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Agenda Non-VA Medical Care Program Overview

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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) Overview Patient-Centered Community Care (PC3) Overview

2 Overview of Non-VA Medical Care
Insert date on slide master Overview of Non-VA Medical Care Non-VA Medical Care is health care VA purchases for eligible Veterans when services are not available at a VA facility Non-VA Medical Care is an augmentation of in-house capabilities and capacity The program has seen considerable growth over the past 8 years In 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 master Reasons VHA Purchases Care from Non-VA Providers Inability to access VA health care facilities Demand exceeds VA health care facility capacity Need for diagnostic support services for VA clinicians Need 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 VA Outside procurement vs. maintaining and operating like services in VA facilities for infrequent use Satisfying patient wait-time requirements

4 Growth of Non-VA Medical Care
Fiscal Veterans Total Cost Per Year Served Disbursed Unique FY ,729 $1.798B $3,362 FY ,768 $2.227B $3,617 FY ,794 $3.029B $3,686 FY ,404 $3.820B $4,150 FY ,836 $4.438B $4,664 FY ,727 $4.594B $4,733 FY ,496 $4.490B $4,565 FY ,065,434 $4.811B $4,516 FY14(YTD) 615,154 $1.733B $2,817 Data depicted based on in-system payments made through VistA Fee As of End of JAN 2014

5 FY 13 Non-VA Expenditures By Program

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 system Develop long term solutions for all Purchased Care programs New Healthcare Claims Processing System will consolidate all claims processing to a single system. Improve processes and business management for both short and long term initiatives Continue to improve business processes and current technology while preparing for long term solution Utilize national contracts to maximize economies of scale when providing care

7 Non-VA Medical Care Options

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 NVCC Non-VA Referral Review: Standardization of consults/referrals in support of future IT automation Appointment Management: Improved customer service, coordination and Veteran provider selection/preference Hospital Notification: Consistent model for documentation, tracking and coordination of patients in community health care facilities Unauthorized & Emergency Care (Mill Bill) Claims Adjudication: Standardized process for adjudicating unauthorized/Mill Bill claims Appeals 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 deployment Each VISN identified a single medical center to serve as a Champion Facility CBO team works closely with the Champion Facilities, providing ongoing virtual and on-site procedural and technical training and support Champion 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 complete September 2103: Enterprise wide deployment complete

11 Measuring Success A national metric plan was developed and implemented to measure the success of NVCC deployment which includes specific metrics for core benefit categories: Increased Operational Efficiency Adoption of NVCC Standardized Processes Increased Satisfaction Enhanced 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-house To 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, and Align resources to deliver sustained value to Veterans. PC3 offers: Access to care when care is not readily available within VA; Quality, coordinated care ; and Standardized purchasing processes, defined performance metrics, and favorable rates VHA 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 it VAMCs may have a lack of available specialists or long wait times, or it is an extraordinary distance from the Veteran’s home The contracts include: The contracts do not include: Inpatient specialty care Primary care Outpatient specialty care Dental care Including Skilled Home Health and Home Infusion Therapy Nursing home care Long Term Acute Care Hospitals (LTAC) Mental health care Homemaker and home health aide services Limited emergency care Limited newborn care for enrolled female Veterans after delivery Chronic dialysis treatments Compensation and pension examinations The 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 surrounding Network Access/Commute Time Provider Orientation Program Accreditation, Certification, Privileging, and Licensing Veteran Safety and Clinical Quality Ordering and Authorization Process Appointment Setting and Urgent Scheduling Continuity of Care Coordination of Inpatient Services Emergency Health Care Complaints and Grievances Pharmacy (mainly VA-provided) DME (VA provided) Return of Medical Documentation Claims Processing For the complete contract, including these requirements, please visit In 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 Coverage Two clinical quality committees (oversight and peer review) Meet federal and state regulatory requirements; may not participate in on CMS exclusionary list Services, facilities and providers must have compliance program in alignment with HHS OIG Compliance Program for Hospitals and USSC Sentencing Guidelines Additional requirements for specialties, such as radiation oncology and rehabilitation medicine All critical events reported to CO/COR within 24 hours Efficient Option to manage high volumes of one type of care Contractor schedules appointment Allows for authorization without additional contracting review Convenient for Veteran Appointments scheduled within five days (48 hours for urgent care) after authorization receipt Appointments held within 30 days Veteran seen within 20 minutes of arrival Establishes commute times (urban – 60 – 120 minutes; rural – minutes; highly rural 240) Veteran receives personal contact confirming appointment and reminding of appointment Veteran can give preference of provider gender, if needed Decreases improper payments Payment rates are defined by contract The 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 hours All transitions of care done in coordination with VA Standardizes processes Contractor submits claims in standardized manner Ensures compliance with USC Title 38 Compliments Non-VA Care Coordination (NVCC) processes Contracting negotiates and PMO oversees contract. Local facilities do not need to negotiate own contracts Supports reimbursement Return of appointment information supports review of third party payer precertification Value On 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 quality Monitor performance against a Quality Assurance Surveillance Plan Regular audits Medical 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, 4 Region 2 which includes VISNs 5, 6, 7, 8 Region 4 which includes VISNs 10, 11, 12, 19, 23 TriWest serves: Region 3 which includes VISNs 9 , 15, 16, 17 Region 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 Islands Region 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, 23 Authorization Concentrations: Optometry, Physical Therapy, and Neurology TriWest Contract availability: All facilities in Region 5 which includes VISNs 18, 20 (excl. AK), 21, and 22 Authorization Concentrations: Internal Medicine/ Gastroenterology, Podiatry and Orthopedic Surgery Total PC3 Authorizations Issued 6487 TriWest 4102 Health Net 2385 *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.

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