Presentation on theme: "Agenda Non-VA Medical Care Program Overview"— Presentation transcript:
0 Non-VA Medical Care 101 VHA Chief Business Office March 2014
1 Agenda Non-VA Medical Care Program Overview Non-VA Care Coordination (NVCC) OverviewPatient-Centered Community Care (PC3) Overview
2 Overview of Non-VA Medical Care Insert date on slide masterOverview of Non-VA Medical CareNon-VA Medical Care is health care VA purchases for eligible Veterans when services are not available at a VA facilityNon-VA Medical Care is an augmentation of in-house capabilities and capacityThe program has seen considerable growth over the past 8 yearsIn FY13, VA purchased care for more than 1 million Veterans at a cost of $4.81 billion even with the expansion of in-house capability
3 Reasons VHA Purchases Care from Non-VA Providers Insert date on slide masterReasons VHA Purchases Care from Non-VA ProvidersInability to access VA health care facilitiesDemand exceeds VA health care facility capacityNeed for diagnostic support services for VA cliniciansNeed for scarce specialty resources (e.g., obstetrics, hyperbaric, burn care, oncology) and/or when VA resources are not available due to constraints (e.g. staffing, space)Ensure cost-effectiveness for VAOutside procurement vs. maintaining and operating like services in VA facilities for infrequent useSatisfying patient wait-time requirements
4 Growth of Non-VA Medical Care Fiscal Veterans Total Cost PerYear Served Disbursed UniqueFY ,729 $1.798B $3,362FY ,768 $2.227B $3,617FY ,794 $3.029B $3,686FY ,404 $3.820B $4,150FY ,836 $4.438B $4,664FY ,727 $4.594B $4,733FY ,496 $4.490B $4,565FY ,065,434 $4.811B $4,516FY14(YTD) 615,154 $1.733B $2,817Data depicted based on in-system payments made through VistA FeeAs of End of JAN 2014
6 Non-VA Medical Care– Strategy for the Future Continue to provide care to Veterans when care is not available within the VA health care systemDevelop long term solutions for all Purchased Care programsNew Healthcare Claims Processing System will consolidate all claims processing to a single system.Improve processes and business management for both short and long term initiativesContinue to improve business processes and current technology while preparing for long term solutionUtilize national contracts to maximize economies of scale when providing care
8 Non-VA Care Coordination The Non-VA Care Coordination (NVCC) model is a system of business processes which standardize front-end business processes, improve patient care coordination, and support future state solutions within the Non-VA Medical Care program VHA-wide.
9 Scope of Non-VA Care Coordination Five major business processes are included within the scope of NVCCNon-VA Referral Review: Standardization of consults/referrals in support of future IT automationAppointment Management: Improved customer service, coordination and Veteran provider selection/preferenceHospital Notification: Consistent model for documentation, tracking and coordination of patients in community health care facilitiesUnauthorized & Emergency Care (Mill Bill) Claims Adjudication: Standardized process for adjudicating unauthorized/Mill Bill claimsAppeals Management: Standardization of process and tools used to track and facilitate appeals
10 Non-VA Care Coordination Approach Utilizes a “train the trainer” approach to enterprise deploymentEach VISN identified a single medical center to serve as a Champion FacilityCBO team works closely with the Champion Facilities, providing ongoing virtual and on-site procedural and technical training and supportChampion Facility then collaborates with VISN leadership to deploy the NVCC model to the remaining medical centers within their VISNs (sister facilities)Deployment time line:November 2012: Champion Facility deployment completeSeptember 2103: Enterprise wide deployment complete
11 Measuring SuccessA national metric plan was developed and implemented to measure the success of NVCC deployment which includes specific metrics for core benefit categories:Increased Operational EfficiencyAdoption of NVCC Standardized ProcessesIncreased SatisfactionEnhanced Communication
12 Patient-Centered Community Care The Patient-Centered Community Care (PC3) contract provides eligible Veterans coordinated, timely access to care through a comprehensive network of non-VA providers who meet VA quality standards when VA cannot readily provide the care in-houseTo start, PC3 is a nationwide program that offers health care contracts to give eligible Veterans access to coordinated, timely, and quality health care.
13 Alignment With Strategic Goals VHA’s three strategic goals:Provide Veterans personalized, proactive, patient-driven health care;Achieve measureable improvements in health outcomes, andAlign resources to deliver sustained value to Veterans.PC3 offers:Access to care when care is not readily available within VA;Quality, coordinated care ; andStandardized purchasing processes, defined performance metrics, and favorable ratesVHA has 3 strategic goals set by Under Secretary of Health, Dr. Petzel. PC3 aligns to these goals by offering access to quality, coordinated care.
14 Services Included and Not Included in PC3 Contracts The PC3 contracts provide health care for eligible Veterans when the local VAMC cannot readily provide the services, ensuring the Veteran receives the care they need when and where they need itVAMCs may have a lack of available specialists or long wait times, or it is an extraordinary distance from the Veteran’s homeThe contracts include:The contracts do not include:Inpatient specialty carePrimary careOutpatient specialty careDental careIncluding Skilled Home Health and Home Infusion TherapyNursing home careLong Term Acute Care Hospitals (LTAC)Mental health careHomemaker and home health aide servicesLimited emergency careLimited newborn care for enrolled female Veterans after deliveryChronic dialysis treatmentsCompensation and pension examinationsThe Denver Acquisition and Logistics Center awarded the PC3 contracts in early September to Health Net and TriWest.The contracts are options for VA Medical Centers to use when a Veteran needs specialty care that is not available in house, at other VA Medical Centers, through sharing agreements or with Academic Affiliates.PC3 is also an option if wait times for specialty care are too long or the site of care is too far away from a Veteran’s home.These contracts offer inpatient and outpatient specialty care (including skilled home health and home infusion therapy), mental health care, limited emergency care and limited newborn care for enrolled female Veterans’ after the birth of a child.We did not incorporate primary care for inclusion into the contract because Primary care is considered a core competency of VHA.There are other types of care that are not included in the contracts for various reasons or because they are already covered by other contracts, such as dialysis.
15 Contract Requirements The collaboration with internal and external stakeholder groups resulted in robust contract requirements surroundingNetwork Access/Commute TimeProvider Orientation ProgramAccreditation, Certification, Privileging, and LicensingVeteran Safety and Clinical QualityOrdering and Authorization ProcessAppointment Setting and Urgent SchedulingContinuity of CareCoordination of Inpatient ServicesEmergency Health CareComplaints and GrievancesPharmacy (mainly VA-provided)DME (VA provided)Return of Medical DocumentationClaims ProcessingFor the complete contract, including these requirements, please visitIn the process of developing the contract requirements, many internal and external stakeholder groups were consulted. The collaboration resulted in an extensive set of requirements. Some of them are listed here.
16 Benefits Ensures clinical quality Efficient Convenient for Veteran Meet Medicare Conditions of Participation and Conditions for CoverageTwo clinical quality committees (oversight and peer review)Meet federal and state regulatory requirements; may not participate in on CMS exclusionary listServices, facilities and providers must have compliance program in alignment with HHS OIG Compliance Program for Hospitals and USSC Sentencing GuidelinesAdditional requirements for specialties, such as radiation oncology and rehabilitation medicineAll critical events reported to CO/COR within 24 hoursEfficientOption to manage high volumes of one type of careContractor schedules appointmentAllows for authorization without additional contracting reviewConvenient for VeteranAppointments scheduled within five days (48 hours for urgent care) after authorization receiptAppointments held within 30 daysVeteran seen within 20 minutes of arrivalEstablishes commute times (urban – 60 – 120 minutes; rural – minutes; highly rural 240)Veteran receives personal contact confirming appointment and reminding of appointmentVeteran can give preference of provider gender, if neededDecreases improper paymentsPayment rates are defined by contractThe contract requirements led to a contract vehicle that offers benefits real for Veterans and the VA.First and foremost, the contract requirements ensure the care Veterans receive meets VA-established quality requirements. We also have two committees per contract to ensure clinical quality – one for oversight and one that conducts peer reviews.It is efficient for the VA Medical Centers. It provides an option to manage high volumes of one type of care. The contractors will be setting the appointments. And PC3 authorizations over $10,000 do not require additional contracting review.It’s convenient for the Veterans, with appointments set and held in a timely manner and held within established commute distances.And it will help decrease improper payments, as rates are defined by the contract
17 Benefits, cont. Supports care coordination Standardizes processes Medical documentation returned within 14 days (outpatient), 30 days (inpatient)Must call VA with critical findings within 24 hoursAll transitions of care done in coordination with VAStandardizes processesContractor submits claims in standardized mannerEnsures compliance with USC Title 38Compliments Non-VA Care Coordination (NVCC) processesContracting negotiates and PMO oversees contract. Local facilities do not need to negotiate own contractsSupports reimbursementReturn of appointment information supports review of third party payer precertificationValueOn average, the pricing for Medical and Surgical Services is 94.5 to 97.5% of Medicare and Skilled home health will be 92 to 97% of Medicare*Ensures contractor qualityMonitor performance against a Quality Assurance Surveillance PlanRegular auditsMedical documentation is returned in a timely manner, supporting VA’s care coordination role.It helps us standardize our processes across the VA Medical Centers.Reimbursement is supported by the contractor providing appointment information back to the VAMC.The pricing is competitive, providing VA great value for the care we buy through this contract.And the PMO will help ensure contractor quality through monitoring performance against specific goals and conducting regular audits.*Region 6, Alaska, not included in these ranges
18 Six Region PC3 Contract Coverage Here is the map of the PC3 regions. The regional model helps with centralized management and oversight of the contracts and leverages contractor’s networks where the contractor is the strongest.Health Net serves:Region 1 which includes VISNs 1, 2, 3, 4Region 2 which includes VISNs 5, 6, 7, 8Region 4 which includes VISNs 10, 11, 12, 19, 23TriWest serves:Region 3 which includes VISNs 9 , 15, 16, 17Region 5 A which includes VISNs 18, 22, 20 (excluding Alaska ), 21 (excluding Hawaii and Pacific Islands and Philippines*)Region 5 B which includes VISN 21 – Hawaii and Pacific IslandsRegion 6 which includes VISN 20 – Alaska The Philippines are not covered by PC3 contracts
20 PC3 Utilization Total PC3 Authorizations * Trend Health Net TriWest Contract availability: VISN 2, 3, 4, 10, 11, 23Authorization Concentrations: Optometry, Physical Therapy, and NeurologyTriWestContract availability: All facilities in Region 5 which includes VISNs 18, 20 (excl. AK), 21, and 22Authorization Concentrations: Internal Medicine/ Gastroenterology, Podiatry and Orthopedic SurgeryTotal PC3 Authorizations Issued6487TriWest4102Health Net2385*All authorization data represents authorizations created using the Vista fee package from January 2, 2014 through February 28, 2014 where the vendor tax ID matched that of the PC3 contractor. Data was extracted from the VA Corporate Data Warehouse (CDW) files on 2/28/14.