Q -- Managed Care Support Services - Request for Information

REQUEST FOR INFORMATION The TRICARE Management Activity invites potential sources to provide an industry perspective to the TRICARE Program in order that the structure of the third generation of TRICARE Managed Care Support (MCS) contracts may be developed to reflect best practices and innovative solutions to the many military health care challenges. Input and information may be provided in writing or through one-on-one meetings with the TRICARE Management Activity. One-on-one meetings are intended to allow full disclosure in an environment that protects any information shared. The one-on-one meetings will be held face-to-face at TRICARE Management Activity Office in Aurora, Colorado; and will occur between June 5, and June 16, 2006. If you are interested in providing input into the future of the military health care system through the services provided under contracts for Managed Care Support, please contact Mr. Scott Lamond, Contracting Officer, via e-mail at [email protected] no later then May 19, 2006, to make arrangements for a one-on-one meeting. If a face-to-face meeting is not possible, conference calls, or submission of written information will be considered. Overview: The Defense Health Program (DHP) consists of direct care provided by DoD personnel through Military Treatment Facilities (MTF) and clinics and purchased care provided through Managed Care Support Contractors. This overview is to describe the purchased care portion of the DHP. Additional information is available on the TRICARE Management Activity World Wide Web site at www.tricare.osd.mil. In order to fulfill the purchased care needs of the DHP, sources/contractors must provide all services necessary to fully support DoD's primary wartime readiness mission while supplementing the services provided through DoD owned and/or operated health care facilities. Information from sources/contractors should address providing clinical and administrative services that are comparable to the best offered in the civilian community and fulfilling the objectives complying with the scope and structure of TRICARE; i.e., benefits and beneficiary liabilities, including technical requirements specified under the TRICARE uniform health care benefit. Information must address the expertise of managed care organizations and health benefit administrators in incorporating and operating the best business model and practices of the private sector in support of DoD healthcare delivery. Any contractor selected for contract award will have to provide the DoD with clinical and administrative services that are comparable to the best offered in the civilian community. Information is sought to assure that the services will be delivered in a manner that achieves a fully integrated health care delivery and financing system for all Military Health System (MHS) beneficiaries. Current Status of the Defense Health Program (DHP): The medical mission of the Department of Defense is to maintain readiness through health and medical services provided to the armed forces during military operations, and to provide health and medical services/support to the members of the armed forces, their family members and others entitled to DoD health care. The MHS must be prepared not only to provide a high quality, cost-effective health care benefit to its eligible members during peacetime, but also must be prepared to support the armed forces during exercises, contingencies, operations other than war, and in wartime. In support of its readiness mission, the MHS maintains a system of MTFs and clinics, located in DoD “catchment areas,” that provide direct care to active duty personnel and to others who are eligible for military health benefits if space is available. Although the number and size of direct care facilities has declined in recent years, it remains important that MTFs are optimized in order to maintain the clinical skills of military clinical staff to support medical readiness. Currently, the direct care system cannot fully support the total demand for health care services; therefore, TRICARE uses the direct care system as the main delivery system, and through the awarding of MCS contracts, augments the direct care system through a civilian network of providers and facilities serving its eligible members. MCS services apply to approximately 9.2 million active and retired members of the Uniformed Services: the U.S. Army, the U.S. Navy, the U.S. Air Force, the U.S. Marine Corps, the U. S. Coast Guard, the Commissioned Corps of the Public Health Service and the Commissioned Corps of the National Oceanic and Atmospheric Administration, their spouses and children and their surviving family members subject to the provisions of Chapter 55 of Title 10, U.S.C. Also eligible are Medal of Honor recipients (Chapter 55 of Title 10, U.S.C., Section 1074h.). Currently, TRICARE provides three health care options for beneficiaries—Prime, Extra, and Standard. TRICARE Prime is similar to an HMO with a Point of Service option and requires beneficiary enrollment. All Active Duty personnel are TRICARE Prime enrollees, although they are required to receive all of their care either in the MTF or under special rules that apply to Active Duty healthcare. Active Duty family members may elect to enroll and are not required to pay an annual enrollment fee or co-pays for care delivered in the network or the direct care system; however, other eligible beneficiaries pay an annual enrollment fee to enroll in TRICARE Prime. TRICARE Extra, which requires no enrollment, is an option in which the beneficiary may choose to use a provider in the contractor-developed network, with reduced cost-sharing for a particular episode of care, but is not restricted to use the network. TRICARE Standard is a fee-for-service option in which the beneficiary is free to use any authorized provider. The three options of TRICARE are described fully in 32 CFR Part 199.17 and 199.18 which may be accessed on the TRICARE Management Activity World Wide Web site at www.tricare.osd.mil. Currently, TRICARE Prime enrollees receive all primary care from a Primary Care Manager (PCM), who may be located at the MTF or may be a civilian provider in the MCS provider network. The MCS contractor is responsible for providing MTF enrollees and Medicare dual-eligible beneficiaries with other services such as network referrals, population health, medical management, and beneficiary education. Therefore, a MCS contractor interface with MTF enrollees will largely occur in catchment areas, with workload driven by the MTF’s capability and capacity. The MCS contractor is currently gains or loses profit based on the cost of (a cost plus incentive fee arrangement) all care and services provided to Prime enrollees (other than Active Duty members) having either MTF or civilian PCMs, and for all TRICARE Extra and TRICARE Standard care. The Government encourages potential sources to comment on this arrangement understanding that provisions of law dictate that health care costs be underwritten by the Managed Care Contractor. The MHS is organized into TRICARE Regions within the United States and around the world. Currently, at a minimum, a MCS contractor is required to establish a TRICARE Prime network in each catchment area surrounding a MTF and in the area of Base Realignment and Closure (BRAC) sites. The Department of Defense (DoD) requires delivery of a uniform health care benefit in the form of uniform healthcare quality, structure and patient cost-sharing. However, DoD is also interested in taking advantage of the expertise of the civilian sector and incorporating best practices. Proposed Contract Performance Objectives: “A world-class health system that supports the military mission by fostering, protecting, sustaining and restoring health” is our vision for fulfilling the MHS’ mission “To enhance DoD and our Nation’s security by providing health support for the full range of military operations and sustaining the health of all those entrusted to our care.” As noted above, this is accomplished through an integrated health care delivery system consisting of our military hospitals and clinics, as well as, services purchased in the civilian sector. The TRICARE Program is accomplishing this mission today through Managed Care Support Contracts (MCSC) that contains the following “Contract Objectives.” These Objectives are not listed by order of importance. Objective 1 – In partnership with the Military Health System (MHS), optimize the delivery of health care services in the direct care system (see the definition of Military Treatment Facility Optimization in the TRICARE Operations Manual, Appendix A) for all MHS beneficiaries (active duty personnel, Military Treatment Facility (MTF) enrollees, civilian network enrollees, and non-enrollees). Objective 2 - Beneficiary satisfaction at the highest level possible throughout the period of performance, through the delivery of world-class health care as well as customer friendly program services. Beneficiary must be highly satisfied with each and every service provided by the contractor during each and every contact. Objective 3 - Attain “best value health care” (See TRICARE Operations Manual, Appendix A) services in support of the MHS mission utilizing commercial practices when practical. Objective 4 - Fully operational services and systems at the start of health care delivery. Minimal disruption to beneficiaries and MTFs. Objective 5 - Ready access to contractor maintained data to support the Department of Defense’s (DoD) financial planning, health systems planning, medical resource management, clinical management, clinical research, and contract administration activities. These “Objectives” are not unchangeable. Potential sources may have more contemporary information on the proper objectives for achieving our vision and mission while clearly focusing on measurable, high quality clinical and administrative services achieved in the most cost efficient manner for the American taxpayer. We are also very interested in the industry’s thoughts concerning performance requirements. Requirements in this setting represent performance that must occur at or exceed specified performance standards and that achieves outcome based objectives identified in a contract. Examples of the performance standards may be found in the TRICARE Operations Manual at www.tricare.mil. TMA is very interested in the industry’s assessment of the existing performance standards and suggestions for new, revised, and or completely changed performance standards. Performance standards information is desired for the following areas of interest that are being included in the contracts. 1. Networks – Access to network providers, location of networks (networks are required around military hospitals and clinics and Base Realignment and Closure Sites (BRAC). Offerors are allowed to propose networks where “cost-effective.” What does industry suggest in relation to networks? 2. Referral Management – TRICARE Prime enrollees currently require a referral from their primary care manager prior to seeing another provider (there are some exceptions for preventive and mental health care). In lieu of obtaining a referral, Prime enrollees may use the point-of-service option and pay a $300 individual deductible and 50% cost share. Referral management is also currently used to direct patients to MTFs who have the “right of first refusal” for any care referred by a civilian provider. What are current practices in an HMO environment and how have these practices impacted cost? 3. MTF Coordination – Close coordination between our MTFs and MCSCs is currently critical as networks and referral management must continuously adjust to support the changes in MTF capability and capacity that occur daily as the result of war, contingency operations, national disasters, deployments, training, transfers, etc. TMA is interested in discussing the impact MTF operations have on contracts and the extent to which this impact affects costs, network management, and industry’s interest in submitting proposals on TRICARE contracts. 4. Medical Management. We define medical management as contemporary practices in areas such as network management, utilization management, case management, care coordination, disease management, and the various additional terms and models for managing the clinical and social needs of the beneficiary to achieve the short and long term cost-effectiveness of the MHS while achieving the highest level of satisfaction among MHS beneficiaries. What is the value of each of the named approaches and are there other opportunities to enhance the quality of care while ensuring the appropriate expenditure of tax dollars. 5. Claims Processing. TRICARE anticipates processing 170 million claims across all contracts (managed care, pharmacy, TRICARE for Life, dental, etc.) next year. How can TRICARE achieve efficiencies while complying with federal laws regarding the expenditure of Government dollars? 6. Customer Service. TRICARE provides customer services via telephone, e-mail, web based materials, on-site service centers at all MTFs, and thousands of briefings annually. How would a commercial concern approach customer service? How is that level of service received by your commercial clients? What percent of a premium is dedicated to customer service other than marketing? 7. Automated Data Processing. TRICARE has a number of unique data processing requirements including Department of Defense mandated security procedures and certifications, interfaces with DEERS to determine eligibility on-line, processing enrollments through Government systems, and submitting payment records in support of claims processing activities. Many of these requirements are not negotiable; however, we are interested in the impact of these requirements on costs and the level of interest in proposing on future contracts. 8. Management Services. This is a broad category that includes staffing, quality management/quality improvement, reporting, responsiveness to change, and managing contractor operations to fulfill the Government’s performance standards while achieving the Government’s outcomes. What should the Government require in terms of management services, how should they be measured, and how should the Government monitor performance? 9. Incentives. What positive and negative incentives are used in the industry, if any, and how do they impact your operations and proposals. What incentives should be created that would help achieve the goals of TRICARE? The Government is interested in any information potential sources would like to address in support of achieving high quality, cost effective delivery of health care services. Please remember there are legislative limitations and recommendations conflicting with statutes may not be able to be implemented. However, any of the administrative requirement changes which support a more efficient TRICARE Program may be acceptable for information presentation. The Regulations, TRICARE Operations Manual, TRICARE Policy Manual, TRICARE Systems Manual, and TRICARE Reimbursement Manual are all requirements of the TRICARE Program and uniform benefit. These are available for review at www.tricare.mil and may provide insight to potential sources.