Medical Group FAQs

It's your choice.

Good choices depend on reliable, accurate and valid information. When choosing a provider, whether it’s a doctor, medical group or hospital, you should have information you need to make a sound choice.

Blue Shield of California makes it easier to find the provider who is right for you and your family with our Find a Provider Performance Profile tool.

This tool provides insights into the quality and efficiency of the large networks of doctors, HMO Medical Groups and IPAs, and Hospitals.

And now, with more comparative ratings at your fingertips, you'll be better prepared to make an informed choice. Our hope is that Performance Profile helps you choose the best provider for you and your family.

• How does Blue Shield measure health care?
• Where does the data come from?
• How do I interpret these scores?
• How can Performance Profile help me choose a medical group?
• What is measured?
• Does a low score mean that a medical group gives poor care?
• How reliable are the scores?
• Is a medical group score the same as a doctor's score?
• Why doesn't my group have a score?
• What does "Not Available" mean?
• What does "Not Willing to Report" mean?
• Where can I find more detailed information on these scores?
• How do I register a complaint about these scores?

It's important to Blue Shield to know that you are getting the care that is best for you and your family. We are committed to providing you with information that is reliable, accurate and valid. The Performance Profile shows you how medical groups and physicians perform in important areas of getting the right medical care, patient satisfaction and health care affordability. In selecting the measures, Blue Shield used the following guidelines:

• Quality measures based on national standards and supported by national quality organizations such as the National Quality Forum and the Joint Commission
• Most scores are provided by trusted third-party sources that are independent of Blue Shield, such as the Integrated Healthcare Association, CMS and the Pacific Business Group on Health
• In areas where standards do not exist, additional measures produced by Blue Shield are selected for display based on impact to member health, finances and decision making

How a medical group performs in these quality, patient satisfaction and affordability measures tells an important story about their overall patient care. That’s why Blue Shield chose to provide our members with these quality scores, which are doctor-reviewed and come from a trusted third party.

Members should keep in mind that these ratings are limited to specific areas of care.

Most scores are from the 2008 Pay for Performance program results. The Integrated Healthcare Association (IHA) is a not-for-profit statewide group that promotes quality improvement, accountability and affordability of health care in California.

IHA is made up of medical groups and healthcare systems, plus academic, consumer, purchaser, pharmaceutical and technology representatives.The IHA-sponsored Pay for Performance program generates all of the patient satisfaction and most of the quality of care measures, which are validated by physician organizations.This program is the nation's largest medical group quality measurement and reward program, and involves over 40,000 HMO doctors in 220 medical groups that care for over 12 million patients in California.

One additional quality measure comes directly from Blue Shield: Adolescent Well Care. We follow national HEDIS standards when calculating these scores.

Recognition for cost of care comes from measures developed by Blue Shield as part of our Performance Improvement Rewards Program for medical groups. These measures capture how well medical groups manage certain high-cost services while maintaining quality of care. We look at how well medical groups manage unnecessary patient visits to the emergency room, provide low-cost generic prescriptions when they are available, conduct outpatient services in the right setting and appropriately manage the duration of a patient's hospital stay.

All scores are reported as percentages and are based on a scale from 0 to 100: a higher percentage means a better score.

Quality Scores: The quality scores reflect the percentage of a group's or physicians' patients who received the recommended care for a specific measure. For example, a group with a 90 percent breast cancer screening score had 90 percent of its female patients ages 52 to 69 receive a mammogram. The Overall Quality score was created by averaging all of the group's quality scores. More detail is provided in the Technical FAQs.

Patient Satisfaction Scores: The patient satisfaction scores reflect the percentage of patients who positively rated their medical group on a specific aspect of their experience with that medical group: the higher the percentage, the better the score. The Overall Patient Satisfaction score is created by averaging all patient satisfaction scores.

Recognition for cost is based on good performance in the Blue Shield of California Performance Improvement Rewards Program (PIRP). PIRP recognizes and rewards IPAs and medical groups for improving or effectively managing four key areas of service that are provided to members:

• ER visits
• Outpatient surgery at ambulatory surgery centers
• Inpatient bed days
• Generic drugs

You can find more information about scores in the Technical FAQs.

Blue Shield is happy to be able to share this important information with its members. You can use the data in this profile to compare the quality of care and patient satisfaction of different medical groups located near you. Certain measures may be more important to you than other measures. For example, if you have children, you may want to look how a medical group scores on adolescent and pediatric measures. Using this data can help you select a Primary Care Physician from a high scoring medical group in your area.

We provide scoring for medical groups and IPAs across seven categories. The descriptions below give an overview of the categories assessed.

1. Preventive Health and Cancer Screenings
This category measures the percentage of a group’s patients who receive screenings to prevent certain illnesses or detect certain conditions. Patients are encouraged to visit their doctor to receive the appropriate screening.

Breast Cancer Screening	Guidelines recommend that women 40-69 years old receive a mammogram every two years in order to detect breast cancer. When cancer is found early, there is a much better chance that it can be cured. A test called a “mammogram” is the best way to find breast cancer early.
Cervical Cancer Screening	Guidelines recommend that women 21-64 years old receive a Pap smear every three years in order to detect cervical cancer. Checking women for cervical cancer helps save lives. When cancer is found early, there is a much better chance that it can be cured. The test, called a “Pap smear,” is the best way to find cervical cancer early.
Chlamydia Screening	Guidelines recommend that sexually active women 16-25 years old be tested for chlamydia yearly. It is important to find sexually transmitted infections (STIs) early. STIs like chlamydia spread easily and can cause serious health problems. If chlamydia is not treated, it can cause pelvic inflammatory disease and even cause infertility.
Colorectal Screening	Guidelines recommend that adults 50-80 years old should have a colorectal cancer screening every five to ten years. Regular tests for colorectal cancer help save lives. When cancer is found early, there is a much better chance that it can be cured. A test called a “colonoscopy” can help detect colorectal cancer early.

2. Diabetes Care
Diabetes is a disease in which the body does not produce or properly use insulin. Diabetes is one of the most common and costly chronic medical conditions in the United States. These measures capture certain procedures and tests that medical groups should regularly give diabetic patients to help keep their diabetes well-managed.

Blood Sugar Testing	Guidelines recommend that diabetics should have their blood sugar (hemoglobin A1C) tested at least once every year. Regular tests can help ensure that blood sugar levels are well controlled, and are an important part of managing your diabetes.
Blood Sugar Under Control	Guidelines recommend that blood sugar levels (hemoglobin A1C)for diabetics should be less than nine percent. It is important to keep blood sugar levels at a safe range; high blood sugar levels can lead to medical emergencies.
Blood Sugar Not Under Control	Guidelines recommend that blood sugar levels (hemoglobin A1C) for diabetics should be less than nine percent. It is important to keep blood sugar levels at a safe range; high blood sugar levels can lead to medical emergencies.
High Cholesterol Screening for Diabetics	Guidelines recommend that diabetics have their LDL cholesterol checked at least once per year. Regular lipid profile tests can help ensure that cholesterol levels are well controlled. If you have diabetes, you are vulnerable to cholesterol issues that can lead to heart disease.
Cholesterol Under Control Diabetics	Guidelines recommend that cholesterol levels (lipid profiles) for diabetics should be less than 130 mg/dL. It is important to keep cholesterol levels under control because high cholesterol levels can damage blood vessels and lead to a heart attack or stroke.
Kidney Monitoring	Guidelines recommend that diabetics should have their kidney function tested yearly. High blood sugar is harmful to the kidneys and can cause them to stop functioning. Testing your urine often is the main way to check for signs of kidney problems. Early signs alert you and your doctor to take steps to prevent kidney failure.

3. Care for Heart Conditions
Heart disease is one of the leading causes of death in the United States. Common cardiovascular conditions like coronary artery disease can lead to heart attacks, strokes and other life-threatening medical conditions. These measures capture certain procedures and tests that medical groups should regularly give patients with heart disease to help keep them healthy.

High Cholesterol Screening	Guidelines recommend that patients who have had a heart attack or heart surgery should have their cholesterol checked at least once per year. Regular lipid profile tests can help ensure that cholesterol levels are well controlled.
Cholesterol Under Control	Guidelines recommend that cholesterol levels (lipid profiles) for patients who have had a heart attack or heart surgery should be less than 130 mg/dL. It is important to keep cholesterol levels under control; high cholesterol levels can damage blood vessels and lead to a heart attack or stroke.

4. Asthma
Asthma is a chronic condition that affects the airways, often making breathing difficult. Asthma may occur at any age, although it's more common in younger individuals (under age 40). These measures reflect standards of care that groups should meet to help keep asthmatic patients healthy.

Asthma Medication

Guidelines recommend that asthma patients with persistent asthma over a two-year period receive anti-inflammatory prescription such as an inhaled corticosteroid. This drug helps patients avoid asthma attacks and the accompanying wheezing, coughing and shortness of breath.

5. Adolescents and Pediatrics
These measures reflect standards of care that groups should meet to help keep adolescents and small children healthy.

Adolescent Checkup	Guidelines recommend that patients 12-21 years old have at least one comprehensive well care visit or check-up each year.
Correct treatment for children with a common cold	Guidelines recommend that children who have an upper respiratory infection (common cold) should not be given antibiotics. Antibiotics don’t work for these viral infections. Each year one out of every five children wrongly receives antibiotics for a common cold.
Infant Vaccination: Measles, Mumps and Rubella	Guidelines recommend that infants receive a vaccination for measles, mumps and rubella before they turn 2 years old. Shots, also called vaccines or immunizations, are an easy and proven way to protect children from serious diseases.
Infant Vaccination: Chickenpox (VZV)	Guidelines recommend that infants receive a vaccination for chickenpox (VZV) before they turn 2 years old. Shots, also called vaccines or immunizations, are an easy and proven way to protect children from serious diseases
Testing and treatment for children with a sore throat	Guidelines recommend that children who are diagnosed with pharyngitis (throat infection) should be tested for strep throat before given an antibiotic medication. Without a test, a child may be given an antibiotic when it is not needed.

6. Adult Care
These measures reflect standards of care that groups should meet to help keep adults healthy.

Breast Cancer Screening	Guidelines recommend that women 40-69 years old receive a mammogram every two years in order to detect breast cancer. When cancer is found early, there is a much better chance that it can be cured. A test called a “mammogram” is the best way to find breast cancer early.
Cervical Cancer Screening	Guidelines recommend that women 21-64 years old receive a Pap smear every three years in order to detect cervical cancer. Checking women for cervical cancer helps save lives. When cancer is found early, there is a much better chance that it can be cured. The test, called a “Pap smear,” is the best way to find cervical cancer early.
Correct Treatment for Bronchitis	Guidelines recommend that adults who have bronchitis should not be given antibiotics. Antibiotics do not work for these viral infections, and misuse and overuse of antibiotics lead to antibiotic drug resistance.
Lower Back Pain Screening	Guidelines recommend that most adults with lower back pain for less than 28 days should not receive an X-ray,MRI, or other imaging studies. Such back pain is often short term and does not require these screenings.
Medication Monitoring	Guidelines recommend that patients on certain medications need to be monitored regularly to make sure there are no bad reactions or side effects. Examples of such medications include ACE/ARBs, Digoxin, and Diuretics. Your doctor can give you a monitoring test to make sure that your health is not harmed.

7. Patient Satisfaction
It is important to know what patients think about the care and service they get from their medical groups. To find out, surveys were done with more than 70,000 California patients ages 18-64. All were patients who had a visit with a doctor in a medical group during 2008.

Patient Satisfaction Overall	This is a summary score based on the average rate for each of the seven patient satisfaction measures.
Rating of Care Received	Percentage of patients who positively rated the health care received from all doctors and other health providers over a year
Rating of Doctor	Percentage of patients who positively rated their personal doctor
Doctor-Patient Interaction	Percentage of patients who positively rated their personal doctor’s communication skills like listening, explanations, respect and easy-to-understand instructions
Receiving Timely Care and Service	Percentage of patients who positively rated how easy it is to make routine and emergency appointments, get questions answered and other aspects of service by their personal doctor’s office
Rating of Specialist	Percentage of patients who positively rated a specialist they visited
Getting Appointment with a Specialist Easily	Percentage of patients who positively rated how quickly they got an appointment with a specialist
Coordination of Care between Doctors	Percentage of patients who positively rated how their care was coordinated between two or more doctors
Satisfaction with Office Staff	Percentage of patients who positively rated their interaction with the office staff.
Received Healthy Living Information from Doctor	Percentage of patients who sais their physician, during the past yeark, discussed healthy behaviors like physical exercise and healthy eating.

No. Blue Shield evaluates each doctor and group before including them in the networks. Every three years we assess factors like work history, license to practice, board certification, education and training and malpractice history. These measures only cover certain aspects of care and are not a comprehensive measure of care. A low score can simply mean that the medical group needs to improve in one aspect of care. A medical group with one low score may still provide good care in other important areas. Results can also reflect, for example, the kinds of patients a medical group sees and how well patients follow their doctor's instructions.

Blue Shield and IHA took several steps to ensure the data is reliable. We only show results for medical groups that met a reliability threshold of 30 patients for each measure. For patient satisfaction measures, we require a response rate of at least 25 percent and a minimum of 100 responses for each question. The measures obtained through the IHA Pay for Performance program were subject to an audit review to ensure that results are an accurate reflection of medical group performance. Finally, all medical groups in the IHA Pay for Performance program are given the opportunity to review their scores before posting them.
Recognition based on the Blue Shield Performance Improvement Rewards Program is only available to groups with over 1000 Blue Shield members. Blue Shield has determined that, based on actuarial experience, results for these metrics are statistically reliable for groups with over 1000 members.  Blue Shield is not suggesting that groups with less than 1000 members are not efficient.

No. The medical group Performance Profile looks at quality of care and patient satisfaction at the level of the medical group. A medical group is a group of doctors that contracts with Blue Shield to provide health care. For each metric, the activities of a medical group's doctors are assessed using California health plan data. Those results are then combined to arrive at the percentage of a medical group's patients who received the recommended care. Although your doctor's patient care may be included in these results, these scores should not be interpreted as their “quality” results. A doctor's score is not always the same as that of his or her medical group.

For some medical groups, we did not have enough data to measure this group's performance with high confidence. One reason may be your group is very small and has a small number of patients, or because your group does not see a particular type of patient. For example, a group that does not see children would not have scores for pediatric measures. In some cases, we do not have data for groups that recently joined Blue Shield's network. “Not Available” should not be interpreted as a poor performance on that measure.

 When you see "Not Available" next to a medical group's name, this means that we did not have enough data to measure the group's performance with high confidence. One reason may be the group is very small and has a small number of patients, or because the group does not see a particular type of patient. For example, a group that does not see children would not have scores for pediatric measures. "Not Available" should not be interpreted as poor performance on that measure.

When you see "Not Willing to Report" next to a medical group’s name, this means that data is available, but the medical group would not allow us to share the results with consumers.

Please see the Performance Profile and the medical group rankings.

If you are a provider and would like to register a complaint, please send an email to perfprof_provider@blueshieldca.com. Please include your full name, provider ID and the specifics of your concerns.

If you are a member and would like to register a complaint, please send an email to perfprof_consumer@blueshieldca.com. We will respond within two business days.