TRICARE Brief

TRICARE Briefing to Navy Medicine Flag Officers

October 6, 2009

RADM C.S. Hunter, MC, USNDeputy Director

TRICARE Management Activity

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TRICARE Overview

• 9.5 million beneficiaries eligible to use TRICARE as a health plan– 3.5 million TRICARE Prime enrollees (MTFs and clinics)

949,711 enrollees at Navy Facilities

– 1.5 million TRICARE Prime enrollees (contractor networks)499,308 DON enrollees in the contractor networks

– 1.8 million TRICARE for Life– Others are TRICARE Standard or TRICARE Reserve Select– Purchased care managed through regional contracts (North, South, West)– Retail and mail order pharmacy managed separately via Express Scripts

• MTFs – 63 hospitals & medical centers, and 414 health clinics

• 347,673 individual network providers

• Selected volume indicators per week– 2.48 million prescriptions – 2,380 births – 1.6 million outpatient visits

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TRICARE Management Activity Near-Term Priorities

• New Domestic and Overseas TRICARE Contract Implementation

• Support to Wounded Warriors and Families

• Improving Access to Care

• Defining/Refining Medical Home Model

• Enhancing Health IT and Knowledge Management

• Ensuring Cost-Effectiveness

• Co-Locating Medical Headquarters under BRAC

Ready – Responsive – Reliable

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“T-3” Managed Care Support Contracts

• New Managed Care Support Contractors Selected– Awards announced on July 13, 2009– Awardees: Aetna, United Health, TriWest– Protests – Resolution Nov. 1?– Minimum 10-month transition period – Current contractors provide care in interim

• Total $55 billion over five years, with annual option periods

• No significant change in covered services

• Improved focus on preventive health, case management, quality outcomes, coordination of care, and consistent communication

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TMA Deputy Director’s “Top 10” Focus Areas to Ensure a Smooth Transition

1. TRICARE Prime Availability – “Prime Service Areas”

2. Wounded Warrior Programs

3. Continuity of Care

4. National Guard/Reserve

5. Clinical Support Agreements and External Resource Sharing Agreements

6. Information Security

7. Claims Processing

8. Provider Relations

9. Health Information Exchange

10. Simultaneous Transition of Overseas Contract

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Global Coverage for All Beneficiaries

TRICARE Overseas Contract

• 3 TRICARE Overseas Regions: Latin America-Canada, Eurasia-Africa, Pacific

• 432,061 beneficiaries living overseas

• Patients receive primary care at MTFs, specialty care available in host nation

• 6 current contracts covering enrollment, claims, medical care, dental care, and emergency care in remote areas (TGRO)

• New contract assumes all functions, plus responsibility for host nation provider relations, and some MEDEVAC functions

• Anticipated announcement of vendor: Fall 2010

• Approximately a 10-month transition

• Transition Risks– Coordination of 6 contracts transitioning out– One vendor for global coverage– Change in customary business practices in Pacific

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Our Ultimate Goal

• Readiness• Pre- and Post-deployment• Family Health • Behavioral Health • Professional Competency/Currency

• Quality OutcomesHealthy service members, families, and retirees

• A Positive Patient ExperiencePatient- and Family-centered Care, Access, Satisfaction

• CostResponsibly Managed

Readiness

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Access is Complex• Parking• MTF Age• Traffic / Drive Time• Hours of Operation

Follow-UpAppointment

TRICARE Service Center

EnrolleesMCSC Prime

UCC

TRICARE Network

• Call Back• Busy System• Dropped from Queue• MTF Doesn’t Return Call• No Apts on TOL

Patient Appointment SystemTraining Service

TRICAREOn-Line

Front Desk

NA / LPN / RN

LAB

RAD

MedicalTreatmentFacility

PCSingRelocation

EnrolleeTo

MCSC

Seek Care

Bounce Out

Provider Cap

Enrolls toProviderCap

Referrals

30% Not ActivatedReferrals

PCM Provider

Pharmacy

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Military Medical Home

Patientis the center

of theMedical Home

Population Health

Patient-Centered Care

Refocused Medical Training

Patient & Physician Feedback

Advanced IT Systems

Access to Care

Team-Based Healthcare

Delivery

Decision Support Tools

Model adapted from the NNMC Medical Home

Medical Home Model

• Medical Home Model Emphasizes: – Access– Continuity– Coordination of Care– Comprehensiveness – Preventive Care– Disease Management

• Enhances Beneficiary’s Relationship with Provider

• Includes Principles of: – Patient- and Family-Centered Care

(Navy)– Enhanced Access (Army WTU)– Competency and Currency (AF FHI)

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Navy: Shifting the Model

Philosophy Model How to Resource Incentives

Help people when they need help

Episodic care – manage trade-offs between cost, quality and access

HistoricFee for services (RVUs/RWPs)

Help people stay healthy

Continuous support for the health of a population – Readiness plus the Triple Aim

Based on needs of population served

Performance based budgeting

NewApproach

CurrentApproach

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Navy: Population Based Business Planning

• Determine population to be managed

• Set up patient- and family-centered primary care and optimize performance around:

• Generate RVU and RWP “revenue” by keeping specialists and IP busy with both enrollee and space available workload (Standard/Extra or other people’s Prime)

• Challenge – choosing the right measures of success

Enrollment/Provider

Accessto Care

Satisfaction HEDISER

VisitsContinuity Readiness

Production of RVUs and RWPs

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Embrace Emerging Opportunities

• How can we utilize T-3 in support of the MTF Medical Home?

• How can we incentivize Medical Home style practices for the 1.5 million network enrollees?

• How do we align business planning and financial incentives with Medical Home goals?

• How do we synchronize efforts at the MTF-network interface?

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Shaping T-3 Implementationto Support the Medical Home

• Enhanced disease & case management

• More emphasis on prevention

• More access to data for managing a patient population – Health information exchange for claims and encounters

• Opportunities for enhancements– Urgent care capability

– Novel arrangements to encourage surge capability and maintain continuity of care

– Innovative after-hours care

• Enhancing bi-directional provider communication

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Business Planning at the MTF-Network Interface

1. Redefining reimbursement and workload− Enrollment accountability, partial capitation

2. Focus on improving health− Healthcare Effectiveness Data and Information Set (HEDIS)

3. Implementing best practices− Quality, Safety, Disease Management, embedded behavioral health

4. Blended team to anchor for continuity− Access, Utilization, Reducing no shows and ER visits

5. Care is rewarding to patient and healthcare teams− Satisfaction, Retention, Staff turnover

6. Synchronize direction and incentives for TRO/MTF/ Regional Commander

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Partnering for Capacity Planning NH Bremerton

Military Treatment Facility

MTFEnrollment

Capacity1

NetworkEnrollment

Capacity2

Combined MTF and NetworkEnrollment

Capacity

MTF

Enrollment3Network

Enrollment4Combined MTF

and NetworkEnrollment

MTF and Network

Availability(or Excess)

NH BREMERTON 26,287 11,150 37,437 30,828 6,058 36,886 551

FY2010 Projection5,6 33,500 11,150 44,650 34,750 6,058 40,808 3,842

MTF and Network Enrollment Availability (or Excess)

• Primary Care: Abundance of PCMs in this PSA

• Specialty Care

− There are no shortfalls− Behavioral Health Medicine Management wait currently 30-45 days (community

standard); additional capacity with Tele-BH program− Only two endocrinologists in the area, one outside drive-time standard (by approx.

25 miles) to Gig Harbor− Targeting additional pediatric OT due to high demand; Harrison Hospital (seven

miles away) and Holly Ridge (two miles away, children up to 3) available − Everett Naval Station reporting difficulty accessing OB/GYN; list of providers

accepting new patients for maternity given to MTF at Sep 9 PSAEC meeting− Four urgent care centers located within 30-minute drive time of NHB

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NH Camp Pendleton

Military Treatment Facility

MTFEnrollment

Capacity1

NetworkEnrollment

Capacity2

Combined MTF and NetworkEnrollment

Capacity

MTF

Enrollment3Network

Enrollment4Combined MTF

and NetworkEnrollment

MTF and Network

Availability(or Excess)

NH CAMP PENDLETON 45,930 125,000 170,930 39,979 30,122 70,101 100,829

FY2010 Projection5,6 43,500 125,000 168,500 43,357 30,122 73,479 95,021

MTF and Network Enrollment Availability (or Excess)

• Primary Care: Abundance of PCMs in this PSA

• Specialty Care

− There is an abundance of specialty providers for this PSA; there are no access to care issues

− There are six urgent care centers in the PSA

Partnering for Capacity Planning

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NH Camp Lejeune

• Primary Care

− Current Excess PCM Capacity: 37,700 enrollees

− Sufficient network PCM capacity

• Specialty Care

− Surgical Specialty providers insufficient in PSA

− However, network providers are available in surrounding areas, particularly Wilmington


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• Primary Care: Civilian network enrolled to 18% capacity

− 120 PCMS contracted within 20 miles of Naval Hospital Pensacola

− Network has ability to enroll 29,181 additional beneficiaries

− PCM Overflow: Not utilized

• Specialty Care: All specialty care available

• Report includes 0038-NH Pensacola, 0260-NBHC NAS Pensacola, 0262-NBHC NATTC Pensacola & 0513-NBHC NTTC Pensacola

NH Pensacola


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• Primary Care: Civilian network enrolled to 20% capacity

− 333 PCMS contracted within 20 miles of Naval Hospital Jacksonville

− Network has ability to enroll 103,907 additional beneficiaries

− PCM Overflow: Not utilized

• Specialty Care: All specialty care available

• Report includes 0039-NH Jacksonville & 0266-NBHC NAS Jacksonville

NH Jacksonville


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• Agree on common goals for MCSC enrolled and MTF enrolled

• Select up to six sites to pilot new methodologies during FY10

– Refine methods for measurement

– Look at alternate reimbursement schemes and periodic performance review

• Use this method to revise FY11 planning guidance

Next Steps

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• Posing strategic questions:

– Alternate delivery and finance models

– Opportunity for federal partnerships

– Individual choice and financial responsibility

– Need for global coverage and products for diverse populations

– Rapid adoption of best practices, knowledge management

– Advances in science and technology, individualized medicine

– Scope of benefit

• Ensuring we maintain:

– Patient- and family-centered care ethics

– Robust direct care system for force projection

– Coordination of care for individual and family readiness

– Focus on health rather than health care

– Stakeholder enfranchisement

Health System Design for the Long-Term “T-4 Study Group”

Documents

TRICARE Brief