Value_Based_Incentive_update.pdf

Subfactor X – Value Based Incentive

L. The offer or will describe its design, approach and best industry practices they will use to implement a variety of value based provider incentives designed reward value, quality, and integrated care. The offer or will describe its approach for developing, implementing and maintaining a Value Based Incentive program that will reward excellence in the delivery of “best value health care ” while creating improved value for the government (positive Return on Investment (ROI)) and facilitating user-friendly Government access to all data related to the program. This program shall include a variety of purchased care sector provider incentives that are aligned to improve the integration of patient care and information, improve health status and safety, improve coordination of care, and increase integration and sharing of information in both the network and with the direct care system. Additionally, this program shall incorporate processes and strategies that are designed to create improved value for the government (positive ROI) when objectively measured outcomes are compared to actual program costs (i.e., all administrative costs and

M. The Government will evaluate the offeror’s proposed approach for developing, implementing and maintaining a Value Based Incentive program that complies with the requirements of C.X.X. . Evaluation will be based on the extent to which the offeror’s proposal details a sound technical approach for developing, implementing, and maintaining a Value-Based Incentive program that incorporates a variety of provider incentives to reward excellence in the delivery of “best value health care; creates improved value for the Government (positive Return on Investment (ROI)); and provides user-friendly Government access to all data related to the Value Based Incentive program. Other criteria which the government will consider in its evaluation are the utilization of industry best practices to achieve value; outcomes measures included; and the value based Incentives included. The government will not evaluate any proposed ROI goals; these shall be established following contract award (see C.X.X.)

C.X.X. The Contractor shall develop a Value Based Incentive program which will not serve as an alternative method of reimbursement for care. Further, it is not a payment from the government to the provider. The Contractor shall develop a Value Based Incentive program that incorporates a variety of purchased care sector provider incentives designed to reward excellence in the delivery of “best value health care” (see the TOM, Appendix B for the definition of “best value health care”). The program shall be implemented at the start of health care delivery and shall be maintained continuously thereafter through the end of the last option period or until termination by the government via contract modification (whichever comes first). The provider incentives shall be aligned to improve the integration of patient care and information;

improve health status and safety; improve coordination of care; and increase integration and sharing of information both within the purchased care system and with the direct care system. All provider incentives should result in improved value for the Government (positive Return on Investment (ROI)) when program provider incentive payments that are directly attributed to the Value Based Incentive program). Finally, the program shall incorporate processes to facilitate user-friendly Government access to all data related to the Value Based Incentive program. The program description should describe the initiatives and provider incentives to be implemented; the estimated number of beneficiaries who will be impacted; the estimated number of providers who will be included in the program; the proposed quantifiable improvements in quality and outcomes in areas that may include measures such as HEDIS, Evidence-Based Medicine, health status, decreased admissions or readmissions, and coordination of care and integration of information; and any other measures which demonstrate the desired improvements. The program description should include a detailed a detailed description of how outcomes and improvements will be objectively measured, documented, reported, and evaluated to determine whether the proposed provider incentives resulted in improved quality outcomes and value to the government (positive ROI); the utilization of industry best practices to achieve value; and a description of the processes for ensuring that the Government will be able to access all data outcomes are compared to actual program costs. Following contract award, the contractor shall provide the government with a projected aggregate ROI goal for the Value Based Incentive program for each option period (i.e., a single ROI goal shall be proposed for each option period, regardless of the number of provider incentives that are implemented). The contractor’s projected ROI goal shall be contractually binding. The contractor’s performance in meeting the projected ROI will be considered as part of the Award Fee process

The Contractor shall propose a plan which identifies providers; the number, geographic locations and applicable specialty for the providers targeted for inclusion; patient populations to include the number, geographic location and applicable disease (s) for TRICARE patient populations who will be addressed;, desired outcomes, incentives to be used, and how it will measure and report both actual outcomes and the return on investment. The plan shall also identify the methodology and expected outcomes for its program, types of incentives to be used, along with the minimum standard that will be exceeded in each related to the value-based incentive program with ease. .

category and how the enhanced outcomes will be quantified. This requirement does not authorize the contractor to use alternate reimbursement methodologies for patient care. The Contractor shall use its best practices in developing and identifying both the number and type of providers, the types of incentives which will be used, additional data and information.

The Contractor shall also include in the plan the anticipated cost of each incentive, and the anticipated outcomes from each type, to include, but not limited to improvements in patient health status; decreased emergency room visits; decreased inpatient admissions;

decreased use of tests; decreased patient safety events; increased experience of care scores; changes in EBM and/or HEDIS measures; an analysis of the cost and quantified outcome of each incentive (ROI).

The Contractor shall include in the plan a mechanism to make all data collected in support of the Value Based Incentive program electronically available to the Government, including, but not limited to, provider-level outcomes.”

The Contractor shall utilize data from a similar patient and provider cohort or the same patients and providers from a previous period to determine outcomes attributable to the value based Incentives.

Additional proposed language for Section G:

G.X.X. (should go in the section for “PAYMENTS FOR ADMINISTRATIVE CLINS – NON-TED”

G.X.X.1. Value Based Incentive invoicing instructions (CLIN 100X – 500X)

Submit invoice no more frequently than monthly and only after completion of the given month in which the contractor incurred costs for provider payments or administrative costs that are directly attributed to the Value Based Incentive program. No payment shall be allowed for transactions which involve the use alternate reimbursement methodologies for patient care. Supporting documentation shall include a detailed description of the actual costs incurred during the reporting period. The total amount that may be reimbursed under this CLIN is capped at $XXmillion per option period. The government will not reimburse the contractor for any additional costs incurred for the remainder of that option period once the cap of $XX million has been met. Unused portions of the option year cap will not be carried over or applied to a different option year period.