Humana Inc., the insurer for 13 million taxpaying United States citizens, wants to hide details of its $45 billion TRICARE Managed Care Contract awarded by the Department of Defense in 2016. Last year, Humana reported more than $53 billion in revenue and its top executive received $3.46 million in compensation.
Humana Files Suit to Hide Government Contract Details
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#humana#tricare#departmentofdefense
On May 29, Humana’s Government Business unit filed a Reverse Freedom of Information Act (R-FOIA) suit against the Defense Health Agency.
Who knew there was such a thing as a “Reverse Freedom of Information Act?”
The Freedom of Information Act allows average citizens full or partial disclosure of previously unreleased information—subject to nine exceptions including national security reasons, geographic maps, trade secrets, personnel or medical records, law enforcement information, and more.
An R-FOIA claim is an attempt to prevent the release of sensitive or proprietary information. A judge must determine whether to allow or prevent the release of the information based on whether one of the nine FOIA exceptions applies.
At Issue, Disclosure of Humana’s “Technical Enhancements”
In its filing, Humana claims that certain portions of its $45 billion TRICARE Managed Care Contract need to be kept confidential. In the complaint, Humana alleges that disclosure of competitive and technical data contained in its bid and proposal will cause the company “competitive injury.”
The suit filed in the U.S. District Court For The District Of Columbia aims to prevent the disclosure of “technical enhancements” contained in Humana’s bid and proposal for the TRICARE contract. Technical enhancements are offerings which “exceed the Government’s minimum requirements.” Technical enhancements, while not required by the Defense Health Agency, are customarily provided by vendors as part of their TRICARE contract proposals. A vendor can distinguish itself from competitors by including enhancements which provide added value to the government in the form of quality healthcare, cost savings or other perceived benefits.
Humana’s Secret Weapon: Data
The HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009 provided grants and funding for the digitization of medical records and other supporting technologies. Since its passage, the amount of patient data that has been collected, stored and analyzed is staggering.
Humana is no exception—its contracts produce massive amounts of data. Humana has access to approximately 1.5 petabytes of data—150 times the information stored in the digitized version of all Library of Congress print collections.
The systems and technologies that Humana has developed to collect, analyze, and use data is likely part of the “technical enhancements” which Humana seeks to suppress. Humana has committed vast resources to develop its data mining and analytics technology. Disclosure of Humana’s data collection and analytic methodologies would be a boon to other market participants who could use this information to their competitive advantage.
Outcomes-Based Reimbursement Model
For several years, Humana has been transitioning from a fee-for-service model to an outcomes-based model The company has invested heavily in technology to improve its data mining and analytic capabilities. Humana established a subsidiary, Transcend Insights™ to pool and analyze information from multiple health record databases to provide proactive patient care.
Transcend Insights™ is an integral part of Humana’s transition away from reactive care to an outcome-based model. Transcend Insights™ seeks to move the reimbursement model from “volume to value” through the use of “real-time health care analytics and intuitive care tools.”
For example, Transcend Insights™ can immediately alert a physician to a drug contraindication or if a patient is due for an annual health screening. The system and associated platforms generate an alert when it identifies a gap in treatment or cost-saving opportunity.
With Humana’s use of Transcend Insights™ and its other proprietary data analytic platforms, the insurer can process vast amounts of data in search of ways to cut costs, reduce risk, streamline healthcare delivery and improve patient outcomes. Some medical professionals welcome the time-saving assistance this technology brings so long as the final diagnosis or treatment decision rests with them.
Data-Driven Clinical Decision Support Systems
Humana has moved to put all of its data into a clinical infrastructure called “CareHub™.”
CareHub™ is intended to optimize the insurer’s ability to affect care and change provider and patient behavior by using predictive insights to create actionable health intelligence at the point of care. This technology has many uses, such as preventing an acute event from happening which can improve patient outcome and reduce costs.
Before CareHub™, a 2016 internal Humana report identified 3.8 million healthcare gaps annually by analyzing 2.5 billion pieces of clinical data per day.
CareHub™ communicates throughout the day with care providers through multiple channels. The technology provides physicians with a comprehensive view of each patient’s medical profile. Access to this information provides medical teams with actionable data to improve outcomes and reduce overall care costs.
Artificial intelligence, neural networks, and algorithms are now being used by health insurance companies and medical professionals to review everything from pathology reports to sepsis risk. Industry analysts predict that by 2021, the health care AI market could reach $6.6 billion.
These platforms are yet another means by which the health insurance company can direct patient care. There are concerns that failure to follow the technology’s recommended treatment or protocol may impact reimbursement models. These are real concerns to be addressed as the confluence of technology and healthcare increases.
Privacy Concerns
Privacy advocates have concerns about how insurance companies are collecting and analyzing patient data within these new platforms. Access to these vast databases will no doubt be a target for hackers. The fallout from the release of millions of patient’s data would be disastrous if it found its way into the wrong hands.
Humana states that it has implemented policies and procedures to ensure the privacy of confidential patient information, throughout the process of analyzing data and providing clinical intelligence. The company claims that its use of information collected through these systems complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all other federal and state laws.
Details of Humana’s TRICARE Contract
The Defense Health Agency awarded Humana Government Business, Inc. a $45 billion TRICARE Managed Care Contract for East Region. The East Region serves approximately 5.9 million TRICARE-eligible beneficiaries residing in 32 states/districts[i]. This contract provides for an average care reimbursement of $7,627 for each TRICARE-eligible beneficiary.
The Defense Health Agency awarded the contract to Humana based on its review of the following factors:
- Network Management
- Referral Management
- Medical Management
- Beneficiary Satisfaction/Customer Service
- Claims Processing
- Program Planning & Control
- Transition
- Cost & Pricing Data
- Financial Viability of Contractor
TRICARE Contract Award Process
Each Managed Care Support Contractor (MCSC) must submit a proposal detailing how their service offering meets or exceed all TRICARE program requirements. MCSCs are encouraged to include technical enhancements highlighting how their service and support provide value to the government, in the form of cost savings, improved patient outcomes, and better customer service.
Under TRICARE, Private Healthcare Access Is Limited
The Defense Health Agency runs the Department of Defense’s TRICARE program. TRICARE provides government-supported health care to approximately 8.8 million active-duty troops, military retirees, military children, and other program beneficiaries.
The TRICARE program has two tiers, TRICARE Prime and TRICARE Select. TRICARE Prime is a managed care plan, which requires treatment at military facilities or through approved network providers. TRICARE Select offers a fee-for-service plan with more provider and facility options for enrollees.
TRICARE patients that do not live near a military base rely heavily on treatment by civilian physicians. Access to care for TRICARE members is not always easy. Many physicians decline to accept new TRICARE patients due to low compensation and reimbursement delays. A 2011 study by the General Accountability Office (GAO) found that over 50% of physicians in California and Texas turned away TRICARE patients.
[i]Alabama, Arkansas, Connecticut, Delaware, District of Columbia, Florida, Georgia, Illinois, Indiana, Iowa (partial coverage), Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Missouri (partial coverage), New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas (partial coverage), Vermont, Virginia, WestVirginia, and Wisconsin.
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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