right Care’. Eighteen quality measures are reported; all measures are combined into six health topics, though only eleven are included in the star rating calculations.

A quality measure gives the percent of 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. Scoring requires several steps:

• First, scores are calculated for important quality measures of recommended medical care. For example, providers ordered a mammogram for their female patients 50-74 years of age every two years.
• Second, measures related to a similar health area like "Preventive Screenings" 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 to a star rating.
• Third, and separately, all clinical measures except for Concurrent Use of Opioids and Benzodiazepines and Preventing Readmission are combined into a single summary star rating using the "same equal weight and average score formula".

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 marks vary for each of the five clinical care topic ratings reported – all are based on comparison to the average scores across all reported medical groups for each specified quality measure
	At or above the 90th percentile of scores for all the medical groups across the specific quality measure
	Scores between 65th and 89th percentile of ratings across all the medical groups for the specific quality measure
	Scores between 35th and 64th percentile of ratings across all the medical groups for the specific quality measure
	Scores between 10th and 34th percentile of ratings across all the medical groups for the specific quality measure
	Scores below the bottom 10th percentile of ratings across all the medical groups for the specific quality measure

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

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. When calculating the star rating for the health topic that includes the quality measure, a formula is used to estimate a score for the missing information. The formula assumes that the medical group result for the missing measure would be similar to the difference between that medical group’s available scores and the average scores for all medical groups.

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

For additional information on OPA’s scoring methodology for the 'Quality of Medical Care' measures, see: Medical Group - Commercial Report Card, 2022-2023 Edition Scoring Documentation for Public Reporting on Clinical Care document

Summary Rating: Patients Rate Overall Experience

Each year, a sample of medical group patients, who are members of commercial HMO health plans, is contacted by mail, phone or email to complete a survey called the Patient Assessment Survey (PAS). This survey collects information about patients’ experiences of care and service with their doctors and medical group. The surveys are completed by adults ages 18 and older, who have commercial insurance and had at least one doctor visit during the year. Usually, about 33% of members who are contacted complete the survey.

Patient experience ratings of the medical groups show PAS survey responses to the care provided by the medical groups in 2020.

The following six patient experience measures are reported in the Medical Group - Commercial Report Card

• Rating of Doctor and Care
• Communicating with Patients
• Timely Care and Service
• Helpful Office Staff
• Coordinating Patient Care
• Health Promotion

Scores for these six topics are based on the most positive choices for each survey question such as:

• “Always” on a scale of “never to always”
• “Definitely” on a scale of “definite to definitely not”
• “Yes” on a scale of “yes or no”
• “9” or “10” on a scale of “0 to 10” with “10” being most favorable

The score is calculated as a percentage of members who responded using the most positive responses for each quality measure. That score is then translated and displayed as a star rating using one of the four performance grades below:

Star Rating Category	Score*: Performance marks vary for each of the five clinical care topic ratings reported – all are based on comparison to the average scores across all reported medical groups for each specified quality measure
	Comparable to the top 10 percent of scores for all the medical groups across the specific quality measure
	Comparable to scores between 65 and 89 percent of ratings across all the medical groups for the specific quality measure
	Comparable to scores between 35 and 64 percent of ratings across all the medical groups for the specific quality measure
	Comparable to scores between 10 and 34 percent of ratings across all the medical groups for the specific quality measure
	Comparable to scores below the bottom 10 percent of ratings across all the medical groups for the specific quality measure

*Percentiles were truncated to the next lowest integer percent and compared with the rounded scores.

Five of the topic scores above are then combined into a single summary star rating, called “Patients Rate Overall Experience.”

The scores are adjusted for a set of patient characteristics—age, gender, mental health status, education, overall health status, race/ethnicity, language spoken and number of chronic conditions. These characteristics have been shown to influence patients’ ratings of their care experience. Scores are also adjusted for the specialty of the physician seen by the patient and by the type of survey—answered in print, online or by phone. These adjustments allow similar comparisons across groups whose patients may differ. Through the adjustments, the groups’ results can be represented as if they all had a similar mix of patients.

For additional information on OPA’s scoring methodology for 'Patients Rate Overall Experience' see: Medical Group - Commercial Report Card, 2022-23 Edition Scoring Documentation for Public Reporting on Patient Experience document

Summary Rating: Total Cost of Care

Each year, all of the participating medical groups that have commercial HMO health plan members are reviewed to determine the average monthly amount paid to care for the members of the medical group. Health plans reported the total amount paid for medical care in 2021 for each member of each of the participating medical groups. This total amount included payments to medical groups and other providers by patients and their health insurance plans. Higher overall payments make a medical group more expensive for everyone.

The ‘Total Cost of Care’ rating is a summary rating developed by comparing medical groups’ costs. Each medical group’s costs are calculated by assessing actual payments from patients and health plans for the care provided to members of any age who belonged to that medical group during 2021.

The ‘Total Cost of Care’ rating along with the star ratings on the quality of each medical group will help you compare and choose a medical group based on both quality and cost. Look for medical groups in this Report Card that have higher quality and lower payments.

Medical groups are rated using one of five performance grades that are displayed as green stars on the Report Card.

Ratings based on comparing average monthly payment per patient across all reported medical groups.
	Less than $348 on average for each patient monthly (lowest 10% of costs)
	$349 - $401 average for each patient monthly
	$402 - $445 average for each patient monthly
	$446 - $507 average for each patient monthly
	$508 average for each patient monthly (highest 10% of costs)

*Because these costs are based on the average for all patients during the year, some patients’ costs will be more than the average and some patients’ costs will be lower than the average.

When choosing a medical group, it is important to understand that higher cost does not necessarily mean higher quality. Many medical groups provide high quality care at a lower average cost than other groups. Independent researchers have found that medical groups that receive more money for the care they provide do not necessarily provide higher quality care.

Research on the cost and quality of health care suggests that higher spending is linked to the number of treatments that patients receive from their medical care team, such as diagnostic tests, minor procedures, doctor’s visits and the length of time patients spend in a hospital. However, receiving more services does not necessarily mean better care or better outcomes for patients. More services may mean:

• Patients got tests or treatments that they did not need.
• Providers have made errors in providing care to patients that had to be corrected, like giving the wrong diagnosis or the wrong medicine.
• Patients returned to the hospital soon after a hospital stay for a reason that could have been prevented.

More medical treatments are costly for patients and may cause side effects that require even more services from the care team. Over time, patients in a medical group with higher overall costs may also have higher out-of-pocket costs.

It is possible for medical groups to provide their patients with higher quality care at a lower cost to health plans and patients.

'Total Cost of Care’ is an overall rating that does not show a specific member’s cost responsibility or the medical group’s own costs. The rating only includes payments for commercial HMO/POS members, so the medical group’s performance may be different for other types of insurance.

The ratings related to ‘Total Cost of Care’ alone do not demonstrate value. This rating should be considered alongside the ‘Quality of Medical Care’ and ‘Patients Rate Overall Experience’ quality star ratings that are also shown on the Medical Group star ratings page. Health care costs in the U.S. are already the highest in the world and are growing rapidly, so it is important to consider cost and quality data together when looking for a medical group.

For more detailed information on OPA's scoring methodology for the ‘Total Cost of Care’ rating, see: Medical Group - Commercial Report Card, 2022-23 Edition Scoring Documentation for Public Reporting on Average Monthly Payment for Care document

_i Fisher, E.S; Wennberg, D.E.; Stukel, T.A.; Gottlieb,D.J., Lucas, F.L.; Pinder, E.L. (2003; 138:273-287). Ann Intern Med. The Implications of Regional Variations in Medicare Spending. Part 1: The Content, Quality, and Accessibility of Care. Retrieved Dec. 9, 2015 from: http://annals.org/article.aspx?articleid=716066

_ii Fisher, E.S; Wennberg, D.E.; Stukel, T.A.; Gottlieb,D.J., Lucas, F.L.; Pinder, E.L. (2003; 138:288-298). Ann Intern Med. The Implications of Regional Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care. Retrieved Dec. 9 2015 from: https://www.dartmouth.edu/~jskinner/documents/FisherESTheimplicationsPart2.pdf

Fisher, E.S. and Skinner, J. (2010). Reflections on Geographic Variations in U.S. Health Care. Retrieved Nov. 17, 2015, from http://www.dartmouthatlas.org/downloads/press/Skinner_Fisher_DA_05_10.pdf

_iii Fisher, E.S.; Goodman, D.; Skinner, J.; Bronner, K. (Feb 27, 2009.) Dartmouth Institute. Dartmouth Atlas: “Health Care Spending, Quality, and Outcomes: More Isn’t Always Better”. Retrieved Nov. 17, 2015, from: http://www.dartmouthatlas.org/downloads/reports/Spending_Brief_022709.pdf

_iv lbid

_v lbid, page 2

_vii Emanuel, E.J. (Nov. 21, 2015). New York Times Sunday Review. “Are Good Doctors Bad for Your Health? Retrieved Dec. 8, 2015 from: are-good-doctors-bad-for-your-health.html

_viii American Institutes for Research (Feb. 2014). Aligning Forces for Quality, Robert Wood Johnson Foundation. “How to Report Cost Data to Promote High-Quality, Affordable Choices: Findings from Consumer Testing”. Retrieved Dec. 9, 2015 from: http://www.rwjf.org/en/library/research/2014/02/how-to-report-cost-data-to-promote-high-quality--affordable-choi.html

_ix Fisher, E.S., et al. (Feb. 27, 2009).

“Too Few Patients,” “Not Enough Data to Score Reliably,” “Not Rated,” and “Not Willing to Report”

On the Medical Group - Commercial Report Card, scores range from one to five stars, with five stars being the highest rating. Sometimes, instead of a star rating or a score on a bar chart, you will see a brief note indicating that the medical group does not have a score. In those cases, you will see one of the following labels:

• Too few patients: This means that based on statistical reliability measures the medical group did not have enough patients who had the experience to be scored.
• Not rated: This means that a given measure is not applicable to a particular group. This could be because their patient population does not match the question, or because the group did not participate in the Patient Assessment Survey.
• Not willing to report: This means that the medical group would not report its results.
• 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.

How Reliable Are the Scores?

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

The ratings 'Quality of Medical Care‘ and ‘Patients Rate Overall Experience’ tell 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 and that doctors and their staff provide good customer service, listen carefully, explain things clearly and treat patients with respect. These ratings cover only certain health conditions and topics and do not cover all aspects of medical care.

To view the Report Card’s (Year) Edition Scoring Documentation for Public Reporting on (Clinical Care, CAHPS, etc.), submit requests and/or questions to opareportcard@ncqa.com.

Medical Group and HMO and PPO Ratings are not comparable

HMOs and PPOs are types of health insurance. The medical groups in the Report Card are groups of doctors who work with the HMOs listed in the Health Plan Report Card as well as other health plans to give medical care to patients. 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.

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 activities include performance measurement, payment innovation, administrative simplification, and promoting the use of health information technology and integrated care delivery. A key initiative of IHA is the Align. Measure. Perform. (AMP) Commercial HMO Program, which collects and aggregates medical group clinical performance and cost information that is used in the ‘Quality of Medical Care’ and ‘Total Cost of Care’ ratings.

The Medical Group – Commercial Report Card also includes information about physician organizations recognized by IHA’s annual Excellence in Healthcare Awards, which recognizes medical groups that achieve strong quality and patient experience results while effectively managing costs. IHA determines the award-winning medical groups using clinical quality, patient experience, and cost data.

Purchaser Business Group on Health (PBGH)

Purchaser Business Group on Health (PBGH), a not-for-profit 501(c)(3), has led efforts to transform U.S. healthcare using the combined influence of some of the largest public and private purchasers of healthcare in the United States. Since its inception, PBGH has made some of the most notable improvements to U.S. healthcare, including launching the first public website displaying health plan, hospital and medical group quality and patient experience data, influencing the drafting of the Affordable Care Act to emphasize federal value purchasing and accountability, representing purchasers in the Meaningful Use Health IT roll-out, and implementing the Intensive Outpatient Care Program (IOCP) for Americans with serious chronic illness in five states.