Clinical quality and cost-efficiency

 

Humana Military offers providers insight into their cost of care and clinical quality performance to help shape a stronger health system and improve outcomes for our beneficiaries. Through methodology transparency, providers can see how the clinical quality and cost-efficiency ratings are determined, including details on evaluated specialties and peer groupings used to compare the minimum requirements to receive a rating.

Clinical quality

Overview

Effective beneficiary care is important for both military readiness and better outcomes over time. The provider clinical quality rating evaluates the quality of care delivered by Primary Care Managers (PCM) and specialists. This rating is a quality measure set to help identify those providers who offer higher quality care. Through a preselected set of measures, providers have numerous opportunities to impact care for both preventive and specialty care. Providers are compared to their peers’ performance in the same geography. Those providers who perform well on their specialty-specific measure set are associated with better quality of care for the TRICARE East population. Ratings are calculated only where Humana Military requirements are met: when there is sufficient data volume, statistical credibility, minimum peer volume, etc.

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Frequently asked questions

For additional information, please review the performance ratings FAQs for providers.

Approach

Humana Military uses TRICARE East beneficiaries’ claims experiences to evaluate their treatment and quality of care and evaluates claims including medical, pharmacy and lab. The measures are calculated using a software solution widely used across the healthcare industry as a basis to review quality delivered by providers.

The clinical quality rating includes measures from the following governing bodies:

  • Centers for Medicare and Medicaid Services (CMS)
  • National Committee for Quality Assurance (NCQA)
  • National Quality Forum (NQF)
  • Pharmacy Quality Alliance (PQA)

Evaluated specialties

  • Allergy and immunology
  • Family practice
  • General practice
  • Internal medicine
  • Midwife
  • Nurse practitioner
  • Obstetrics and gynecology
  • Pediatrics
  • Physician assistant
  • Psychiatry and neurology

Cost-efficiency

Overview

Efficient beneficiary care is important for reducing waste and increasing healthcare sustainability. The provider cost-efficiency evaluates the cost of care managed by Primary Care Managers and specialists. Providers have numerous opportunities to impact the beneficiaries they care for and manage costs efficiently. Providers who perform well on their specialty-specific measures are identified and associated with a lower cost of care for the TRICARE East population.

Ratings are calculated only when Humana Military’s requirements are met. These requirements include sufficient data volume, statistical credibility and minimum peer volume.

Approach

Humana Military bundles TRICARE East beneficiaries’ experiences in medical, pharmacy and lab claims into episodes of care attributed to a single responsible provider. An episode represents more than a provider’s direct spending, including the total amount for clinical and resource homogenous services for which a provider is the largest contributor. The episodes are calculated through widely-used industry software as a basis to review providers’ costs.

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
  • Pediatrics
  • Physical medicine and rehabilitation
  • Physical therapist
  • Physician assistant
  • Podiatrist
  • Psychiatry and neurology
  • Psychologist
  • Social worker
  • Speech-language pathologist
  • Surgery
  • Urology

Program methodology

Measurement level

TRICARE providers are captured at the identifier level of Tax Identification Number (TIN) and National Provider Identifier (NPI).

Geographic areas

Geographic areas include states in the TRICARE East Region of the United States.

Peer groups

Peer groups include providers of the same specialty and type of care within the same state. Providers working in multiple states will be evaluated per the volume performed in each state (see Minimum volume requirements below).

Frequency of evaluation

The clinical quality and cost-efficiency ratings are updated on a quarterly basis.

Minimum volume requirements

Clinical quality

The clinical quality rating is measured for all providers who have a minimum of 20 measure results for their attributed beneficiaries and at least five distinct TRICARE members. Peer groups will contain at least five peers for providers to be individually compared against.

Cost-efficiency

The cost-efficiency rating is measured for all providers in the specialty/episode target list who have a minimum of ten episodes and five beneficiaries. Each peer group will contain at least 100 episodes for providers to be individually compared against. Providers are often in more than one peer group. Each specialty/state must contain at least 10 providers.

Provider attribution

Clinical quality

Providers who contribute the most to a beneficiary’s care are attributed. Attribution is prioritized utilizing a hierarchy per specialty that begins with the highest visit count, most recent visit and highest claim allowed amount.

Cost-efficiency

Providers who contribute the highest total allowed amount for evaluation and management and/or surgery costs are attributed to an episode of care. The attributed provider is considered the director of care for treating that patient’s condition.

Methodology

Humana Military rates providers only when there is sufficient data volume, statistical credibility and minimum number of peers available. A weighted average approach is used to create a composite score for individual providers compared to their peer group(s). Humana Military compares performance of the individual provider to performance of their peers at the specialty/state level to determine the rating displayed on the Find Care tool.

Provider feedback

Representatives are available to answer questions about provider clinical quality and cost-efficiency. Providers may contact us via secure message by logging into self-service.