Participating Physician Group (PPG) Performance Management
As the health care industry in California continues to demand increased performance and value, Health Net has improved our delegation program tools to include an enhanced PPG Performance Scorecard to evaluate PPGs in seven performance areas (PDF). Delegated PPGs are reviewed for performance measures including grievances, contractual financial requirements, delegated medical management, service and quality (see Provider Oversight). The PPG scorecard brings these together in a 360-degree view of performance through an executive dashboard format, with the goal of helping ensure that delegated PPGs are meeting or exceeding standards. The resulting performance management process operations under oversight of the Delegated Provider Performance Governance framework.
The PPG Performance Scorecard is used to:
- Ensure transparency in performance.
- Jointly identify opportunities to improve performance and commit to developing performance improvement plans that are regularly reviewed at joint operation meetings (JOMs) and regular meetings.
- Ensure performance exceeds minimum performance standards.
- Serve as a catalyst for corrective action and improvement plans.
- Align performance to performance standards, penalties and rewards outlined in PPG contracts.
Dissemination of scorecard results
PPGs will receive individualized scorecard results electronically on a quarterly basis via JOMs. Results, opportunities and actions are reviewed in JOMs and workgroups for PPGs with minimum membership thresholds.
Performance scoring
PPG performance is measured in seven key performance areas (PDF) including quality, delegation oversight utilization management (UM), delegation oversight claims, risk adjustment, financial solvency, network and encounters. Multiple measures are compiled and calculated by performance area. Findings are weighted by membership to form the performance score, defined through the following scale:
- 80% or greater: Performing – meeting/exceeding performance targets.
- 50-79%: Monitoring – inconsistently meeting performance targets.
- Less than 50%: Below standard – consistently below performance targets.
Performance Management
PPG Scorecard Performance Process
Health Net’s delegated PPGs are evaluated at least quarterly through the PPG Scorecard performance process (PPG Scorecard) to ensure quality and service levels meet Health Net criteria. In addition, Health Net may conduct a review upon findings that the PPG failed to meet regulatory criteria, or upon regulator request for escalation.The PPG Scorecard includes an overall performance score, line of business (LOB) performance score, and measure area points.
Formal Corrective Action Plan
Continued low performance may trigger a corrective action plan (CAP), with expected improvement within a defined timeframe outlined in the written CAP notice. This formal CAP process applies to functions that are not already governed by an existing CAP process. Measure areas subject to this process include:
- Quality
- Encounters
- Risk adjustment
The following CAP notifications will be sent to the PPG:
Notice | PPG Action | Health Net Action |
|---|---|---|
Initial notice of deficiency and request for corrective action |
| Health Net reviews the submitted plan for completeness and appropriateness and notifies the PPG whether the plan is accepted. If revisions are needed, Health Net may require the PPG to update and resubmit the plan within a timeframe determined by Health Net. |
Follow-up notice for failure to respond or insufficient response | Provide the requested response or submit the required improvement plan within the timeframe specified by Health Net. | PPGs that do not respond adequately or within the required timeframe, may be subject to additional remediation, corrective action, or sanctions, as appropriate. |
Following Health Net’s approval of a CAP action plan, the PPG must demonstrate measurable progress by providing Health Net with a completed CAP tracker that includes improvement activities, along with objective performance data, in advance of each monthly workgroup meeting until CAP implementation is complete. PPGs must also ensure that appropriate staff with decision-making authority attend monthly workgroup meetings and participate in quarterly CAP governance calls to review progress, address barriers, and support timely completion of corrective actions.
At the end of the measurement period, Health Net will evaluate the PPG’s overall CAP performance. If the PPG meets the agreed-upon performance expectations, Health Net will close the CAP. If the PPG demonstrates progress but does not fully meet expectations, Health Net will determine whether to require additional corrective action, extend the CAP period, or both. If performance does not improve as expected or required, Health Net may initiate an escalation process. If warranted, Health Net may take formal action, including but not limited to, the following:
- A reduction in capitation.
- A freeze on enrollment.
- Revocation of delegation.
- Contract termination.
Any sanctions imposed will remain in effect until Health Net verifies that the required performance goals have been achieved.
Sample Scorecard and Performance Improvement Resources
The PPG Performance Scorecard Sample (PDF) highlights performance improvement opportunities across seven domains. To learn more about how PPGs can improve their performance scores, explore the following helpful resources:
Quality Improvement and HEDIS Information
CAHPS Provider Resources
Provider Appointment Availability Survey (PAAS):