1.0 Purpose
In addition to the
authority under Section 1092, Chapter 55, Title 10 of the United
States Code (USC) which allows the Secretary of Defense to conduct
studies and demonstration projects as described in Chapter 18,
other statutory provisions specifically authorize the Secretary
to conduct TRICARE VBP initiatives. This chapter (Chapter 29) shall
include notice describing each value-based initiative, whether authorized
under Section 1092 or any other statute, designed to achieve such
results as including the improvement in: (a) quality of health care;
(b) a beneficiary’s experience in receiving health care; and/or
(c) the health of beneficiaries. Examples of statutory authority
authorizing value-based initiatives include the following:
1.1 The National
Defense Authorization Act (NDAA) for Fiscal Year (FY) 2016, Section
726 authorized one or more demonstrations to determine whether the
Department of Defense (DoD) can reduce the rate of increase in health
care spending and improve health care quality, beneficiaries’ health,
and beneficiaries’ experience of care by implementing one or more VBP
initiatives.
1.2 Additionally,
the NDAA for FY 2017, Sections 701(h), 705(a), and 729 authorized
additional VBP pilots to further explore
the feasibility of incorporating VBP into the purchased care sector
of the TRICARE program.
2.0
Background
2.1 NDAA
FY 2016, Section 726 permits the Secretary to adopt a VBP initiative(s)
conducted by the Centers for Medicare and Medicaid Services (CMS)
or any other governmental or commercial health care program for
a TRICARE demonstration project. The size, scope, and duration of
the demonstration must be reasonable relative to the project’s purpose,
and the project’s criteria and data collection must enable proper
evaluation of value-based incentives to allow informed decision-making
regarding any future implementation of value-based incentives in
the Military Health System (MHS). Beneficiaries must have timely
access to health care during the project and not incur any additional
financial costs as a result of participation in the demonstration.
2.2 NDAA FY 2017, Section
701(h) directs the Secretary to carry out a pilot program to demonstrate and
assess the feasibility of incorporating value-based health care
methodology in the purchased care component of the TRICARE program
by eliminating or reducing copayments or cost-shares for targeted populations
of covered beneficiaries in the receipt of high-value medications
and services and the use of high-value providers under such purchased
care component, including by exempting certain services from deductible
requirements. The amount of any reduction or elimination of copayment
or cost-share shall be credited towards meeting any applicable deductible
as if such reduction or elimination had not been applied.
2.3 NDAA
FY 2017, Section 705(a) directs the Secretary to develop and implement
value-based incentive programs as part of any contract awarded under
chapter 55 of title 10, United States Code (10 USC 55), for the
provision of health care services to covered beneficiaries 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
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.
2.4 NDAA
FY 2017, Section 729 directs the Secretary to implement programs
to improve health outcomes and control health care costs. Specifically,
this Section directs the implementation of medical intervention
programs, healthy lifestyle interventions, and healthy lifestyle
maintenance programs which may include lowering fees for enrollment
in the TRICARE program by a certain percentage or lowering copayment
and cost-share amounts for health care services during a particular
year for covered beneficiaries with chronic diseases or conditions
described in paragraph 2.0 who met participation milestones,
as determined by the Secretary, in the previous year in such medical intervention
programs.
3.0 Policy And
Eligibility
3.1 In the purchased care sector, both
network and non-network providers and facilities will be considered
for demonstration/pilot/program participation
based on TRICARE utilization and other factors selected by the Defense
Health Agency (DHA). In the direct care sector, Military Treatment Facilities
(MTFs)/Enhanced Multi-Service Markets (eMSMs) may be considered
for participation at the request of
the Services or DHA. Specific provider/hospital
and beneficiary eligibility criteria are described within the detailed
administrative processes for each value-based initiative described
in this section.
3.2 Upon DHA’s identification of one
or more providers or facilities for a specific value-based demonstration
in the purchased care sector, the appropriate regional contractor
shall contact the provider or hospital and provide details of demonstration
/pilot/program participation
as appropriate.
These details include any DHA decision
to make participation in a VBP
initiative mandatory
for purchased care sector providers and facilities. The contractor
shall contact DHA within five calendar days if:
• A network provider or hospital indicates,
either verbally or in writing, that they refuse to renew their network
agreement as a direct result of VBP participation,
or
• A non-network provider or hospital indicates,
either verbally or in writing, that they intend to deny access to
TRICARE beneficiaries as a result of VBP participation.
4.0 General Description
Of Administrative Processes
4.1 In order to conduct a comprehensive
analysis of VBP in the MHS, all value-based initiatives will evaluate
a variety of value-based Alternative Payment Methodologies (APMs)
and incentives across multiple TRICARE markets. DHA, the Services,
and other key stakeholders will establish a process for evaluating
VBP concepts, determining which initiatives would add value to the project,
and designing and implementing appropriate initiatives to be conducted
in accordance with NDAA requirements.
4.2 At
the Government’s discretion, new VBP initiatives may be introduced
at any time during the demonstration/pilot/program period.
Additionally, the Government may decide to revise the terms and/or
terminate existing VBP initiatives prior to the end of the demonstration/pilot/program period.
4.3 When
authority exists to conduct a value-based initiative, Federal
Register notice shall be published describing the initiative
and any statutory or regulation provision that is being waived or modified
by the initiative. If existing statutory or regulation provisions
will continue to be implemented without interfering with the terms
or conditions of the initiative, no Federal Register notice
is mandated. However, for purposes of transparency, in general, Federal
Register notice will be given for all initiatives unless
the DHA Director determines that such notice will not be practicable,
in which case alternative forms of notice will be required to provide
transparency to the public in conduct of the TRICARE program.
4.4 Unless
otherwise noted under the specific administrative processes below,
the contractor shall provide quarterly written feedback to providers
and hospitals in the purchased care sector regarding their cost
and quality performance as compared to the established benchmarks
for each value-based initiative. These
feedback reports shall be provided to VBP participating providers
and hospitals no later than 30 days following the Government’s completion
of the data analysis. The contractor
shall provide copies of all calendar year reports
to the Director, TRICARE Health Plan (THP). The format for these
reports shall be at the discretion of the contractor; however, the
reports must clearly identify the provider or hospital name and
the value-based initiative period of
performance, and shall include all applicable data elements provided
in the Government’s quarterly data analysis. Reports shall commence
following the completion of the first full calendar quarter of the
demonstration/pilot/program (covering
services provided since the start date of the initiative)
and every subsequent calendar quarter thereafter.
4.5 Unless
otherwise noted under the specific administrative processes below,
the contractor shall provide annual feedback to VBP providers
and hospitals in the purchased care sector regarding their cost
and quality performance and their eligibility for a positive or
negative incentive (as determined by the Government). These feedback
reports shall be provided to VBP participating providers
and hospitals no later than 30 days following the Government’s completion
of the annual data analysis and determination of positive
or negative incentive payments. The contractor shall
provide copies of all annual reports to the Director, THP. The format
for these reports shall be at the discretion of the contractor;
however, the reports shall clearly identify the provider or hospital
name and the period of performance,
and shall include all applicable data elements provided in the Government’s
annual data analysis and incentive determination.
4.6 Unless
otherwise noted under the specific administrative processes below,
any earned incentive payments will be paid to
VBP
participating providers and hospitals on a retrospective
basis. Negative incentives, if applicable, will be withheld from
future claims payments. DHA will share data used in calculating
any incentives; however, the final dollar amount of any incentive
(positive or negative) is not appealable.
4.6.1 The recoupment process outlined
in
Chapter 10, Section 4 shall apply to the collection
of any negative incentives (including the requirements for multiple
demand letters and offsets). DHA will provide the file to the contractor
to initiate any necessary recoupments.
4.6.2 Negative collections shall be recorded
on non-underwritten bank reconciliation reports as a non-TED “unable
to adjust” collection.
Note: Although the
final dollar amount and calculation methodology are not appealable,
the government may consider recalculating if errors are identified.
4.7 Unless
otherwise noted under the specific administrative processes below,
DHA will not recalculate any incentives (positive or negative) after
the analysis for each demonstration/pilot/program year
has been completed.
4.8 Unless otherwise noted under the
specific administrative processes below, one or more cohort providers
and/or hospitals will be identified in each market.
These cohort providers and/or facilities shall serve as control
groups for the VBP initiatives. Cohort
providers and hospitals are not eligible for VBP incentive payments
regardless of their performance during the value-based
initiative. Cohort performance and data will be used
exclusively by the Government to assist in evaluating the effectiveness
of the MHS initiatives.
5.0 DHA
Responsibilities
5.1 The Director,
DHA is the designated Executive Agent for MHS
value-based initiatives.
5.2 The Director, THP, is the DHA Program Manager
for MHS value-based initiatives.
5.3 The Director,
THP, will designate a project officer for each MHS
value-based initiative.
5.4 DHA
Contracting Officer (CO) will add a Contract Line Item Number (CLIN)
to the existing contract (CLIN: VBP Incentives). The contractor
shall invoice DHA for the incentive payments to providers. The DHA
Project Officer will analyze and evaluate the worksheets showing
calculations for positive incentives, as well as negative incentives,
and certify the amount due. If the sum of the incentives results
in a net-negative being owed to the government, the negative amount
due by the contractor will be collected against other future incentive
payments (Network discount, Network usage, etc.).
6.0 CONTRACTOR
Responsibilities
6.1 The contractor shall maintain sufficient
staffing and management support services to achieve and maintain
compliance with all value-based initiative requirements
as described below.
6.2 The contractor shall educate
VBP
participating providers and facilities regarding
the goals
, terms and conditions of
the initiative.
Note: The
contractor is not required to educate cohort providers or hospitals;
however, information will be shared
upon request.
6.3 The contractor shall continually
monitor access to care for VBP participating providers
and hospitals according to existing TRICARE requirements. The contractor
shall contact DHA within five calendar days if it is determined
that VBP participation is adversely
impacting access to care.
7.0 Applicability
Value-based
initiatives are applicable to TRICARE beneficiaries
who receive care from designated VBP participating providers
or hospitals within the 50 United States and the
District of Columbia. Refer to specific administrative processes
below for a description of the beneficiary population for each demonstration/pilot/program.
8.0 Exclusions
Unless
otherwise noted, TRICARE beneficiaries with Other
Health Insurance (OHI), beneficiaries enrolled in the TRICARE Overseas
Program (TOP), Medicare/TRICARE Dual Eligible Fiscal
Intermediary Contract (TDEFIC) beneficiaries, and
beneficiaries in the Continued Health Care Benefit Program (CHCBP)
are excluded from all value-based initiatives.
Refer to the specific administrative processes in the
specific pilots for additional exclusions that may
apply to an individual initiative.