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
Not enough information to measure
Highest rating
Lowest rating
There is not enough information to rate this provider
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.
Methods
The Provider Readiness Designation in our directory highlights mental health providers who are familiar with military culture and evidence-based treatments. This includes a wide range of professionals such as psychiatrists, psychologists, psychiatric nurse specialists, clinical social workers, marriage and family therapists, mental health counselors, and pastoral counselors under a physician’s supervision. It's important to note that this designation does not extend to the TRICARE Overseas Program (TOP).
To earn this designation, providers must complete four specific courses offered by the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences.
Mental Health care providers who have earned the Department of Defense TRICARE Provider Readiness Designation (TPRD), as indicated by a check mark icon, have specific knowledge of military culture and awareness of evidence informed treatments for mental health concerns common among members of the Armed Forces.
Upon completion, Humana Military will receive a quarterly list from the Department of Defense (DoD) to be recognized in our provider locator with the readiness designation.
