A06 J and A-1605C1-22-P-00069 (003)_Redacted.pdf

Ser #: J&A DOL-22-50

Justification for Other than Full & Open Competition

1. Identification of the agency and contracting agency:

Contracting Activity Customer Agency Department of Labor (DOL) Department of Labor Office of Senior Procurement Executive Employee Benefits Security Administration 200 Constitution Ave. NW 200 Constitution Ave. NW Washington, DC 20210 Washington, DC 20210

2. Nature and/or description of the action being approved:

This justification authorizes and approves the issuance of a contract to FAIR Health, Incorporated, 530 5TH Ave FL 18, New York, NY 10036-5109 ( ) for one 12-month base period and up to one 12-month option period.

EBSA requires benchmarks representing the charged and allowed amounts for professional medical and HCPCS services as well as for services that occur in specified places of service (i.e., outpatient facilities, inpatient facilities, ambulatory surgical centers, urgent care facilities, telemedicine) and for services with temporary codes for “emerging” technologies, services, or procedures. All statistics should be presented at the Current Procedural Terminology [CPT] or Healthcare Common Procedure Code System [HCPCS] code and shown for each available zip code location as well as the United States as a whole. Separate from this request, EBSA may require ad-hoc analytical assistance.

3. Description of supplies/services required to meet the agency’s needs (including the estimated value):

EBSA requires statistics reflecting charged and allowed amounts for a comprehensive set of healthcare services, including, but not limited to professional outpatient services, HCPCS codes, services occurring in inpatient facilities, outpatient facilities, ambulatory surgical centers, urgent care facilities, and at home (telemedicine), as well as for services that are billed with a temporary “Gapfill” procedure code. These statistics shall be representative of the health claims experience of the privately insured population. At a minimum, EBSA requires these statistics to be the mean and 80th percentile of both the charged and allowed amounts, where both amounts are available from the contractor.

For types of services or benchmark files based on place of service for which allowed amount benchmarks are not yet available, EBSA seeks to obtain the allowed amount benchmark files as soon as the contractor makes those benchmark files available. EBSA’s tools and enforcement support may evolve to require more than just the mean and 80th percentile of the

8. A description of market research conducted (part 10) and the results or a statement of the reason market research was not conducted:

EBSA conducted market research using two methods: 1) conducting a U.S. General Services Administration (GSA) search for firms that provide services for health insurance claims data and analysis and 2) gathering information on additional companies that could provide the services required, in which EBSA reviewed vendors and/or sources that staff had previously worked with or had knowledge of.

The GSA search results yielded only 2 matches, B-Square Consulting and Fidelis Sustainability Distribution. However, none of them meet the requirements listed in the Performance Work Statement.

EBSA is aware of several other entities that provide health claims cost data, which were reviewed and discussed by subject matter experts:

All-Payers Claims Database. Only 23 states have all-payer claims database which means we would not have data for all geozips required.1 The states mandate different requirements in their datasets and so there is no standards information across those states that do participate. Self- Insured plans cannot be compelled to participate and so it’s unclear the degree to which these plans are represented.

FAIR Health. FAIR Health obtains data from more than 60 insurance carriers, third-party administrators and health plans that contribute claims data through the FAIR Health Data Contribution Program. FAIR Health data are organized into 493 geozips, which tend to track with the first three digits of a zip code. The dataset include most data fields reported on medical and dental claims, including diagnoses, procedures, dates and places of service, billed charges, allowed amounts reimbursed and other information. All types of services are captured in the repository, including lab services, surgeries, radiology, durable medical equipment, emergency services, behavioral health, ambulance services, specialty drugs, primary care and the like. The data also include place of service and provider specialty, as well as the age and gender of the patient.

Health Care Cost Institute (HCCI). HCCI dataset contains over 55 million individuals with employer sponsored insurance per year as well as 100% of Medicare FFS claims data for 40 million individuals per year.2 However, access to the HCCI data is restricted to connecting to their secure enclave. The HCCI does not transfer physical health insurance claims data to clients.

IBM Marketscan Research Databases. This product is a family of datasets that integrate deidentified patient-level health care data (drug, medical, and dental) for health care research.

Data are contributed by large employers, managed care organizations, hospitals, Medicare, and Medicaid. This product has over 160 contributing employers, 40 contributing health insurance

1 Another eight states have more limited efforts, and several more are considering creating one. Source, https://www.apcdcouncil.org/state/map 2 https://healthcostinstitute.org/data plans, and more than 263 million covered lives since 1995. The data is generally limited to narrowly defined research purposes and so it is unlikely the government could procure the data for enforcement.3

Medicare. The Centers for Medicare & Medicaid Services (CMS) offers Medicare claims files for each claim type (inpatient, outpatient, skilled nursing facility, home health agency, hospice, carrier and durable medical equipment).4 While these claim files have been widely used by researchers, they don’t meet the requirements described in the PWS because they do not have any claims from employer-sponsored health plans and are focused on the 65 and older population.

Milliman Health Cost Guidelines (HCG)-Commercial. Their commercial guidelines include ‘Area Factors’ that might be able to be broken out by Rating Structure (Fee-For-Service, PPO, HMO, etc.). The Area Factors adjust national average costs to geographic locations.5 However, Milliman’s online brochure does not define a geographic area (e.g., at the level of geozip or county). While Milliman is known to serve many self-funded health plans in providing actuarial services or benefit consultation, the information provided does not explain the number of insurance carriers contributing to the commercial guidelines or whether Milliman can transfer physical health insurance claims data to clients.

The results of market research have determined that the Government's needs can be met by:

FAIR Health.

9. Any other supporting facts supporting the use of other than full and open competition:

None.

10. A listing of sources, if any, that expressed, in writing, an interest in the acquisition:

None.

11. A statement of the actions, if any, the agency may take to remove or overcome any barriers to competition before any subsequent acquisition for the supplies or services required:

Once the Government has developed the tool and determined its efficacy, they will review sources to update the underlying tool data annually.

12. Signature blocks:

3 https://www.ibm.com/downloads/cas/OWZWJ0QO 4 https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for- Order/LimitedDataSets/StandardAnalyticalFiles 5 https://www.milliman.com/- /media/products/hcgsuite/hcg_commercial.ashx?la=en&hash=F13C57BF38212D4B58DAEE82D75623C0