Overview

In an effort to provide beneficiaries with additional information in their selection of healthcare providers, clinical quality and cost-efficiency ratings may appear next to certain providers. These ratings represent the clinical quality and cost-efficiency delivered by providers. Absence of clinical quality and cost-efficiency ratings means a provider does not meet the criteria to receive a rating. 

These ratings take into account a provider’s specialty and compares them to a peer group of providers with the same specialty who deliver care in the same state. 

Some providers do not have clinical quality or cost-efficiency ratings associated to them. Reasons for this may include:

  • Not all specialties are evaluated by Humana Military 
  • Minimum requirements, such as data volume, statistical credibility or minimum peer volume, are not met 

A provider receives ratings when their specialty is one of the specialties evaluated by Humana Military, and when they meet minimum evaluation requirements. There are instances where a provider appears with a clinical quality rating and no cost-efficiency rating, and vice versa, as the clinical quality and cost-efficiency ratings are independent of each other.

Clinical quality

The clinical quality rating metric is derived from Humana Military’s provider clinical quality rating, which is a quality measure set encompassing preventive and specialty care to help identify providers who offer higher quality care. 

Evaluated specialties: 

  • Advanced practice midwife
  • Allergy and immunology
  • Cardiovascular disease
  • Emergency medicine
  • Endocrinology
  • Family medicine
  • General practice
  • Internal medicine
  • Mental health nurse practitioner
  • Midwife
  • Nurse practitioner
  • Obstetrics and gynecology
  • Ophthalmology
  • Pediatrics
  • Physician assistant
  • Psychiatry and neurology
  • Pulmonary disease
Clinical quality Description 0000 Highest rating 0001 Lowest rating Not enough information to measure There is not enough information to rate provider

Cost-efficiency 

The cost-efficiency rating metric is derived from Humana Military’s provider cost-efficiency rating, which identifies providers who efficiently manage costs across specialty-specific episodes of care.

Evaluated specialties:

  • Allergy and immunology 
  • Anesthesiology 
  • Counselor 
  • Dermatology 
  • Emergency medicine 
  • Family practice 
  • General practice 
  • Internal medicine 
  • Marriage and family therapist
  • Neurological surgery 
  • Nurse practitioner 
  • Obstetrics and gynecology 
  • Occupational therapist 
  • Ophthalmology
  • Optometrist 
  • Orthopedic surgery 
  • Otolaryngology 
  • Pain management
  • Pediatrics 
  • Physical medicine and rehabilitation
  • Physical therapist
  • Physician assistant 
  • Podiatrist 
  • Psychiatry and neurology 
  • Psychologist 
  • Social worker 
  • Speech-language pathologist 
  • Surgery 
  • Urology
Cost-efficiency Description 0000 Highest rating 0001 Lowest rating Not enough information to measure There is not enough information to rate provider

FAQs

Humana Military shares clinical quality and cost-efficiency ratings (represented by icons under the provider’s name). You can see these ratings when you use the Find Care tool, which helps beneficiaries search for in-network providers. These ratings should be used only as information when choosing care.

You won’t be able see a rating for these reasons: 

  • If a provider’s specialty or geographical area is out of scope 
  • If there is not enough data to complete a comprehensive evaluation, “Not enough information to measure” will be displayed

TRICARE beneficiary feedback does not affect a provider’s rating.

Efficiency, or cost-efficiency, measures a provider's total cost for treatment that TRICARE beneficiaries received compared to treatment provided by other providers in the same specialty type and geography. Treatment could include services such as doctor's visits, lab test, related medications and hospital surgeries.

Effectiveness, or clinical quality, measures a provider’s adherence to evidence-based medicine when treating TRICARE beneficiaries as compared to a peer group in the same specialty type and geography.

Other insurance companies may use similar methods, but each payer's program could yield different results since ratings are based on a unique set of claims data for a unique group of beneficiaries.

There are instances where a provider may not receive a rating and the message “Not enough information to measure” will appear. There could be several reasons a provider does not receive a rating, such as: the specialty may not be among those evaluated, the provider’s geographic location may not be in scope, the data may not be statistically credible or not enough data is available to complete a full evaluation.

A better cost-efficiency rating does not correlate with beneficiaries out of pocket cost experienced per visit.

While a better cost-efficiency rating does not correlate with beneficiaries out of pocket experience per visit, it does impact overall cost of care by avoiding unnecessary visits, unnecessary procedures, etc.