Managed Care Support Services

The Defense Health Agency (DHA) invites potential sources to provide an industry perspective so that the next iteration of TRICARE Managed Care Support (MCS) contracts may be developed to reflect best commercial practices and innovative solutions to the many military healthcare challenges. The DoD requires delivery of uniform healthcare benefit in terms of quality, structure and patient cost-sharing. DoD is interested in leveraging best commercial practices to the greatest extent practicable. Potential prime vendors for MCS services are invited to provide input and information in writing or through one-on-one meetings with the DHA. One-on-one meetings are intended to allow full exchange of information in an environment that protects proprietary information. The one-on-one meetings will be held face-to-face at the DHA Headquarters (DHHQ) in Falls Church, VA; and will occur between July 14, and July 18, 2014. Meetings will be scheduled in three -hour blocks and will be provided on a first-come-first-served basis. If you are a potential prime vendor interested in providing input into the future of the Military Health System (MHS) through the services provided under contracts for MCS services and have the ability to provide meaningful input to the below areas of discussion, please contact Ms. Danita Hunter, via e-mail at [email protected] no later than 4:00 PM (EDT) July 2, 2014, to make arrangements for a one-on-one meeting. Meeting times will be established based on availability; you are encouraged to respond as soon as possible if interested. If a face-to-face meeting is not possible, conference calls, or submission of written information will be considered. Due to time limitations, DHA is requesting that only vendors able to provide information for all areas of interest outlined below attend the one-on-one meetings. If a vendor is unable to provide information across the full breadth of these interest items, but would still like to contribute information specifically addressing only some of the areas, written information will be accepted. Overview: The MHS consists of direct care provided by Department of Defense (DoD) personnel through Military Treatment Facilities (MTF) and clinics and purchased care provided through MCS Contractors. This overview is to describe the purchased care portion of the Defense Health Program (DHP). Additional information is available on the DHA web site at www.tricare. mil. In order to fulfill the purchased care needs of the DHP, prime vendors/contractors must provide all services necessary to fully support DoD's primary wartime health and medical readiness mission while supplementing the services provided through DoD-owned and/or operated healthcare facilities, to include, but not limited to, claims processing, network management, enrollment, customer services, medical management, and referral management. 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 program. 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 consistent with current and emerging industry best practices. Information is sought to assure MHS requirements are structured in a manner that facilitates a fully integrated healthcare delivery and financing system for all MHS beneficiaries. The medical mission of the DoD 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 healthcare. The MHS must be prepared not only to provide a high-quality, cost-effective healthcare 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 Prime Service Areas (PSAs) 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. The direct care system is the main delivery system for TRICARE, augmented by MCS contracts. MCS contracts provide services to approximately 9.6 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 offers three healthcare options for beneficiaries-Prime, Extra, and Standard. TRICARE Prime is similar to a Health Maintenance Organization (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. Also, not requiring enrollment, TRICARE Standard is a fee-for-service option in which the beneficiary is free to use any authorized provider but must pay an annual deductible (individual or family) and cost shares. The three options of TRICARE are described fully in 32 CFR Part 199.17 and 199.18 which may be accessed on the DHA web site at www. http://manuals.tricare.osd.mil/. There are other TRICARE plans and programs under which some beneficiaries may qualify for other benefit options such as, TRICARE Prime Remote-TPR, or the premium-based programs of TRICARE Retired Reserve-TRR, TRICARE Reserve Select-TRS, TRICARE Young Adult-TYA, and Continued Healthcare Benefit Program (CHCBP) depending on their location, Active/Reserve status, etc. 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. A MCS contractor interface with MTF enrollees will largely occur in PSAs, with workload driven by the MTF's capability and capacity. MCS contractors are required to financially underwrite healthcare costs for eligible beneficiaries, minus some exceptions. The MCS contractors are incentivized to maximize cost savings as much as practicable. The Government encourages potential sources to comment on this arrangement understanding that provisions of law dictate that healthcare costs be underwritten by the MCS 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 PSA, which may include areas surrounding Base Realignment and Closure (BRAC) sites. The goal of the MHS is 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. The TRICARE Program accomplishes its mission through utilization of an integrated healthcare delivery system consisting of military hospitals and clinics. Additionally, the TRICARE Program purchases services in the civilian sector via contracts whose goals are aligned with the MHS "Quadruple Aim": • Readiness. Support the MHS readiness mission by partnering with the MTFs to optimize the delivery of healthcare services in the direct care for all MHS beneficiaries. • Experience of Care. Provide a care experience that is patient- and family- centered, compassionate, convenient, equitable, safe and always of the highest quality. • Manage Per Capita Cost. Create value by focusing on quality, eliminating waste, and reducing unwarranted variation; considering the total cost of care over time, not just the cost of an individual healthcare activity. Demonstrate use of Patient Centered Medical Homes, Accountable Care Organizations, and other forward leaning care delivery systems. Demonstrate models and methods to align networks and populations in such a manner to promote quality and efficiency. • Population Health. Within the constraints/boundaries/benefits of the current program, encourage beneficiaries and providers to seek ways to improve health. DHA is interested in current and emerging industry trends and recommendations to enhance the TRICARE program in the following areas: Provider Networks, Referral Management, Integrated healthcare delivery system (MTF Coordination), Medical Management (utilization management, case management, disease management), Claims Processing, Enrollment, Customer Service (Call center, website, communications), Information Technology/Systems Integration, Management Services, Incentives (provider/network, electronic claims, clinical quality, program integrity), Healthcare Data Interoperability, and Electronic Health Records (EHRs). The Government is interested in other information that interested vendors would like to address in support of achieving high-quality, cost-effective delivery of healthcare services. The focus of these meetings and/or written input from interested vendors is to identify best commercial practices as they apply to military healthcare. Any information provided will be included in market research analysis and vendor recommendations may or may not become a requirement of future government efforts.