NoA_Attachment_1_Statement_of_Objectives.pdf

Notice of Availability

HT9402-19-S-C001

Attachment 1 Statement of Objectives

TABLE OF CONTENTS

1.0 BACKGROUND

2.0 SCOPE

3.0 PERIOD OF PERFORMANCE

4.0 OBJECTIVES

5.0 CONSTRAINTS

1.0 BACKGROUND

Fiscal Year (FY) 2018 National Defense Authorization Act (NDAA) Section 731 requires the Secretary of Defense to carry out a pilot program to provide health care assistance services for certain TRICARE Select beneficiaries using purchased care to improve the health outcomes and patient experience for covered beneficiaries with complex medical conditions to include the elements below:

Assist beneficiaries with complex medical conditions in understanding and using health benefits under the TRICARE program.

Support such beneficiaries in accessing and navigating the purchased care health care delivery system.

Provide such beneficiaries with information to allow the beneficiaries to make informed decisions regarding the quality, safety, and cost of available health care services.

Improve the health outcomes for such beneficiaries.

The CONUS Military Health System (MHS) is organized into two TRICARE Regions:

TRICARE East, and TRICARE West. Each region has a “Regional Contractor” to support the Defense Health Agency (DHA) and Military Treatment Facilities (MTF) efforts to provide TRICARE eligible beneficiaries access to high quality health care. The Regional Contractors administer TRICARE benefit plans by providing high value program management, benefit determinations, medical care management, customer services, provider networks, and claims processing. The current MHS TRICARE East contract is held by Humana Government Business dba Humana Military under contract № HT9402- 16-C-0001. The current MHS TRICARE West contract is held by Health Net Federal Services under contract № HT9402-16-C-0002.

TRICARE Select is a fee-for-service plan similar to a Preferred Provider Organization (PPO) health plan, available in the United States and requires enrollment. Beneficiaries have the option of using network or non-network TRICARE authorized providers, to include MTFs as available. All beneficiaries (active or retired) electing to enroll in TRICARE Select pay a calendar year deductible and cost-shares for all care received from non-MTF providers. Cost-shares are limited to an annual catastrophic cap of either $1,000 (Active Duty Family Members (ADFMs)), or $3,000 (Retired beneficiaries).

2.0 SCOPE

The scope of the program is implementation a nation-wide Pilot Program to provide TRICARE Select beneficiaries with complex medical conditions (complex medical conditions is defined as two or more medical conditions requiring the coordination of multiple specialties for at least 12 months ) or high cost claimant status ($100K/year or above) assistance with the following:

Understanding and using the health benefits under the TRICARE program, Accessing and navigating the direct and purchased care health care delivery system and the MHS, Providing/obtaining information to allow them to make informed decisions, regarding the quality, safety, and cost of available health care services, Improving the health outcomes for such beneficiaries, Increasing the use of high value care and services and reduce or eliminate the use of low value care and services.

The purpose of carrying out the Pilot Program is to assess whether such a program improves health outcomes and patient experience for covered beneficiaries with complex medical conditions.

The Secretary of Defense is required to submit a report containing an evaluation of the effectiveness of the pilot program to the committees on Armed Services of the House of Representatives and the Senate not later than January 1, 2021.

3.0 PERIOD OF PERFORMANCE

The period of performance includes (a) a base period for the transition-in period from contract award to full pilot performance as proposed by the vendor, (b) with three one-year option periods for pilot performance, and (c) one transition-out and final report period.

4.0 OBJECTIVES

The Contractor will provide a Performance Work Statement, to include performance standards, deliverables, and minimum quality levels necessary to achieve the objectives listed below as well as a value-based pricing structure that incentivizes the contractor to reduce costs, and improve health outcomes and patient experience and satisfaction for covered beneficiaries with complex medical conditions or high cost claimant status.

4.1 OBJECTIVE 1 – Integrated: Integrated health care assistance services that optimizes the delivery and quality of care through strong partnerships with the Defense Health Agency, Military Treatment Facilities, TRICARE contractors, providers, healthcare teams and community resources.

4.2 OJECTIVE 2 – Innovative: Innovative identification and outreach methodologies that encourage beneficiaries with complex medical conditions or high cost status to utilize the program.

4.3 OBJECTIVE 3 – Robust: Robust high quality healthcare assistance services that enables holistic, personalized, dedicated care, eases the burden of navigating the health care system throughout the continuum of care, and addresses not only the pilot program elements described in the NDAA, but the full spectrum of factors that affect well-being and health outcomes, including clinical factors, scheduling and access limitations, fear, stress and lack of family/social support.

4.4 OBJECTIVE 4 – Easy to Use: Easily accessible, seamless and consistent health care assistance services, available on demand to beneficiaries leveraged and supported by technology and knowledge resources.

4.5 OBJECTIVE 5 – Innovative Contract Pricing: An innovative contract pricing structure that incorporates cost savings, improved patient satisfaction, and health outcomes into a guaranteed positive return on investment (e.g. shared savings models and incentives/payments tied to achieving measurable outcomes, not traditional per member per month pricing structures)

4.6 OBJECTIVE 6 – Outcomes Focused: Outcomes-driven healthcare assistance program that measures financial, health and patient satisfaction outcomes against established baselines, benchmarks, and program goals. Gathering, analyzing, and reporting will be required on a quarterly basis including a baseline analysis, an analysis of the implementation of OBJECTIVES 1-5 and the feasibility of incorporating such elements into TRICARE support contracts. A measurable and reportable evaluation of success (including a definition of success) is essential to this program.

5.0 CONSTRAINTS

This section lists laws, rules, regulations, standards, technology limitations and other constraints that the service and/or service provider must adhere to or work under.

TRICARE Program Manuals 2015 edition (T-2017) apply to this effort (https://manuals.health.mil/).

The contractor will need to maintain a strong and secure partnership with DHA, MTFs, and the MCSCs and their fiscal intermediaries to optimize the delivery and quality of health care assistance services provided in the pilot program throughout the 50 United States and the District of Columbia, to include capability for real-time data exchange.

The contractor will need to access DEERS in determining eligibility/ TRICARE Select Enrollment.

Eligible beneficiaries are beneficiaries aged 0-64 who have complex medical conditions, or high cost claimant status ($100K/year or above) for inclusion in this program. Note:

complex medical condition is defined as two or more medical conditions requiring the coordination of multiple specialties for at least 12 months.

In-depth knowledge and understanding of TRICARE Encounter Data System (TEDs) is needed to support understanding of claims, denials, and appeals.

In-depth knowledge and understanding of the TRICARE pharmacy benefits is needed, including formulary, quantity limits, prior authorization requirements, therapeutic alternatives, applicable copays and deductibles.

The Contractor will need processes and procedures for identifying and referring beneficiaries in need of assistance from Case Management Programs or current MCSCs medical management services.

More metrics relating to improved health outcomes, patient experience, and quality of program execution is better.

Contractor will comply with the Personally Identifiable Information, Protected Health Information, and Federal Information Requirements (NoA - Attachment 2)

Contractor proposed PWS shall address the following:

o Transition-in, transition-out and final report development.

o Outreach to beneficiaries with complex medical conditions who may benefit from this program.

o Handling / referring crises situations.

o Data collection in support of measuring outcomes.

o Ensuring quality, including supervision of staff and documentation of beneficiary encounters.

o Continuous process improvement, including management of complaints.

o Quarterly reporting on all of the above.

Sufficient data shall be available for use in developing the required report the Government will prepare evaluating the effectiveness of the pilot program to the committees on Armed Services of the House of Representatives and the Senate, currently due not later than January 1, 2021

5.1 Non-Disclosure Agreements

Standard non-disclosure agreements shall be provided as required for personnel who may have access to Government data in the course of their duties.

5.2 Data

The Contractor shall provide unlimited access and rights to the data used in developing the annual report as well as the value-based pricing structure and eventual price determination and call/encounter records and case notes.