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.