WTCHP_HealthProgramEvaluation_RFI_20240328.docx

WTC HEALTH PROGRAM

RFI 75D301-24-RFI-541611

World Trade Center Health Program Request for Information

HEALTH PROGRAM EVALUATION FOR THE WORLD TRADE CENTER HEALTH PROGRAM

REQUEST FOR INFORMATION 75D301-24-RFI-541611

RESPONSE DUE DATE: 12 PM Eastern, April 26, 2024

Title: Health Program Evaluation for the World Trade Center Health Program This Request for Information (RFI) is issued solely for information and planning purposes and is not a solicitation for proposals, proposal abstracts, or quotations. Release of this RFI shall not be construed as a commitment to procure items or services. Responses are not offers and cannot be accepted by the Government to form a binding contract. The Government will not pay for any information or administrative cost incurred in response to this RFI; all associated costs with responding to this RFI is solely at the respondent’s expense. Respondents should indicate which information in their response they consider to be proprietary. Responses will assist the Government in the development of its acquisition strategy, including the determination of small business capabilities and interest in any possible future acquisition.

I. Purpose The purpose of this RFI is to identify potential contractors who would provide health program evaluation services to the World Trade Center (WTC) Health Program. Additionally, the WTC Health Program requests information on methods and best practices for evaluating a limited-benefit healthcare program, including understanding utilization and spend, analyzing stakeholder feedback, and conducting medical and pharmacy claims audits.

II. Background On January 2, 2011, the President signed into law the James Zadroga 9/11 Health and Compensation Act of 2010 (the Zadroga Act). The Act established the WTC Health Program within the Department of Health and Human Services, to provide medical monitoring, screening, and treatment for responders and survivors of the 9/11 terrorist attacks. Responders include workers or volunteers who provided services in the aftermath of the September 11, 2001, attacks on the World Trade Center, the Pentagon, and the airliner crash site near Shanksville, PA. Survivors include persons who worked, lived, or attended school, childcare, or adult day care in the New York City disaster area, and were adversely affected by the attacks in New York City. In order to enroll in the Program, survivors and responders must meet certain criteria described in the Zadroga Act.

The WTC Health Program is a limited-benefit program: treatment is covered only for a limited set of health conditions and only when a member’s 9/11 exposure is substantially likely to have been a significant factor in aggravating, contributing to, or causing the member’s condition. There is a list of applicable WTC-related health conditions that must be diagnosed by a Program provider; meet specified exposure, latency, and symptom-onset requirements; and be certified by the Program for the Program to cover the member’s treatment. Information on the Program is available at http://www.cdc.gov/wtc.

The WTC Health Program plans to work with an independent health program evaluation contractor to evaluate performance and utilization of the Program, identifying areas for improvement and development. The Program is interested in identifying potential contractors who could provide health program evaluation services to the WTC Health Program and understanding their capacity for evaluation and audits.

III. Supplemental Information In order to receive Program-covered care, eligible responders and survivors must apply to the Program and be enrolled. Once enrolled, members are eligible to receive an initial health evaluation, at which time they may begin the process of certification for a covered condition. Once certified, members can receive medical and pharmaceutical care for their certified condition(s). For additional information about eligibility, enrollment, initial health evaluations, annual medical monitoring, and certification, see the Methods section in the linked article: https://www.cdc.gov/mmwr/volumes/70/ss/ss7004a1.htm. Understanding these policies is integral to understanding the nature of this limited-benefit healthcare program.

Currently, eight (8) Clinical Centers of Excellence (CCEs) in the New York metropolitan area (NYMA) and one Nationwide Provider Network (NPN) administer the benefits to members. The CCEs provide monitoring, treatment, and case management to members within the NYMA. The NPN contractor manages the nationwide provider network and provides monitoring, treatment, and case management to members living outside of the NYMA.

Since the inception of the Program, the WTC Health Program, with support from external vendors, has monitored membership, certification, and utilization/cost. The Program uses this data to identify and monitor trends. The WTC Health Program shares data on membership, member demographics, and certified conditions quarterly at: https://www.cdc.gov/wtc/ataglance.html. Data on healthcare services is also shared quarterly at: https://www.cdc.gov/wtc/reports.html.

In addition to routine analyses, the WTC Health Program is interested in data that addresses emerging issues in healthcare. Recently, this has included topics such as COVID-19 and the increase in utilization of telemedicine (e.g., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8562919/; https://pubmed.ncbi.nlm.nih.gov/38298086/).

In recent years, the Program has examined trends in membership, certification, and utilization data, projected medical and pharmacy costs, and identified a comprehensive list of metrics and indicators. The Program hopes to continue and expand many of these efforts. The Program understands that best practices, benchmarks, and industry standards change over time; thus, the Program is interested in gaining an understanding of the landscape to enhance WTC Health Program services and the member experience.

IV. Information Requested The WTC Health Program is interested in receiving comments and relevant, evidence-based information addressing each of the areas listed below.

1. The WTC Health Program is a limited-benefit healthcare program that covers specific types of medical and pharmacy claims based on certified conditions of members. The Program must ensure it is covering services and devices for only certified conditions, while also not impeding access, within appropriate limits. The WTC Health Program is in need of periodic medical and pharmacy claims audits. Please describe how your company would address this need for a limited-benefit health plan. In your response, please address any number of the following:

a. Describe your company’s capability to conduct audits on both medical and pharmacy claims, including any specialized capabilities applicable to only medical claims or only pharmacy claims.

b. Describe the routine medical claims audits your company suggests for the WTC Health Program (or a limited-benefit healthcare program in general).

c. Describe the routine pharmacy claims audits your company suggests for the WTC Health Program (or a limited-benefit healthcare program in general).

d. Describe how your company would ensure that audits are appropriate and reflective of the unique policies of the WTC Health Program (or a limited-benefit healthcare program in general). Describe how your company would ensure audits are responsive to shifts in policies, vendor transitions, changing circumstances, or emerging trends. See WTC Health Program Administrative Manual at https://www.cdc.gov/wtc/ppm.html and key Policies and Procedures at https://www.cdc.gov/wtc/policies.html.

e. Describe (1) the types of data that are necessary to conduct claims audits on limited-benefit healthcare programs; (2) how frequently each type of data is needed; (3) the systems and/or data formats that are required to obtain each data type for audits.

f. Describe the type of medical and/or pharmacy claims audits your company is able to complete without access to medical records.

g. Describe the different types of methodologies your company may use to select a sample of claims for audits.

h. Please provide any additional information that your company feels is relevant for the WTC Health Program, including any challenges faced in: (1) conducting medical and/or pharmacy claims audits as it relates to working with third-party administrators, pharmacy benefit managers, or other entities; (2) obtaining required data; or (3) reconciling data when issues are found that may impede an audit. Please also provide your company’s approaches to resolving these challenges.

i. Please provide any examples of audit reports your company believes would be of interest to the Program (examples will not be counted towards the 25-page limit).

2. The Program is interested in understanding your company’s capacity for records management and storage. Describe how your company has previously handled receiving a large volume of claims data and medical records. Describe how your company handles the storage and transfer of sensitive information. Describe how your company has accessed needed records in the past if they have not been transferred to your company.

3. Please outline your company’s approach to quality assurance processes for recurring data exports with multiple touchpoints pre- and post-processing. Please also describe how your company would interact with the source-of-truth vendor if discrepancies are identified, and how your company would approach data reconciliation.

4. The Program has an interest in identifying emerging trends in cost, utilization, and other areas. Describe how your company would approach: (1) identifying trends and proposing new methodologies for analytic topics relevant to the Program; (2) involving/collaborating with the WTC Health Program as you develop these methodologies; and (3) utilizing new evaluation and/or analytic methodologies as they emerge to ensure implementation of best practices.

5. Describe how your company leverages artificial intelligence and/or machine learning methods to support audits and/or identify notable trends, outliers, or discrepancies in medical and pharmacy claims data.

6. The population of the WTC Health Program is comprised of an aging population, with most members between 45 and 74 years of age, and no members born after 2001. Many Program members have comorbidities. Given the changing demographics of the population, describe your company’s suggestions for the evaluation of anticipated needs and services for this population.

7. The WTC Health Program has a Nationwide Provider Network that provides care to members outside of the NYMA. Some states have many members, while others have just a few. Describe your company’s suggestions for the Program’s routine monitoring and evaluation of the adequacy of the network outside of the NYMA.

8. The Program is interested in obtaining feedback from Program members and providers.

a. Describe your company’s capacity for survey development, data entry (manual or automated) of scanned handwritten (Likert-scale and open-ended response questions) survey responses, and survey analysis.

b. Describe your company’s experience with focus groups and any areas for Program awareness as the Program works towards establishing a protocol for focus groups.

9. The Program has an interest in establishing various clinical and administrative benchmarks. Describe how your company would assist the Program in developing new appropriate and tailored benchmarks, or refining existing benchmarks.

10. The WTC Health Program resolicits contracts periodically, which can result in the transition of Program vendors. Describe how your company could assist the Program with the following:

a. Ensure data from outgoing vendors is accurate and complete, and if not, identify and otherwise support data cleanup projects;

b. Quickly learn incoming vendor systems and processes to ensure alignment with industry standard, where applicable; and

c. Identify and mitigate risks during vendor transition periods.

11. Identify the level of effort and labor categories your company recommends to accomplish these services. Please delineate the level of effort for each labor category and provide high-level breakdowns. For example: Data Analyst (labor category) = 600 hours (200 hours for medical audits; 300 hours for claims audits, 100 hours for pharmacy audits) V. Instructions for Submission

1. Page limit: twenty-five (25) pages to address the questions listed in section IV. Information Requested.

2. Interested parties should respond to this RFI with a white paper by 12 PM Eastern on April 26, 2024, to Michael Baron at lpc0@cdc.gov. Please include “WTC Health Program | RFI 75D301-24-RFI-541611” in the subject line.

3. Page 1 of the white paper shall include the chart below, completed by your organization:

Company Name

Company Address

Unique Entity ID (UEI)

Primary Point of Contact Name

Primary Point of Contact Email

Primary Point of Contact Phone Number

Business Type (large business, small business, nonprofit, minority- or woman-owned, etc.)

GSA or other Federal Schedule Awards

The World Trade Center Health Program is administered by the National Institute for Occupational Safety and Health, part of the Centers for Disease Control and Prevention image1.jpeg image2.jpeg