1.0 Purpose
The purpose of the P-BMP pilot is to meet requirements
set forth in the
National Defense Authorization Act
for Fiscal Year 2017 (NDAA FY 2017
),
Section 705(a) which authorizes the implementation of value-based
incentive programs to encourage health care providers under the TRICARE
program (including physicians, hospitals, and other persons and
facilities involved in providing such health care services) to improve
the following:
• The quality of health
care provided to covered beneficiaries under the TRICARE program;
• The experience of
covered beneficiaries in receiving health care under the TRICARE program;
and
• The
health of covered beneficiaries.
2.0 BACKGROUND
VBP
is an emerging strategy in the health care industry that seeks to
reward better health outcomes, enhance the beneficiary’s experience
of care, and reduce health care costs over time. The P- BMP pilot
is a value-based initiative that seeks to improve health outcomes
for mothers and babies via an increased emphasis on maternity care
quality in the TRICARE networks. Phase I of the pilot implemented beneficiary-friendly
tools to promote greater transparency regarding the quality of maternity
care delivered by hospitals in the TRICARE network. This initial
phase of the pilot was designed to help
beneficiaries understand the risks associated with specific delivery
choices and facilitate meaningful dialogue with health care providers
during this pivotal time in a woman’s life. Phase II of the pilot
incorporates performance-based payments (incentives) to
network hospitals related to network maternity care.
3.0 APPLICABILITY
The P-BMP pilot is applicable to hospitals
that are in the TRICARE network.
4.0 PILOT PROGRAM OVERVIEW
4.1 The P-BMP pilot incorporates
quality metrics and survey findings from the Leapfrog Group, a national
nonprofit organization established in 2000 to drive improvements
in health care quality and safety. Leapfrog conducts an annual Hospital
Survey and compares reported hospital performance against nationally-recognized
benchmarks for five maternity care measures (early elective deliveries,
C-sections, episiotomies, maternity care processes, and high-risk
deliveries). Leapfrog posts its survey results on a public website
(http://www.leapfroggroup.org) that
clearly shows how each hospital performed on each reported measure
in comparison to Leapfrog’s posted target measure.
4.2 The
Defense Health Agency (DHA) has
designated the first four Leapfrog measures (early elective deliveries,
C-sections, episiotomies, and maternity care processes) as core
metrics (key and essential elements) for the P-BMP pilot. Network
hospitals assigned a performance rating of Fully Meets
Standard by Leapfrog on three
core metrics (as evidenced by Leapfrog survey results) will be awarded
a Value tier rating. Network hospitals assigned
a performance rating of Fully
Meets Standard on all four core metrics will
be awarded a High Value tier rating.
4.3 A fifth
Leapfrog measure (
High-Risk Deliveries) is not considered
a core metric for the P-BMP pilot
; however, Value and High
Value tier hospitals may be eligible for an additional incentive
based on their performance regarding high-risk delivery volume and
care quality. In order to achieve a Leapfrog Group performance rating
of Fully Meets Standard for high-risk deliveries, hospitals
must deliver ≥ 50 very-low birth weight (VLBW) infants annually
(defined as infants weighing less than 1,500 grams at time of birth)
AND meet the Leapfrog Group target for the antenatal steroid process
measure. Network hospitals assigned a performance rating of Fully
Meets Standard by the Leapfrog Group will be awarded a High-Risk
Deliveries tier rating. Hospitals that have achieved a High-Risk
Deliveries tier rating and that have also achieved a Value or High
Value tier rating shall be considered for an additional P-BMP
incentive payment as outlined in paragraph 7.2.3.
4.4 P-BMP tier ratings
(Value, High Value, and High-Risk
Deliveries) will be based upon the most current survey data
posted by Leapfrog on its public website as of August
1st each year.
4.5 Upon
implementation of the pilot, and on an ongoing basis thereafter,
the contractor shall obtain the most current Leapfrog Annual Hospital
Survey results for maternity care and identify all network hospitals
that achieved
Value,
High Value, and
High-Risk
Delivery tier ratings during
the survey rating period. Based on the contractor’s review of the
Leapfrog survey data and their identification of
Value,
High
Value, or
High-Risk Delivery tier ratings,
the contractor shall update their web-based network Provider Directory
with unique provider designation symbols that will effectively communicate
the hospital’s quality rating and P-BMP pilot status to beneficiaries
within 30 days that it is posted by Leapfrog on its public website.
Specific Provider Directory designation processes are described
in
paragraph 6.2.
5.0 POLICY CONSIDERATIONS
5.1 The implementation of the
P-BMP pilot does not limit or change normal TRICARE reimbursement
methodologies or claims submission policies and processes. Hospital
claims for maternity care services will continue to be processed
following normal TRICARE reimbursement rules. Nothing in this pilot
changes the beneficiary’s right to choose their network provider.
5.2 Participation in the annual
Leapfrog Hospital Survey is voluntary. Hospitals
will not be reimbursed by the Government for any administrative
costs associated with participation in the Leapfrog survey.
5.3 In order to be eligible for
designation symbols (indicating Value, High
Value, or High-Risk Delivery tier
ratings) or to be eligible for incentive payments,
hospitals must have an active provider network
agreement with the appropriate regional contractor on August
1st for consideration of an incentive for the preceding year.
Hospitals with TRICARE network agreements that are in process, but not
yet completed, are not eligible for the P-BMP pilot.
6.0 Phase I - Quality Transparency For Beneficiaries
6.1 Upon commencement of the P-BMP pilot, and on
an ongoing basis thereafter (following publication of Leapfrog findings),
the contractor shall obtain the most current Leapfrog survey results and
determine which TRICARE network hospitals in its respective region
have achieved a Value or High Value rating.
The contractor shall also use this survey data to identify Value and High
Value tier hospitals that also were assigned
a performance rating of Fully Meets Standard by the
Leapfrog Group for the High-Risk Delivery tier
rating.
6.2 No later
than June 1, 2018, using the most recent data available, the contractor
shall have annotated their web-based Provider Directory with unique
provider designation symbols for hospitals who achieved a Value, High
Value, or High-Risk Delivery tier rating
during the preceding year (e.g., “Silver Stork” for Value tier;
“Gold Stork” for High Value tier, etc.). The
contractor shall select the specific symbols to be used for this
purpose. The contractor shall include clarifying information on
the Provider Directory to ensure that beneficiaries understand how
to interpret these symbols that align with posted Leapfrog methodology.
6.3 The contractor shall update their Provider
Directory
within 30 calendar days following publication
of any refreshed Leapfrog data as specified in
paragraph 4.5,
to maintain consistency with Leapfrog’s website.
Hospitals
no longer meeting Leapfrog criteria will have their designation
status removed. As new hospitals are added to the
TRICARE network, the Provider Directory shall be refreshed to ensure
that any appropriate P-BMP quality designation symbols are included
within 30 calendar days of the hospital joining the network.
6.4 Since participation in the Leapfrog survey
is voluntary, the lack of a P-BMP quality designation symbol on
the provider directory does not infer that a particular hospital
provides low quality care. The contractor shall provide clarifying
information on its Provider Directory
to preclude any misinterpretation of the data by beneficiaries such
as a construing that a hospital without a stork rating is somehow
considered low value by TRICARE or the DHA.
6.5 The contractor shall provide the Government
with a Performance-Based Maternity Payment (P-BMP) Report, identifying
those hospitals which have been designated as Value, High
Value, with an additional endorsement for Value or High
Value in the High-Risk Delivery category on
the network provider directory. Details for reporting are identified
in DD Form 1423, Contract Data Requirements List (CDRL) located
in Section J of the applicable contract.
7.0 Phase II - Performance-Based Hospital
Incentives
7.1 Eligibility7.1.1 Network hospitals that provide
childbirth services to TRICARE beneficiaries will be automatically
considered for Value, High Value, or High-Risk
Delivery incentive payments on a retroactive annual basis
if they elected to participate in the Leapfrog Group Hospital Survey,
and have provided applicable performance data to the Leapfrog Group
on their maternity quality metrics. Network hospitals that do not
report maternity care metrics in the Leapfrog Group Hospital Survey
and non-network hospitals are not eligible for P-BMP incentives.
Alternative forms of evidence for maternity care quality will not
be accepted for P-BMP pilot purposes or incentives (only official
Leapfrog data are accepted).
7.1.2 Network hospitals that achieve Value, High
Value, or High-Risk Delivery tier
ratings will be awarded a retroactive annual incentive payment (subject
to the provisions of the P-BMP pilot) based upon their performance
rating, the volume of TRICARE deliveries at each hospital during
each incentive cycle, and the total TRICARE allowable amount for
these deliveries. The rating in effect on August 1st each year will
be used for incentive calculation purposes; this rating shall be
applied retroactively to TRICARE deliveries during each incentive
cycle as follows:
|
Incentive Cycle
|
Leapfrog Rating (as of
date)
|
Date of Service (Hospital
Admission)
|
|
*
Or last day of health care delivery under the contract, whichever
comes first.
|
|
1
|
August
1, 2019
|
Commencement
of Phase II September 1, 2018 through December 31, 2018*
|
|
2
|
August
1, 2020
|
January
1, 2019 through December 31, 2019*
|
|
3
|
August
1, 2021
|
January
1, 2020 through December 31, 2020*
|
Note: Incentive cycles end on December
31st each year to allow time for claims processing to occur prior
to incentive calculations, which will commence on August 1st of
the following year.
7.1.3 P-BMP incentive payments are
not appealable; however, if hospitals identify a suspected calculation
error, they may provide written notification of the suspected error
(with substantiating documentation) to the attention of the appropriate
regional contractor within 180 calendar days of the date of the
incentive payment with the suspected error. The contractor shall
investigate the matter, and if it indicates that a calculation error
occurred, the contractor shall notify DHA and request appropriate adjustments
to incentive payment(s) within 90 calendar days following receipt
of the hospital notification and all substantiating documentation.
7.1.4 Hospital maternity care incentive
payments under this pilot shall be excluded from National Cost Trend
Incentive calculations.
7.1.5 At the Government’s discretion,
hospitals that are active subjects in fraud or abuse investigations,
including civil prosecution and civil litigation, may be deemed
ineligible for P-BMP incentive payments. If the investigations are
later resolved, and it is determined that the hospital did not commit
fraud or abuse, the hospital may be eligible for retroactive P-BMP
incentive payments at the normal rate. Hospitals with confirmed
fraudulent or abusive actions are ineligible for P-BMP incentive
payments.
7.2 Incentive Payment CalculationsBeginning in 2019, and on an
annual basis thereafter, the contractor shall issue incentive payments
(from non-underwritten funds) as determined by the Government to
eligible network hospitals, using the Leapfrog rating as of that
date. The Government will calculate incentive payments as a percentage
of total TRICARE allowed charges for TRICARE maternity cases with
admission dates in the applicable incentive cycle (Medicare Severity-Diagnosis
Related Groups (MS-DRGs) 765-768, 774, and 775) as follows:
7.2.1 High Value Tier (hospital
met the target for all four core metrics): Hospital receives High Value incentive
payment (equal to 2% of allowed charges on all TRICARE deliveries
(MS-DRGs 765-768, 774 and 775) that occurred during the applicable
incentive cycle).
7.2.2 Value Tier (hospital
met the target for three core metrics): Hospital receives Value incentive payment
(equal to 1% of allowed charges on all TRICARE deliveries that occurred
during the applicable incentive cycle).
7.2.3 High-Risk
Delivery Tier: High Value and Value tier
hospitals that also achieved a High-Risk Deliveries tier
rating will receive an additional incentive payment (equal to 1%
of allowed charges on High-Risk TRICARE deliveries
that occurred during the applicable incentive cycle). High-risk
TRICARE deliveries include all deliveries with 2018 International
Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM) diagnosis code series O09.XX with admission dates in
the applicable incentive cycle and performed at facilities with
the High-Risk Delivery tier designation.Note: Hospital
claims must include an ICD-10-CM diagnosis code in the O09.XX series
in order to be included in incentive calculations. The Government
will not retroactively search for high-risk pregnancy diagnoses
in outpatient maternity care claims for incentive calculation purposes. Contractors
shall ensure that hospitals are aware of this process.
7.2.4 Hospitals who met two, one, or
zero core metrics, or who chose not to participate in the Leapfrog
Hospital Survey (or who are rated “not applicable” by Leapfrog),
even if they fully met the Leapfrog standard for High-Risk
Deliveries will not receive incentive payments.
7.2.5 The contractor shall provide
annual feedback reports to participating providers and hospitals
in the purchased care sector regarding their cost and quality performance
and their eligibility for a positive incentive (as determined by
the Government). These feedback reports shall be provided to participating
providers and hospitals no later than 30 days following the Government’s
completion of the annual data analysis and determination of incentive
payments.
7.2.6 Contractors
shall follow normal processes and procedures for non-underwritten
manual check requests for P-BMP incentive payments. Contractors
shall request funding approval from the DHA, Contract Resource Management
(CRM) Office prior to issuance of P-BMP incentive checks/Electronic
Funds Transfers (EFTs) to hospitals. P-BMP incentive payments shall
not be reported on the TRICARE Encounter Data (TED).
7.2.7 See Addendum A for
specific data elements for P-BMP reporting purposes.
7.2.8 See
Addendums B and C for specific incentive calculation processes
and procedures.
8.0 EXCLUSIONS
8.1 Hospitals
located outside the 50 United States and the District of Columbia
(DC).
8.2 Hospitals
in Maryland that are not reimbursed under the MS-DRG
system, although they may participate in the Provider Directory
designation.
8.3 Critical
Access Hospitals (CAH) not paid under the DRG reimbursement methodology.
8.4 Beneficiaries with Other Health Insurance (OHI).
8.5 Designated Providers (DPs) under the Uniformed
Services Family Health Plan (USFHP).
9.0 EFFECTIVE AND TERMINATION DATES
Phase I of the P-BMP pilot commence
d on
April 1, 2018. Phase II
of the P-BMP pilot commences on
September 1, 2018. The P-BMP pilot will continue
through the last day of health care delivery of a Region’s current
contract, or three years from the start of the pilot project, whichever
comes first, subject to the Government’s discretion under
Section 1, paragraph 4.2.