T-5 Draft RFP Section M v1.1.pdf

SECTION M

EVALUATION FACTORS FOR AWARD

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M.7.2.6. Subfactor 6 - Planned Demonstrations/Product Improvements

M.7.2.6.1. Advanced Primary Care:

M.7.2.6.1.1. The Government will evaluate the effectiveness of the Offeror’s proposed approach for identifying, including in its networks, and continuously improving Advanced Primary Care (APC) practices. Proposals shall include all specific qualifying features, payment methodologies, and a recruiting plan.

M.7.2.6.1.2. The Government will evaluate the effectiveness of the proposed APC administrative infrastructure, systems, and plans to support APC practices and promote their utilization by TRICARE beneficiaries. Proposals shall:

M.7.2.6.1.2.1. Clearly describes the Offeror’s governance model and support infrastructure.

M.7.2.6.1.2.2. Clearly describes how the Offeror will facilitate medical record and data transfers between APCs, other providers, and the Offeror.

M.7.2.6.1.2.3. Clearly describes how the Offeror will measure, report on and continuously improve the performance of the APC practices.

M.7.2.6.1.3. Demonstrates an ability to achieve improved clinical quality outcomes regarding prevention and chronic condition management, improved service utilization rates (primary and specialty care, emergency room, inpatient hospital, diagnostics, pharmacy, and behavioral health), appropriate care delivery, and reductions in the total cost of care.

M.7.2.6.1.4. The Government will also evaluate whether the Offeror’s proposed approach will deliver improved warfighter readiness, improvements in referral management, and enhanced beneficiary experience and access.

M.7.2.6.1.5. Demonstrates payment methodologies that include risk adjustment.

M.7.2.6.2. Beneficiary Choice Demonstration

M.7.2.6.2.1.The Government will evaluate the number and type of alternate health plans in the proposal. The Government places a high value on an Offeror being able to establish or create choices for beneficiaries within the first year of healthcare delivery under the T-5 contract. The Government will evaluate the offeror’s proposal structure for plan choice. The criteria is met when:

M.7.2.6.2.2. The proposal includes criteria for access, quality and cost control that differentiates the partner from its own local network.

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M.7.2.6.2.3. The proposal demonstrates the offeror’s oversight, monitoring and reporting processes resulting in effective control of demonstration outcomes and management reporting to the Government.

M.7.2.6.2.4. The proposed outcome metrics will assess the efficiency, effectiveness, and cost of and beneficiary satisfaction with the demonstration.

M.7.2.6.3. Advanced Care Management

M.7.2.6.3.1. The Government will evaluate the Offeror’s strategy for managing beneficiaries who may qualify for or benefit from services provided under more than one case management program, (e.g. disease management, behavioral health. etc.), including such things as coordination between programs, avoiding duplication of assessments and contacts, integrating care plans and staffing coordination.

M.7.2.6.3.2. The Government will evaluate the Offeror’s proposed predictive analytic tools and capability to identify, support and manage the healthcare of beneficiaries.

M.7.2.6.3.3. The Government will evaluate Offeror’s description of other tools and processes for identifying, risk-stratifying, referring and managing beneficiaries.

M.7.2.6.3.4. The Government will evaluate Offeror’s description of their staffing plan, case assignment and caseload methodology to be employed to support the CM program as identified in TOM Chapter 7, Section 2.

M.7.2.6.3.5. The Government will evaluate the Offeror’s description of assessments and tools that will be used to identify beneficiaries in need (high-need and at risk for readmission) of in-home services; processes to offer in-home CM services with first visit within 48 to 72 hours post discharge; and tools used to evaluate need for continued in-home visits.

M.7.2.6.3.6.The Government will evaluate the Offeror’s strategy to communicate, collaborate, and coordinate with purchased care providers, Markets/MTFs and Government Designated Authority (GDA) as well as define and implement care coordination for beneficiaries.

M.7.2.6.4. Care Collaboration Tools Requirements

M.7.2.6.4.1. The Government will evaluate the Offeror’s proposed approach for developing and continuously improving an integrated care collaboration program that facilitates virtual provider-to-provider consultations (e-Consult).

M.7.2.6.4.2. The Government will evaluate how the Offeror’s proposed e-consult system will include MTF providers will enhance KSAs through the care collaboration platform.

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M.7.2.6.4.3. The Government will evaluate the Offeror’s proposed machine-to-machine interoperability using healthcare EDI standards [e.g. HIPAA X12 transactions and Health Level 7® (HL7) Fast Healthcare Interoperability Resources® (FHIR) between MCSCs, network providers, the Direct Care System and other authorized contractors].

M.7.2.6.4.4. The Government will evaluate the Offeror’s proposed it will promote and support the implementation of e-Consult services throughout its network, including any provider incentive programs or other financial support.

5. Clinically Integrated Networks (CINs)

M.7.2.6.5.1. The Government will evaluate the Offeror’s approach for including CINs in its network and monitoring and continuously improving CIN performance. The criteria is met when the Offeror’s proposal clearly describes the following:

M.7.2.6.5.1.1. A cohesive process for evaluating the (1) effectiveness, (2) stability, (3) governance, (4) financial model and (5) integration of provider organizations within CINs;

M.7.2.6.5.1.2. A clearly defined data management, reporting, and accountability processes;

M.7.2.6.5.1.3. An incentive approach that motivates providers to adopt effective care delivery;

M.7.2.6.5.1.4. A continuous improvement methodology to monitor and improve CIN performance

M.7.2.6.5.1.5. Value-based incentives impactful enough to motivate providers to invest in and adopt new approaches to care delivery, without subjecting providers to burdensome financial and clinical risk.

M.7.2.6.6. Provider Recognition and Reward

M.7.2.6.6.1. The Government will evaluate the Offeror’s proposed approach to implement a Provider Recognition and Reward program in accordance with requirements of H.16.1.6.

M.7.2.6.6.2. The Government will evaluate whether the recognition and reward methodology will drive improved warfighter readiness, cost efficiency and clinical quality.

M.7.2.6.7. Targeted Utilization Management (UM)

M.7.2.6.7.1. The Government will evaluate the Offeror’s proposal for its Targeted UM program based on delivery of:

A) Improved readiness of the force, B) Improved consistency of care

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C) Improved clinical quality outcomes and;

D) Financial savings.

M.7.2.6.7.2. The Government will evaluate the Offeror’s reporting metrics and assess whether they will accurately measure and report program performance.

M.7.2.6.7.3. The Government will evaluate the Offeror’s Targeted UM design proposal work plan proposal work plan and evaluation protocol to evaluate whether the demonstration can be properly measured and assessed. .

M.7.2.6.7.4. The Government will evaluate the Offeror’s proposal to implement Targeted UM value based payment incentives to providers that deliver high quality health care as measured by leading health quality measurement organizations.

M.7.2.6.7.5. The Government will evaluate whether the offeror is or will be nationally accredited in Utilization Management.

M.7.2.6.8. Advanced Telehealth

M.7.2.6.8.1. The Offeror’s proposal will be evaluated on the feasibility and effectiveness of its approach to creating and administering payment incentives, value based care, or risk sharing mechanisms for providers and beneficiaries. Successful approaches will reduce cost, drive provider and beneficiary use of telehealth, and establish an equitable provider payment model for telehealth encounters.

M.7.2.6.9. Virtual Value Network (VVN)

M.7.2.6.9. The Government will evaluate the Offeror’s process for selecting and monitoring VVN providers. The criteria is met when the proposal describes the following:

M.7.2.6.9.1. A consistent, validated provider selection criteria, clearly defined KPIs, data management, reporting and accountability processes; identification of third-party tools, M.7.2.6.9.2. A cohesive engagement and communication strategy to maximize beneficiary awareness and use of VVN providers, including any financial incentives.

M.7.2.6.10. Wellness and Disease Management (Population Health)

M.7.2.6.10.1.The Offeror’s proposal will be evaluated on the effectiveness of its approach to wellness and disease management program design. The criteria is met when the proposal includes best-practice behavior designs, including behavioral economics; self-directed incentive

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M.7.2.6.10.2. The Government will assess the effectiveness and feasibility of the proposed beneficiary engagement plan. Successful proposals will incorporate a personalized, omni-channel communication strategy; a feasible plan for engaging providers as touchpoints for information; a behavior change based and non-coercive approach; and include spouses and adult children.

M.7.2.6.10.3. The Government will assess the effectiveness of proposed technologies and tools that support the wellness and disease management program(s). The criteria is met when the offeror’s proposal demonstrates the ability to consistently capture data; provide multiple program interaction modalities (e.g., digital apps, digital trackers) and include the use of advanced data analytics.

M.7.2.6.10.4.The Government will assess the effectiveness of the measurement, reporting and ongoing performance improvement capabilities.

M.7.2.6.11. Centers of Excellence

M.7.2.6.11.1. The Offeror’s proposal will be evaluated for the Offeror’s approach to identifying, maintaining and referring beneficiaries to a network of CCoEs designated by the offeror for health conditions found in the DoD population... The criteria is met when the proposal clearly describes:

a. Methodology for identifying and designating CCoEs

b. Mechanism to educate and refer beneficiaries to CCoEs

M.7.2.6.11.2.The Offeror’s proposal will be evaluated based on its clear methodology to measure the following outcomes of CCoE:

a. Cost Efficiency

b. Clinical Quality

c. Beneficiary experience

M.7.2.6.11.3. The Government will evaluate the extent to which the Offeror’s proposal demonstrates an effective approach for incentivizing high value care in the CCoE program.