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MAXIMUS is the National Quality Monitoring Contractor contracted by the government to work with Humana Military and other contractors to promote and provide the highest quality of care to TRICARE beneficiaries. MAXIMUS reviews inpatient care in the South Region and identifies potential issues in quality of care and patient safety. These findings are forwarded to Humana Military for investigation and follow-up, as appropriate. Here are some patient care issues we reviewed recently:
       

• Heart failure –
  • measurement of left ventricular function
  • angiotensin converting enzyme inhibitor/angiotensin receptor blocker prescribed at discharge, if documented left ventricular systolic dysfunction
     
• Acute myocardial infarction –
  • use of beta blockers within 24 hours
  • use of aspirin and beta blockers at discharge
     
• Surgical infection prevention –
  • prophylactic antibiotics given 1 hour prior to incision
  • prophylactic antibiotics consistent with current recommendations
  • prophylactic antibiotics discontinued within 24 hours of surgery end time
     

Humana Military’s quality management staff will follow up with providers when the chart review indicates deviation from accepted practice guidelines. This affords an opportunity to understand reasons for the perceived deviation and encourage adherence to guidelines.

The National Guideline Clearinghouse^TM (NGC) is a comprehensive database of evidence-based clinical practice guidelines and related documents. NGC is an initiative of the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. You can access and search this database from the National Guideline Clearinghouse Web site.

Referring beneficiaries to Centers of Excellence (COEs) for bariatric surgery may reduce the risk of postoperative complications and early death after surgery.1 Surgeons and facilities with higher volumes of bariatric surgery have lower rates of complications.

In May 2006, the Centers for Medicare and Medicaid Services (CMS) implemented a Medicare National Coverage Decision that allows coverage for bariatric surgery only in approved facilities. These facilities are certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center or certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence. These facilities are listed at the Centers for Medicare & Medicaid Services Approved Facilities web site. Since March 2006, Humana Military has worked to bring these centers into the TRICARE South network.

Please carefully consider referring candidates for this surgery to certified facilities. For TRICARE beneficiaries in the South Region, bariatric surgery requires prior authorization by Humana Military.

Thank you for your cooperation and participating in the care of TRICARE beneficiaries.

¹ Relationship between provider volume and postoperative complications for bariatric procedures in New York State. Weller WE, Hannan EL. J Am Coll Surg. 2006 May;202(5):753-61.

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Created:  March 21, 2007