About the PPO Ratings

Meeting National Standards of Care

Each year, samples of PPO members are selected and their records are reviewed to determine if members received care that meets nationally recognized standards for good care. The member's care is documented using the PPO’s records. Often, PPO records include information from the patient billings that are sent by doctors and others for medical and prescription drug services.

Information from the PPOs’ records are collected and scored based on standards established 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 familiar topics, like Heart Care to score PPOs on providing the right care across a range of important health conditions. Then, these topic scores are combined to calculate a single summary rating for the PPO: Meeting National Standards of Care.

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Member Ratings Compared to Plans Nationwide

Each year, a sample of PPO members is contacted by mail or phone to complete a survey, about their PPO experiences, called CAHPS® (Consumer Assessment of Healthcare Providers and Systems) which is described in greater detail below. Typically, about one-third of the members who are contacted answer the survey. PPOs are scored on the members’ survey answers about their experiences of care and service. The Member Ratings Compared to Plans Nationwide is organized into two summary ratings – Getting Care Easily and Plan Service. In addition to these summary ratings, PPOs are scored on various aspects of plan members’ experiences of care and service using the members’ survey answers.

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Scoring and Rating Methods

PPO quality scores were constructed using the HEDIS® and CAHPS® quality performance systems. The quality measures are based on the services, care, and experiences of samples of commercial PPO members who were enrolled in the PPO throughout 2010. Medical services were documented by checking information on the billings that are submitted by doctors and others to the PPO. And, PPO members were surveyed in a standardized way through the coordination of the California Cooperative Healthcare Reporting Initiative (CCHRI).

The Meeting National Standards of Care scores represent the percent of members who got the right care. Scoring a topic requires several steps. First, scores are calculated for a number of important measures of good medical care – like, are the cholesterol levels regularly checked for patients with heart disease. Next, those measures that concern a particular area of health like heart and cardiovascular care are combined into a topic score. A number of topic scores are calculated. The measures for each topic are combined by giving them equal weight and calculating an average score. Last, the topic scores are combined into a single summary rating using the same “equal weight and average score formula.” The score is given one of four performance grades that are indicated in the report card with stars. The possible grades for the single summary rating Meeting National Standards of Care are:

  • Excellent: This means that about 3 of every 4 PPO members got the right care.
  • Good: This means that about 2 of every 3 PPO members got the right care.
  • Fair: This means that about 3 of every 5 PPO members got the right care.
  • Poor: This means that fewer than 3 of every 5 PPO members got the right care.

A “buffer zone” adjustment is used for the Meeting National Standards of Care scores. This adjustment accounts for the error that occurs in measurement and scoring when the formula is based on samples of members rather than all the members in a PPO. 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 HEDIS scoring methodology refer to this pdf document.

Member Ratings Compared to Plans Nationwide is organized into two summary ratings – Getting Care Easily and Plan Service. Getting Care Easily concerns member’s experiences in getting appointments with doctors and other providers when needed and getting tests, treatments and other care without delay. The Plan Service topic shows member-reported experiences in getting claims paid, customer service help and information about the member’s costs for care.

The Getting Care Easily and Plan Service indicator ratings are scored using one of four performance grades that are indicated in the report card with stars. The possible grades are:

  • Excellent: This means that more than 8 of every 10 PPO members report favorably about this experience with the plan.
  • Good: This means that about 8 of every 10 PPO members report favorably about this experience with the plan.
  • Fair: This means that more than 3 of every 4 PPO members report favorably about this experience with the plan.
  • Poor: This means that fewer than 3 of every 4 PPO members report favorably about this experience with the plan.

Scores for the various CAHPS® topics are based on the proportion of members who gave a positive response to the survey question ("always" or "usually" for most questions). Scores use a 0-100 point range; higher scores mean better performance. For most questions, responses are scored using one of four possible answers ranging from the member “always” had a positive experience with a particular need like getting an appointment to the member “never” had a positive experience. Each member’s responses for a set of questions about a particular topic like “Getting Doctors and Care” are combined to create a per-member topic score; then the average of all of the members’ scores is calculated to create a PPO score for that topic. The scores represent the average or typical experience that that PPO’s members reported.

A “buffer zone” adjustment is used for the Member Ratings Compared to Plans Nationwide two summary indicators. This adjustment accounts for the error that occurs in measurement and scoring when the formula is based on samples of members rather than all the members in a PPO. 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 pdf document.

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Star Ratings: Comparisons to Nationwide Performance

Summary ratings are scored using one of four performance grades that are indicated in the report card with stars. This scoring compares the health plan to nationwide results for all of the plans that report to NCQA (described below). Nationwide results are calculated by combining all of the health plans scores to define the performance grades as:

  • Excellent: PPO performance is in the top 10% of all plans nationwide
  • Good: PPO performance is in the 50th-89th percentile plans nationwide
  • Fair: PPO performance is in the 25th-49th percentile plans nationwide
  • Poor: PPO performance is in the bottom 24% of all plans nationwide
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“Too Few Members” and “Did Not Report”

On the PPO rating charts, most scores range from one to four stars, with four stars being the highest rating. Sometimes 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?

Enough people had their medical services reviewed or replied to surveys to give a very clear picture of how well each PPO provides care and service to its members. However, your experiences may be different. These ratings concern members who typically get insurance through their job though it does not include HMO plan members. The ratings also do not include members of Medi-Cal, Healthy Families, or Medicare.

The Meeting National Standards of Care rating tells an important story about how well the PPO and its doctors do in meeting national standards for good care. But, because the rating is limited to a particular set of health conditions there are many aspects of medical care that are not part of this rating.

The Member Ratings Compared to Plans Nationwide results are based on member surveying that is done in a way to show the typical experience of PPO members. The people who were surveyed were randomly drawn from the PPO's full list of commercial members. Adults who were members of the PPO throughout 2010 were included on the survey list. Nonetheless, your experience with doctors or other providers who belong to the PPO or with the health plan’s staff may differ from the experiences reported in the survey.

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California Cooperative Healthcare Reporting Initiative

The California Cooperative Healthcare Reporting Initiative (CCHRI) is a group of employers, health plans, and health care providers across the State. Most of the PPO plan enrollees in California belong to plans that are part of CCHRI. CCHRI makes sure that people get information they can trust on how well health plans and medical groups provide care and service.

The CCHRI commitment to precise standardization supports “apples to apples” comparison of health plan and medical group performance so consumers can more easily make informed choices about their health care. CCHRI uses a common approach to measuring quality that is based on both the services members receive and on members’ experiences. As described above, HEDIS® is used to measure the care members receive, while CAHPS® assesses members’ experiences of their care and service. The collection of this information also is audited to be sure that the same approach is used for all PPOs.

PPOs that are a part of CCHRI voluntarily provide the information that is used for this report card. These PPOs allow outside experts to score their care and service and make that information public. We are grateful to CCHRI for providing the data that our experts used to score quality results. We thank the CCHRI PPOs for their commitment to quality measurement and public reporting.

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

HEDIS® and CAHPS® measures are important components of a national system of accreditation of heath plans and some physician organizations that is 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 HEDIS® measures are based on randomly selected lists of members who are eligible to be included in an evaluation of quality for a particular condition or need, such as members who have had a heart attack or members who are children. The PPO supplies the information on whether or not the member received a particular service. PPOs gather this information from the member’s administrative records. The accuracy of this information is independently checked. The score typically is the proportion of members whose records indicate that they obtained a particular service.

Most HEDIS® measures are collected once a year based on the health plan members’ experiences in the prior 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 chose to collect and report the rotated measures information this year while others plans did not and instead reported results for the past year. This 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. Follow-up phone calls also were used to interview some members who do not respond by mail. A research firm collected the survey responses and independent researchers scored the answers. The CAHPS® score typically is the proportion of members who answered the survey reporting 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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