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About the HMO Ratings

 

Care Members Receive

The following sources of information are used to rate each HMO on the Care Members Receive.

  • Member (patient) medical charts.
  • Records of the services provided to members.

Information from the HMOs record of health services provided to the member, and reviews of the members medical chart, are collected and scored based on standards established by the HEDIS® (Health Plan Employer Data Information Set) performance measurement system. HEDIS® is described in greater detail below.

HEDIS® measures are used to calculate the HMO quality scores related to care members receive. The Care Members Receive information is organized into three set of topics for the OPA report card; Care for Staying Healthy, Care for Getting Better, and Care for Living with Illness. The scoring for Care for Staying Healthy is slightly different from the other two topics because it includes a measure of how well HMOs help members quit smoking that is based on a survey that is not a HEDIS® measure. The Helping Smokers Quit measure comes from CAHPS® (Consumer Assessment of Health Plans Survey), a survey of HMO members that is described in more detail below. How HMOs rate on the Helping Smokers Quit measure is reported by itself as a health topic under Care for Staying Healthy but it is not included in that topic's summary score because for several health plans, too few members answered the member survey questions about smoking.

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Member Rating of Health Plan

The following source of information is used to score each HMO on the quality measures related to Member Rating of Health Plan.

  • Member answers to mail or phone surveys.

Every year, a sample of HMO members is contacted by mail or phone to complete a survey called CAHPS® (See below). The Member Rating of Health Plan summary topic is based on a single CAHPS® survey question that asks members to rate all of their experience with the health plan. The member rating of health plan section includes responses to seven other questions from the CAHPS® survey that are each reported individually in the "explore ratings" found on the Members Rating of Health Plan webpage. Unlike the care members receive , the seven topics that are listed under "explore ratings" in the Member Rating of Health Plan section are not included in the Member Rating of Health Plan summary score.

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Scoring and Rating Methods

HMO quality scores were constructed using the HEDIS® and CAHPS® quality performance systems described above. The quality measures are based on the services, care, and experiences of commercial HMO members who were enrolled in the HMO throughout calendar year 2004. Medical chart and service records were collected and HMO members were surveyed in a standardized way through the coordination of the California Cooperative Healthcare Reporting Initiative (CCHRI, see below). CCHRI's work helps make sure that these are "apples-to-apples" comparisons among HMOs.

The summary topic grades represent the proportion of members who got the right care or had a positive experience. Scoring a summary topic requires several steps. First, scores are calculated for a number of important measures of good medical care - like are patients with harmful, high blood pressure seeing good results in lowering their blood pressure. Next, a number of these measures are combined into a single summary score. Typically 8-10 measures that concern similar aspects of medical care are combined by calculating an average across these measures. To combine the measures, most of them are given equal weight but a small number of measures that have a big influence on people's health are weighted more highly. Once these measures are combined, the summary, average score is given one of four performance grades that are indicated in the report card with stars as indicated below.

  • Excellent
  • Good
  • Fair
  • Poor

Excellent
Generally, this grade means that more than 80% of the health plan's members had a positive experience or got the right care.

Good
Generally, this grade means that three of every four of the health plan's members had a positive experience or got the right care.

Fair
Generally, this grade means that about two of every three of the health plan's members had a positive experience or got the right care.

Poor
Generally, this grade means that fewer than 60% of the health plan's members had a positive experience or got the right care.

For more information on scoring and grading formulas see OPA's Managed Care Research & Reports page, then click on the link entitled, "2005 HMO Report Card Scoring Guidelines."

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The Definition of "No-Info", “Too Few Patients” and "Not Willing to Report"

"Not Willing to Report" means that the HMO refused to report its results to our independent experts to score and compare the plan's performance. Research has shown that health plans that refuse to report results have lower performance than those plans that publicly report. "Too Few Patients" term means that not enough members reported or had the experience that is being measured.

"No Info" term means that the HMO did not report all the information that is used to score performance for a topic. Most common reasons that the information is not reported are that the HMO:

1. Has too few members to report a meaningful score for the topic
2. Made a mistake in collecting the information so it cannot be used or
3. Chose not to collect the information because of the cost to do so

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Comparing Medical Group and HMO Ratings

Medical group and HMO ratings should not be compared as these results often differ because the information and the performance measures for each are different:

  • There may be a very different mix of patients whose care is being measured even for similar ratings of medical groups and HMOs,
  • The standards used to measure performance differ for the medical group and HMO,
  • The patient's medical chart is used as an information source for a number of HMO quality measures but the chart is not used for measuring medical group performance,
  • The performance topics that are combined to rate medical groups overall differ from those used to rate HMOs,
  • The information that is kept by medical groups and HMOs is different; so, the steps to check the quality of each differs.

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HEDIS®, CAHPS®, and the National Committee for Quality Assurance

HEDIS® and CAHPS® measures are important components of a national system of accreditation of HMOs 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 HMO 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 HMO supplies the information on whether or not the member received a particular service or the results of a test for that member. HMOs gather this information from the member's medical chart or an administrative record or both. The accuracy of this information is independently checked. The quality score typically is the proportion of members whose records indicate that they obtained a particular service or test result.

Most HEDIS® measures are collected once a year based on the health plan members' experiences in the prior year(s). However, HMOs and medical groups 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 HMOs 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 HMO, randomly selected people who are HMO members are asked to complete the CAHPS® survey. For our 2005 OPA report card, CAHPS® survey responses from HMO members in 2004 were used. These members were mailed a copy of the CAHPS survey and asked to report about their experiences with the HMO 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 not having a problem getting needed care. For more information about HEDIS®, CAHPS®, or NCQA visit www.ncqa.org

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California Cooperative Healthcare Reporting Initiative

CCHRI is a statewide collaborative of employers, health plans, and providers dedicated to providing accurate, standardized, comparable reports on health care performance. The CCHRI commitment to precise standardization supports "apples to apples" comparison of plan performance so consumers can 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 member's perceptions. As described above, HEDIS® is used to measure the care members receive, while CAHPS® assesses members perceptions of the care they received. The collection of this information also is audited to be sure that the same approach is used for all HMOs.

HMOs associated with CCHRI voluntarily provided the data that independent experts used to score quality results for this site. This means that not all California HMOs are listed on this site though the CCHRI plans represent more than 90% of the California commercial HMO members. The CCHRI HMOs have taken an important step in allowing outside experts to judge their quality and report it for all consumers to use.

We are grateful to CCHRI for providing the data that our experts used to score quality results. We thank the CCHRI HMOs for their commitment to quality measurement and reporting.

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Limitations

The number of members whose medical charts were reviewed or who were surveyed was large enough-typically hundreds of members for any single quality measure-to get a clear picture of how each HMO perform overall. However, your experience with an HMO may be different. This report card also is limited as it includes commercial HMO members only; it does not include members with Medicare or MediCal HMO coverage.

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HMO Member Complaints: Where to Get Help

DMHC Complaint Process. HMO members can call or write the California Department of Managed Health Care (DMHC) about their HMO's failure to resolve a care or service problem. You can contact the DMHC by mail, email or telephone:

Mailing Address:
Department of Managed Health Care
California HMO Help Center
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725

HMO Complaints:
(888) HMO-2219

Helpline:
helpline@dmhc.ca.gov

FAX:

(916) 229-0465

TDD:
(877) 688-9891

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