How do health plans and medical groups rate in quality?

From our director of administrative advocacy Elizabeth Abbott:

The Office of the Patient Advocate (OPA) released their 2013 Health Care Quality Report Cards last week!
You can see what these scores look like by going to the OPA 2013 Report Card.    As we begin to see major provisions of The Affordable Care Act kick in, many of us need more information to make smart choices about health plans, preferred provider organizations (PPOs), or medical groups.  The report card assigns star ratings based on quality data that is compiled by California’s state regulator, the Department of Managed Health Care.  They are:    

  1. How well they deliver recommended health care, such as care for heart conditions, diabetes, cancer screenings, and other measures based on national quality criteria,

  2. How patients rate their HMO,

  3. How easy it is to get care, and

  4. How well the HMO helps their members get answers to their questions

Here is a snapshot of what information you will find on the OPA website: 

  • Managed care organizations (also called Health Maintenance Organizations or “HMOs”) provide integrated health care delivery.  The best scores went to Kaiser Permanente in both northern and southern CaliforniaThey are both ranked 4 star “Excellent.”    

  • Preferred Provider Organizations (“PPOs”) are rated on the same scorecard.  The highest rated PPOs are Cigna PPO and United Health care PPO, each rated 3 star “Good.”

  • They rate over 200 medical groups and they are sorted by county.  For example, in San DiegoCounty, the Sharp Rees-Stealy Medical Group and the (Kaiser) Permanente Medical Group—San Diegoare rated the highest medical groups with 4 stars “Excellent.”  Some medical groups have too small a sample to be fairly rated and some refused to furnish information. 

  • You can also find out how well your health plan, PPO, or medical group performed in light of a particular illness or condition.  One example is if you or your family member receives (or should receive) care for a particular chronic condition or illness, such as chronic back pain.  The two best health plans for diagnosing and treating back pain are Kaiser Permanente Northern California (89%) and Western Health Advantage (84%).  You can also see how California’s health plans compare nationally.  In this measure, these plans are better than the national average because the top-scoring health plans nationally rate get scores of 82%. 

  • Comparative data is important.  You can also make comparisons of the health plan you are enrolled in or are considering enrolling in with their competition.  OPA cautions that percentage differences of less than four percent do not mean very much.  However, although some differences are very small, by looking at these ratings you can determine substantial differences.  For example, you can gauge how health plans performed in treating Chronic Obstructive Pulmonary Disease (COPD) which is a serious chronic condition that affects your ability to breathe.  Aetna rated the highest in the state (97%), while the lowest rated plan is Anthem Blue Cross HMO at 67%; this difference is significant. 

  • The report also contains information regarding languages spoken.  California law says that a person should be able to access health care in a language they can understand.  It displays a chart of which languages are spoken in the clinical setting by the doctor, nurse, or other health care professional.  This ability to communicate can have a tremendous impact on the patient’s understanding of their condition and the course of their care and will have a positive impact on health outcomes. 

How Should You Use This Quality Data? 

  • If you have health care coverage now, you should use this data to evaluate how your health plan (and/or its medical groups) perform on this quality scorecard.   While out-of-pocket costs (premiums, co-payments, deductibles) are certainly important, the quality of the health care you receive is critical as well.  It does no good to get “bargain-basement” health insurance coverage that does not deliver high quality care. 

  • This report card takes the guesswork out of rating your health insurance because it uses specific, measurable clinical data to evaluate performance including things such as screening and diagnostic tools and whether we receive appropriate care.  This report card measures, for example, whether you are encouraged to get a flu shot and other preventive measures as well as the kind of care you receive on an ongoing basis. 

  • If you do not have health care coverage, start your research now!   A new health care insurance marketplace will be available to Californians starting in January 2014.  It will enable people to get insurance if they could not afford it previously or would not be issued a policy by any insurance company at any cost because they have a “pre-existing condition.” 

  • If you receive your health care through your employer, union, or other purchaser, this is an excellent tool for them to determine what is the best health insurance value (that is the comparison of cost for the quality received).  Make sure they are aware of this report card to ensure that they contract with plans that offer high quality care at a reasonable cost.  

Health Access California promotes quality, affordable health care for all Californians.
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