Presentation on theme: "1 Robert D. Seaman General Counsel TRICARE Management Activity March 3, 2008 TRICARE MANAGEMENT ACTIVITY UPDATE."— Presentation transcript:
1 Robert D. Seaman General Counsel TRICARE Management Activity March 3, 2008 TRICARE MANAGEMENT ACTIVITY UPDATE
2 OBJECTIVES TMA Overview TRICARE Acquisitions MHS Clinical Quality and Transparency Selected Statutory Changes to TRICARE
3 TMA MISSION DoD Field Activity of the USD(P&R), Operating Under the Authority, Direction and Control of the ASD(HA) (DoDD ) Mission –Manage TRICARE –DoD Contracting Activity –Administer, Manage, and Execute Unified Medical Program/DHP Appropriations –Support Services in Implementation of TRICARE Program and CHAMPUS
Organizational Structure TRICARE Management Activity Acting Chief Medical Officer 1 Dr. Smith Acting Chief Medical Officer 1 Dr. Smith Acting Chief Financial Officer 1 Mr. Middleton Acting Chief Financial Officer 1 Mr. Middleton Chief Information Officer 1 Mr. Campbell Chief Information Officer 1 Mr. Campbell Chief Force Health Protection and Readiness Programs 1 Ms. Embrey Chief Force Health Protection and Readiness Programs 1 Ms. Embrey General Counsel Mr. Seaman General Counsel Mr. Seaman Director, TMA Dr. S. Ward Casscells Director, TMA Dr. S. Ward Casscells Senior Enlisted Advisor (SEA) OASD (Health Affairs) & TMA CMSgt Manuel Sarmina, USAF Senior Enlisted Advisor (SEA) OASD (Health Affairs) & TMA CMSgt Manuel Sarmina, USAF Chief Health Plan Operations Ms. Storck Chief Health Plan Operations Ms. Storck Chief of Staff Mr. Gidwani Chief of Staff Mr. Gidwani Acting Regional Director TRO North Mr. Williams Acting Regional Director TRO North Mr. Williams Regional Director TRO South 1 Mr. Gill Regional Director TRO South 1 Mr. Gill Regional Director TRO West 1 RADM Lescavage Regional Director TRO West 1 RADM Lescavage Deputy Director, TMA MG Elder Granger, MC, USA Deputy Director, TMA MG Elder Granger, MC, USA Director TAO Latin Am/Can 1 COL Franco Director TAO Latin Am/Can 1 COL Franco Director TAO Pacific Mr. Chan Director TAO Pacific Mr. Chan Director TAO Europe 1 COL Bradley Director TAO Europe 1 COL Bradley Chief Pharmaceutical Operations 2 RADM McGinnis Chief Pharmaceutical Operations 2 RADM McGinnis 1 Non-TMA 2 Public Health Service Director, Program Integration Ms. Speight Director, Program Integration Ms. Speight Director, DoD/VA Program Coordination Office Mr. Cox Director, DoD/VA Program Coordination Office Mr. Cox Executive Officer LTC Wooldridg e Executive Officer LTC Wooldridg e TRICARE Military Education/Executive Assistant to SEA OASD (HA) & TMA HMCS Joseph Galang, USN TRICARE Military Education/Executive Assistant to SEA OASD (HA) & TMA HMCS Joseph Galang, USN
5 TRICARE Overview TRICARE is a comprehensive health benefits program comprised of the military medical treatment facilities and health care received from private sector health care providers and institutions, worldwide. Uses the Military Healthcare Structure as the Primary Healthcare Delivery System Augmented by a Civilian Network of Providers and Facilities (Purchased Care) Serving Active Duty Service Members, Reserve Components, Retirees and their Families and others Worldwide
6 TRICARE Overview TRICARE Administration Military Treatment Facilities are run by the Services Surgeons General TMA develops overall policies and program guidance for the health benefit programs TMA awards and administers contracts in support of ASD(HA)s administration of the purchased care portion of the TRICARE program
7 TRICARE Overview TRICARE Facts and FiguresProjected for FY 2007 Total Beneficiaries 9.2 million Prime Enrollees 5.0 million Pharmacy Benefit Users6.6 million 115M Rx in FY06 = $6.18 B Military Hospitals & Medical Centers 65 Medical Clinics 412 Dental Clinics414 Total Military Health System Personnel 132,700 Total Unified Medical Program (UMP): $28.16 billion* * Includes direct care and private sector care funding, military personnel, and military construction, but not the Medicare Eligible Military Retiree Healthcare Fund, $11.16 Billion.
8 TRICARE Management Activity A cquisitions Laurel Gillespie Deputy General Counsel TRICARE Management Activity
9 TRICARE Family of Programs Managed Care (includes overseas claims processing) TRICARE for Life (TFL) and Senior Pharmacy Pharmacy:-- Military Pharmacies -- Purchased Care (Retail and Mail Order) Overseas (TRICARE Overseas Program, Puerto Rico, TRICARE Global Remote Overseas) Dental: TRICARE Dental Plan (TDP) and Retiree Dental Plan Reserve Health (TRICARE Reserve Select/Other) Uniformed Services Family Health Plan (USFHP) Demonstrations/Miscellaneous Programs (Women, Infants, and Children – Overseas, Chiropractic, Continued Health Care Benefit Program, Counter Narcotics, Transitional Assistance Medical Program, Tobacco Cessation, Weight Management, etc.)
10 Managed Care Contracts Fixed Price/Cost plus Incentive fees with positive and negative incentives –Financially Underwrite the Civilian Component of Care –Delivery of health care which is comparable to best offered in civilian community –Partnership with MHS to optimize delivery of health care services; beneficiary satisfaction; best value health care; access to data; and, minimal disruption to beneficiaries –Contractor Provides: networks, referral management, MTF coordination, medical management, claims processing, customer service and ADP –Uniform Benefit TRICARE Third Generation (T-3) –Fixed Price/Cost plus fixed fee and positive/negative incentives –Currently in draft –http://www.tricare.mil/contracting/healthcare/solicitations/http://www.tricare.mil/contracting/healthcare/solicitations/
11 Current Contracts -Managed Care Contracts (3) – $6.5 B 5 Option Periods – Contracts Due To Expire 3/31/ Designated Provider Contracts (6) -- $4.5B 4 Option Periods – Contracts due to Expire 5/31/2008 -TRICARE Dental Contracts (2) TRDP and TDP- $2.4 B 5 Option Periods – TRDP Contract Due To Expire 9/30/ Option Periods – TDP Contract Due To Expire 1/31/2011 -TRICARE Dual Eligible Fiscal Intermediary Contract - $594 M 6 Option Periods – Contract Due To Expire 6/30/2014 -Mail Order Pharmacy Contract - $275 M ($.74B/year drug costs) 5 Option Periods – Contract Due To Expire 2/29/ Retail Pharmacy Contract - $245.4 M ($3.89 B/year drug costs) 5 Option Periods – Contract Due To Expire 3/31/2009
12 - Puerto Rico Contract – $9.1 M 4 Option Periods -- Contract Due To Expire 7/31/2008 -Tobacco Quit Line Demo Contract - $5.4 M 2 Option Periods -- Contract Due To Expire 9/30/2008 -Weight Management Demo Contract - $8.3 M 2 Option Periods -- Contract Due To Expire 9/30/2008 -Health Information Technology - $933.2 M 4 Option Periods -- Contract Due To Expire 3/31/2010 -National Quality Monitoring Contract, NQMC - $24.5 M 4 Option Periods -- Contract Due To Expire 4/20/2009 -Claims Audit Review Services, CARS - $6.2 M 4 Option Periods -- Contract Due To Expire 2/20/2009 Current Contracts
13 Current Solicitations - TRICARE Quality Monitoring Contract (TQMC) Base Period and 5 Option Periods Through April 30, TRICARE Claims Audit Review Services (TCARS) Base Period and 5 Option Periods Through January, 31, Active Duty Dental Program (ADDP) Base period and 5 Option Periods Through June 20, TRICARE Pharmacy (TPharm) Base Period and 6 Option Periods Through November 30, TRICARE Overseas (TOP) Base Period and 5 Option Periods Through May 31, Managed Care Contracts (T-3) Base Period and 5 Option Periods Through March 31, Designated Provider Contracts Base Period and 7 Option Periods through May 31, 2016
14 Sources of Authority Government Contract Rules –Federal Acquisition Regulation (FAR) 48 CFR Parts 1-52 The Basic Framework for Government Contract Procurement and Administration –Defense Federal Acquisition Regulation Supplement (DFARs) 48 CFR 201 et. Seq. –Statutes/Regs/Manuals –Case Law
15 Whats Happening in 2008 Potential litigation following contract award TMA attorney/paralegal teams prepare for likely bid protests Proactive counsel Up front participation Conclusion
MHS Clinical Quality and Transparency Carol J. Cooper Associate General Counsel, TMA March 3, 2008
17 Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs It is the purpose of this order to ensure that health care programs administered or sponsored by the Federal Government promote quality and efficient delivery of health care through the use of health information technology, transparency regarding health care quality and price, and better incentives for program beneficiaries, enrollees, and providers. It is the further purpose of this order to make relevant information available to these beneficiaries, enrollees, and providers in a readily useable manner and in collaboration with similar initiatives in the private sector and non-Federal public sector. Executive Order 22 August 2006
18 Key Points for Transparency Release of MHS quality assurance data is governed by: –Title 10 §1102 Event level data can not be released Aggregate statistical data may be released but: –It must be numerical with a numerator and denominator and –It must not Identify individual patients or individual providers The MHS monitors and uses nationally recognized, validated quality measures Some DoD aggregate statistical data, and some MTF level data is currently available to the public – for example –Aggregate DoD data in the annual MHS RTC on Clinical Quality –MTF JC quality (ORYX ® ) measures/patient safety goals on the JC Quality Check website
19 TITLE 10 U.S.C. §1102. Confidentiality of medical quality assurance records… a) Confidentiality of Records. Medical quality assurance records created by or for the Department of Defense as part of a medical quality assurance program are confidential and privileged. Such records may not be disclosed to any person or entity, except as provided in subsection (c). [Includes our QA, RM, PS and Peer Review Programs.] (d) Disclosure for Certain Purposes. (1) Nothing in this section shall be construed as authorizing or requiring the withholding from any person or entity aggregate statistical information regarding the results of Department of Defense medical quality assurance programs. * (j) Definitions. – (1) The term medical quality assurance program means any activity carried out … by or for the Department of Defense to assess the quality of medical care… *[ Aggregate statistical data is numerical data that constitutes all of the data in pre-defined common demographic groupings that have been assembled in order to facilitate its interpretation. The pre-defined common grouping (or denominator) must have at least 3 (3 or more) members or the numbers may not be released.]
20 MHS Enterprise Wide Metrics Selected HEDIS ® Breast Cancer Screening Colorectal Cancer Screening Cervical Cancer Screening Asthma - Appropriate Medications for Asthma Diabetes - HbA1c Test Diabetes - HbA1c in Control Diabetes Patient - LDL Test Diabetes Patient - LDL < 100 mg/dL JC ORYX ® Aspirin at arrival for AMI Aspirin at discharge for AMI Beta-Blocker at arrival for AMI Beta-Blocker at discharge for AMI Percutaneous coronary intervention within 120 mins. of arrival for AMI CHF – Left ventricular function (LVF) assessment CHF - Detailed Discharge Instructions CHF – ACEI for LVSD PN- Pneumococcal vaccination status PN– Antibiotic timing Neonatal mortality SIP –Timing of antibiotic administration (surgical patients)
21 HARMONIZING EFFORTS BETWEEN FEDERAL PARTNERS – VHA/HIS/DoD The goal is to have federal agencies report on the same measures in the same way. By December 2008 report to OMB on Departmental efforts to harmonize the core subset of AQA measures and measurement methodologies so as to reach consistency with other Departments. If harmonization not possible, report defines in explicit detail why it could not be accomplished. By December 2009, evaluate the ability to electronically extract harmonized quality measures from active sites.
22 Factors Affecting Federal Agency Harmonization Different data availability in electronic systems Different patient populations Different quality measures currently available through abstraction Different business rules resulting in different denominator (eg: users vs. enrolled; attribution of resident patients)
23 Way Forward with MHS Quality Performance Sharing Aggregate statistical data may be released outside of DoD if precautions are taken to protect the identity of and privacy of both patients and providers –Data may be released for an identified MTF or group of MTFs only by DoD (QA reg allows the Services to release Service Data and DoD to release the MTF level data.) Continue work with other Federal agencies (VA and Indian Health Service) to harmonize quality performance measures Determine a set of measures currently or potentially collected appropriate for public release Determine the level of aggregation and the venue in which measures will be released – DSGs have in principal agreed to post facility-level data
24 Purchased Care Quality Transparency Facility specific data is publicly available for ORYX/CMS measures and may be compared to facility specific MTF data on the JC Quality Check website Plan is to present available MHSPHP HEDIS- like measures rolled up to the regional level on the TMA website NQMC will be collating aggregated publicly reported CMS/JC data for network participating hospitals by region as an on- going deliverable – this data may also be posted to the TMA website when available
25 Provider Level Performance Data Is used internally, but will not be published for MTF providers; in part due to interpretation of Title 10 §1102 Contractor may internally use quality measures as a management tool for network providers and for patient channeling Network quality measures published publicly should be standardized across regions and to the extent possible should mirror data publicly published by TMA for the direct care system
26 TJ McGrath Associate General Counsel, TMA NDAA 2007/2008 Employer-Sponsored Group Health Care Plans Expanded TRICARE Reserve Select Program
27 10 USC 1097c TRICARE program: relationship with employer-sponsored group health plans (a) Prohibition on Financial Incentives Not to Enroll in a Group Health Plan- (1) Except as provided in this subsection, the provisions of section 1862(b)(3)(C) of the Social Security Act shall apply with respect to financial or other incentives for a TRICARE-eligible employee not to enroll (or to terminate enrollment) under a health plan which would (in the case of such enrollment) be a primary plan under sections 1079(j)(1) and 1086(g) of this title in the same manner as such section 1862(b)(3)(C) applies to financial or other incentives for an individual entitled to benefits under title XVIII of the Social Security Act not to enroll (or to terminate enrollment) under a group health plan or a large group health plan which would (in the case of enrollment) be a primary plan (as defined in section 1862(b)(2)(A) of such Act).
28 10 USC 1097c (f) Definitions- In this section: (1) The term employer includes a State or unit of local government. (2) The term group health plan' means a group health plan (as that term is defined in section 5000(b)(1) of the Internal Revenue Code of 1986 without regard to section 5000(d) of the Internal Revenue Code of 1986). (3) The term `TRICARE-eligible employee means a covered beneficiary under section 1086 of this title entitled to health care benefits under the TRICARE program. (g) Effective Date- This section shall take effect on January 1, 2008.
29 10 USC 1097c Permitted: –Cafeteria Plans –Service Contract Act Options Prohibited: –TRICARE Supplemental Plans Enforcement: –Civil monetary penalties not to exceed $5000 for each violation –Remedies under the Debt Collection Improvement Act, 31 U.S.C et seq.
30 10 USC 1076d History – TRICARE Reserve Select –NDAA 2005 – 90 day deployment in support of a contingency –NDAA 2006 – 3 Tier System with staggered premiums –NDAA 2007 – All Selected Reserves except FEHB eligibles, effective October 1, 2007
31 10 USC 1076d NDAA 2008 –Sec 706 – Continuation of eligibility for TRICARE Standard coverage for certain members of the Selected Reserve Permits coverage under NDAA 2006 to run before excluding reservists from coverage for being eligible for FEHB