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.
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:
Evaluated specialties
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
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.
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.
Clinical quality ratings and cost-efficiency ratings are displayed on the provider results page of our find care tool.
The main focus of these ratings is transparency. These ratings should be used only as information when choosing care. TRICARE beneficiaries are encouraged to consider all relevant information and to consult with their treating provider.
Users will not see anything related to ratings if a provider specialty or geography is out of scope. If a specialty and/or geography are in scope, but the data is not statistically credible or there is not enough data to complete a comprehensive evaluation, "Not enough information to measure" will be displayed.
A provider's rating is not affected by TRICARE beneficiary feedback.
Efficiency, also described as 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 medication, surgeries done in hospitals, etc.
Effectiveness, also described as 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.
Provider's ratings will not affect payments, nor will they affect TRICARE beneficiary's premium or benefits.
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 "Not enough information to measure" will appear in place of the rating symbols. 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.
Providers can access additional information by visiting Effectiveness and efficiency of care - program methodology.
Providers can submit detailed questions or feedback at any time by logging into self-service and sending a secure message. Providers may register for self-service if they don’t have an account.
Administrative claims including labs, pharmacy and medical.
Providers can submit detailed questions or feedback at any time by sending a secure message through provider self-service.
Yes, ratings are updated quarterly.
Humana Military is sharing information about your practice with its members and other providers. Provider ratings will help you and your TRICARE beneficiaries make better-informed healthcare decisions. If you would like to learn more about the program, please visit Effectiveness and efficiency of care - program methodology.
We ask that you review the reports for accuracy of information.
To access the reports, log in or register for provider self-service, then: