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.