Non-VA Medical Care 101 VHA Chief Business Office

Non-VA Medical Care 101

VHA Chief Business Office

March 2014

VETERANS HEALTH ADMINISTRATION

Agenda

• Non-VA Medical Care Program Overview• Non-VA Care Coordination (NVCC) Overview• Patient-Centered Community Care (PC3) Overview

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Overview of Non-VA Medical Care

• Non-VA Medical Care is health care VA purchases for eligible Veterans when services are not available at a VA facility– Non-VA Medical Care is an augmentation of in-house

capabilities and capacity• The program has seen considerable growth over the past 8

years– In FY13, VA purchased care for more than 1 million Veterans at

a cost of $4.81 billion even with the expansion of in-house capability

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Reasons VHA Purchases Care from Non-VA Providers

• Inability to access VA health care facilities– Demand exceeds VA health care facility capacity– Need for diagnostic support services for VA clinicians– Need for scarce specialty resources (e.g., obstetrics,

hyperbaric, burn care, oncology) and/or when VA resources are not available due to constraints (e.g. staffing, space)

• Ensure cost-effectiveness for VA– Outside procurement vs. maintaining and operating like

services in VA facilities for infrequent use• Satisfying patient wait-time requirements

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Growth of Non-VA Medical Care

POI

Fiscal Veterans Total Cost Per Year Served Disbursed UniqueFY 06 534,729 $1.798B $3,362FY 07 615,768 $2.227B $3,617FY 08 821,794 $3.029B $3,686FY 09 920,404 $3.820B $4,150FY 10 951,836 $4.438B $4,664FY 11 970,727 $4.594B $4,733FY 12 983,496 $4.490B $4,565FY 13 1,065,434 $4.811B $4,516FY14(YTD) 615,154 $1.733B $2,817Data depicted based on in-system payments made through VistA Fee

As of End of JAN 2014


FY 13 Non-VA Expenditures By Program

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Community Nursing Home, $616,761,803

Home Health Services, $686,465,947

Mill Bill $396,591,467

Preauthorized Inpt/Ancillary, $1,328,665,046

Preauthorized Otpt/Ancillary, $1,479,095,230

Unauthorized, $176,706,251

Other$126,822,276

FY 13 Fee Expenditures by Major Program Element

Total = $4,811,108,020Other= Fee Dental $48.9M, Comp & Pension $77.7M, Fee Pharmacy $.204M


Non-VA Medical Care– Strategy for the Future

• Continue to provide care to Veterans when care is not available within the VA health care system

• Develop long term solutions for all Purchased Care programs • New Healthcare Claims Processing System will consolidate all claims

processing to a single system. • Improve processes and business management for both short and long

term initiatives– Continue to improve business processes and current technology

while preparing for long term solution• Utilize national contracts to maximize economies of scale when

providing care

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Non-VA Medical Care Options

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Non-VA Care Coordination

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The Non-VA Care Coordination (NVCC) model is a system of business processes which standardize front-end business processes, improve patient care coordination, and support future state solutions within the Non-VA Medical Care program VHA-wide.


Scope of Non-VA Care Coordination

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Five major business processes are included within the scope of NVCC Non-VA Referral Review: Standardization of consults/referrals in support of future IT automation

Appointment Management: Improved customer service, coordination and Veteran provider selection/preference

Hospital Notification: Consistent model for documentation, tracking and coordination of patients in community health care facilities

Unauthorized & Emergency Care (Mill Bill) Claims Adjudication: Standardized process for adjudicating unauthorized/Mill Bill claims

Appeals Management: Standardization of process and tools used to track and facilitate appeals


Non-VA Care Coordination Approach

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• Utilizes a “train the trainer” approach to enterprise deployment– Each VISN identified a single medical center to serve as a Champion

Facility– CBO team works closely with the Champion Facilities, providing ongoing

virtual and on-site procedural and technical training and support– Champion Facility then collaborates with VISN leadership to deploy the

NVCC model to the remaining medical centers within their VISNs (sister facilities)

• Deployment time line:– November 2012: Champion Facility deployment complete– September 2103: Enterprise wide deployment complete


Measuring Success

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• A national metric plan was developed and implemented to measure the success of NVCC deployment which includes specific metrics for core benefit categories:

– Increased Operational Efficiency– Adoption of NVCC Standardized Processes– Increased Satisfaction– Enhanced Communication


Patient-Centered Community Care• The Patient-Centered Community Care (PC3) contract provides eligible Veterans

coordinated, timely access to care through a comprehensive network of non-VA providers who meet VA quality standards when VA cannot readily provide the care in-house

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Alignment With Strategic Goals

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VHA’s three strategic goals:

Provide Veterans personalized, proactive, patient-driven health care;

Achieve measureable improvements in health outcomes, and

Align resources to deliver sustained value to Veterans.

PC3 offers:

Access to care when care is not readily available within VA;

Quality, coordinated care ; and

Standardized purchasing processes, defined performance metrics, and favorable rates

http://www.va.gov/


Services Included and Not Included in PC3 ContractsThe PC3 contracts provide health care for eligible Veterans when the local VAMC cannot readily provide the services, ensuring the Veteran receives the care they need when and where they need it

– VAMCs may have a lack of available specialists or long wait times, or it is an extraordinary distance from the Veteran’s home

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• The contracts include: – Inpatient specialty care– Outpatient specialty care

– Including Skilled Home Health and Home Infusion Therapy

– Mental health care– Limited emergency care– Limited newborn care for enrolled

female Veterans after delivery

• The contracts do not include: – Primary care– Dental care– Nursing home care– Long Term Acute Care Hospitals (LTAC)– Homemaker and home health aide

services– Chronic dialysis treatments– Compensation and pension

examinations


Contract Requirements The collaboration with internal and external stakeholder groups resulted in robust contract requirements surrounding

– Network Access/Commute Time – Provider Orientation Program – Accreditation, Certification, Privileging, and Licensing– Veteran Safety and Clinical Quality– Ordering and Authorization Process– Appointment Setting and Urgent Scheduling– Continuity of Care– Coordination of Inpatient Services– Emergency Health Care – Complaints and Grievances– Pharmacy (mainly VA-provided)– DME (VA provided)– Return of Medical Documentation – Claims Processing

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For the complete contract, including these requirements,

please visithttp://pccc.hac.med.va.gov/

http://pccc.hac.med.va.gov/




Benefits

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Ensures clinical quality– Meet Medicare Conditions of Participation and Conditions for Coverage– Two clinical quality committees (oversight and peer review)– Meet federal and state regulatory requirements; may not participate in on CMS exclusionary list– Services, facilities and providers must have compliance program in alignment with HHS OIG

Compliance Program for Hospitals and USSC Sentencing Guidelines– Additional requirements for specialties, such as radiation oncology and rehabilitation medicine– All critical events reported to CO/COR within 24 hours

Efficient– Option to manage high volumes of one type of care– Contractor schedules appointment– Allows for authorization without additional contracting review

Convenient for Veteran– Appointments scheduled within five days (48 hours for urgent care) after authorization receipt– Appointments held within 30 days – Veteran seen within 20 minutes of arrival– Establishes commute times (urban – 60 – 120 minutes; rural – 120-240 minutes; highly rural 240) – Veteran receives personal contact confirming appointment and reminding of appointment– Veteran can give preference of provider gender, if needed

Decreases improper payments– Payment rates are defined by contract


Benefits, cont.

18*Region 6, Alaska, not included in these ranges

Supports care coordination– Medical documentation returned within 14 days (outpatient), 30 days (inpatient)– Must call VA with critical findings within 24 hours– All transitions of care done in coordination with VA

Standardizes processes– Contractor submits claims in standardized manner– Ensures compliance with USC Title 38– Compliments Non-VA Care Coordination (NVCC) processes– Contracting negotiates and PMO oversees contract. Local facilities do not need to negotiate own

contracts

Supports reimbursement– Return of appointment information supports review of third party payer precertification

Value– On average, the pricing for Medical and Surgical Services is 94.5 to 97.5% of Medicare and Skilled

home health will be 92 to 97% of Medicare*

Ensures contractor quality– Monitor performance against a Quality Assurance Surveillance Plan– Regular audits


Six Region PC3 Contract Coverage

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PC3 Utilization

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Total PC3 Authorizations * Trend

Health NetContract availability: VISN 2, 3, 4, 10, 11, 23

Authorization Concentrations: Optometry, Physical Therapy, and Neurology

TriWestContract availability: All facilities in Region 5 which includes VISNs 18, 20 (excl. AK), 21, and 22 Authorization Concentrations: Internal Medicine/ Gastroenterology, Podiatry and Orthopedic Surgery

*All authorization data represents authorizations created using the Vista fee package from January 2, 2014 through February 28, 2014 where the vendor tax ID matched that of the PC3 contractor. Data was extracted from the VA Corporate Data Warehouse (CDW) files on 2/28/14.

Total PC3 Authorizations Issued 6487

TriWest 4102

Health Net 2385

1/3/2014

1/8/2014

1/13/2

014

1/18/2

014

1/23/2

014

1/28/2

014

2/2/2014

2/7/2014

2/12/2014

2/17/2014

2/22/2

014

2/27/2

0140

1000200030004000500060007000

PC3

TriWestHealthnet

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Non-VA Medical Care 101 VHA Chief Business Office