Reducing Redundant Medical Group Oversight and Promoting Standardized Quality Reporting - Provider Group Oversight Improvement Project (P-GO)

Problem: Physician groups contracting with health plans experience many redundancies in oversight of their compliance with quality standards set by public and private groups. For example, there is considerable duplication of credentialing oversight. Each year, health plans conduct an estimated 900 on-site audits of credentialing at fewer than 200 physician groups, reviewing the same standards. The medical groups waste their limited resources responding to these duplicative processes. Beyond the problem of oversight that does not add value, there is a huge gap in the availability of standardized quality and performance measures for physician groups.

A cross-stakeholder project team identified two oversight processes that offered great potential for cost savings—credentialing oversight and management of appeals, grievances and complaints. There is an Improvement Team for each of the processes. These Improvement Teams seek ways to reduce the variance in how plans interpret the same oversight agency standards and look for ways to streamline the collection of information used to assess physician group compliance with the standards.

Impact: The goal for the first phase of this project was to reduce the burden of compliance with oversight requirements at the physician group level. Staff resources in the average California physician group's office are overtaxed by compliance with redundant processes. Improvements should allow resources to be redirected to patient care, leading to better care and customer service. Future impacts should include developing standardized systems to measure and report physician group-level performance.

Recommendations have been adopted for reducing the time to resolve appeals, complaints and grievances. Six of California's largest health plans agreed to revise their processes to make them consistent. Three recommendations have been adopted to reduce the number of duplicative plan oversight visits to review group-credentialing practices.

Current Activities: Goals include developing standardized, statewide quality reporting by medical groups with voluntary participation by groups representing at least 70% of the commercial population within three years. The P-GO team is serving as the technical support to the efforts to standardize clinical and consumer experience performance information that will serve as the platform for the Pay for Performance initiative involving six health plans.

In the vital area of care management processes, health plans and physician groups alike are interested in better clarification of roles and responsibility. To that end, a new P-GO project has been launched in partnership with the California HealthCare Foundation and the National Committee on Quality Assurance.

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