TRICARE: 2017 and Beyond!

MG Richard Thomas, Director, Healthcare Operations and

Chief Medical Officer, DHA

Ms. Mary Kaye Justis, SESDirector, TRICARE Health Plan

Disclosures

• The presenter has no financial relationships to disclose.

• This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS.

• Neither PESG,AMSUS, nor any accrediting organization support or endorse any product or service mentioned in this activity.

• PESG and AMSUS staff has no financial interest to disclose.

• Commercial support was not received for this activity.

Learning Objectives:

At the conclusion of this activity, the participant will be able to:

1.Learn about the key changes in the TRICARE 2017contract

2.Learn about some of the reform initiatives that are part of the FY 2016 NDAA

3.Learn about TRICARE initiatives on mental health parity and Extended Care Health Option (ECHO) Expansion

4.Gain a better understanding of the TRICARE Program

History of TRICARE – Program Development

Civilian Health & Medical Program of the

Uniformed Services(CHAMPUS)

CHAMPUS Reform Initiative

Birth of 1st TRICARE Region

TRICARE Prime enrollment portable across Regions;TRICARE Management Activity;

Retiree Dental Program

TRICARE Retail Pharmacy Program;

Regions Consolidated

TRICARE Mail Order Pharmacy; TRICARE Global

Remote OverseasTRICARE For Life;TRICARE Senior Pharmacy;

Dental Program TRICARE Reserve Select; Extended Care Health Option

TRICARE Overseas Program; TRICARE Retired Reserve

Birth of Medicareand Medicaid

3 Domestic Regions & 1 Overseas Region

2004

12 Domestic Regions & 3 Overseas Regions

1965 1995 1999 2001 2003 2005 200720062004200220001997/981988/921967 20102008/09 2011

TRICARE Young Adult

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Who We Are:

• 151,785 personnel (84,564 military / 67,221 civilians)

• 55 Inpatient hospitals and medical centers

• 373 Ambulatory care clinics

• 264 Dental clinics

• 253 Vet clinics

• 550,194 Network providers

• 3,812 TRICARE network acute care hospitals

• 1,757 Behavioral health facilities

• 59,670 Contracted (network) retail pharmacies

Who We Serve: 9.5 M Beneficiaries

• 5.0 M TRICARE Prime

• 3.7 M in direct care

• 1.3 M in contractor networks

• 2.3 M TRICARE Standard/Extra

• 2.0 M TRICARE For Life *FY 2015 TRICARE Annual Report

The Military Health System*:Who We Are and Who We Serve

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TRICARE & TRICARE Transformation

• TRICARE Prime

• TRICARE Standard 

• TRICARE Extra

• TRICARE Overseas 

• TRICARE For Life

• TRICARE Reserve Select

• TRICARE Retired Reserve

• TRICARE Young Adult

• TRICARE Pharmacy

• TRICARE Dental Plans

• Optimize purchased care contracts• Align incentives with health outcomes• Change how we "buy care" • Standardize definitions and metrics• Tricare Regional Office (TRO) governance• Data sharing• eMSM best practices• Emerging Technologies and Treatment (ET2)• Referral Management Reform (RMR)

• Optimize purchased care contracts• Align incentives with health outcomes• Change how we "buy care" • Standardize definitions and metrics• Tricare Regional Office (TRO) governance• Data sharing• eMSM best practices• Emerging Technologies and Treatment (ET2)• Referral Management Reform (RMR)

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Key Changes in Managed CareSupport Contracts (T-2017)

Goal: Modernize and Sustain the Benefit while Preparing for the Future and taking into account the dynamic changes in healthcare such as the ACA, EHR and PCMH

Two RegionsImproved Efficiency / Automation: •Electronic data system for the Medical Management/Utilization Management program that will offer real time access, reporting and information•Encourages electronic claims processing•Electronic Delivery of beneficiary notifications and education•Contractors must connect to Government Referral Management System and health information exchanges (HIEs)•Align Call Centers with Best Practices

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Key Changes in Managed CareSupport Contracts (T-2017)

Enhanced Quality:•Revisions made to the clinical quality and patient safety requirements based on MHS review •Improved disease management, case management and advanced analytics

Increased Integration between Purchased and Direct Care:•Provider agreements to include communication with MTFs•Increased engagement with eMSMs (Care Coordination Manager at each eMSM

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TRICARE Initiatives – FY 2016 NDAA

• Access to care for Prime beneficiaries

• Waiver of recoupment of erroneous payments

• Portability of TRICARE Prime coverage

• Pilot program on urgent care visits

• Pilot program on incentive programs (value based contracting)

• Plan to improve experience with and eliminate performance variability (Purchased Care)

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TRICARE Initiatives – Mental Health Parity

• Eliminates any differential in cost-sharing between mental health and substance use disorder (SUD) benefits and medical/surgical benefits:o Reduce outpatient mental health copayments for Non Active Duty Dependents (NADD) under TRICARE Prime 

from $25 per visit to $12 per visit for individual visits from $17 per visit to $12 per visit for group visits 

o Reduce Retiree and NADD Prime per diem for PHP from $40 inpatient rate billed to outpatient rate of $12 per day 

o Reduce Active Duty Family Member (ADFM) Extra/Standard cost sharing for inpatient mental health from a $20 per day to $18/day (medical/surgical)

While the Mental Health Parity Act of 1996, Mental Health Parity Addiction Equity Act (MHPAEA) of 2008, and plan benefit provisions contained in the Patient Protection and Affordable Care Act do not apply to the TRICARE program, DoD fully supports the principle of mental health parity; aligning the TRICARE benefit with Mental Health Parity is one of the President’s MH Executive Actions (Aug 2014)

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TRICARE Initiatives – TRICARE Extended Care Health Option (ECHO) Expansion*• Identify Gaps in ECHO Provided Services

o Survey being developed on EFMP, ECHO and institutional care• Evaluate increasing respite care and providing incontinence supplies

o Proposed rule to decouple respite care with another ECHO benefit is in coordinationo Incontinence supply coverage  for those ECHO enrolled beneficiaries over age 3 started Oct 1, 2015

• Conduct an Investigation into Requirements for Providing Custodial Careo High level cost analysis performed but need survey results to determine ECHO expansion  to incorporate custodial care, consumer-directed care or other Medicaid Home and Community Based Services

• Identify Services Provided under State Medicaid for Utility for our Populationo Survey will be used to identify gaps in care so TRICARE does not expend unnecessary resources for services that would not be useful or valued by ECHO beneficiaries

• Identify Requirements and Costs Associated with Consumer Directed Care Program

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*Military Compensation and Retirement Modernization Commission (MCRMC) Recommendations

The“ Why”

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Questions?

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History of TRICARE – Major Statutory Enhancements to the TRICARE Benefit since 1995

• Active Duty & Their Familieso Introduced TRICARE Prime Remote for service members and their families o Eliminated all Prime cost-sharing for care delivered to AD Family Members by civilian providers o Added TRICARE Reserve Select for activated Guard and Reserve members and their families; expanded in NDAA for FY 06 and 07

o Prime travel benefito Extended Care Health Option for family members

• Retirees & Familieso Reduced catastrophic cap for retirees under age 65 in TRICARE Standard from $7,500 to $3,000o Introduced a civilian network prescription drug benefit for Medicare-eligible beneficiarieso Introduced TRICARE For Life, which established TRICARE as a second payer to Medicare for dual-eligible beneficiaries

o Prime travel benefit

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TRICARE Today - TRICARE Family of Plans

• TRICARE Prime• TRICARE Standard • TRICARE Extra• TRICARE Overseas • TRICARE For Life• TRICARE Reserve Select• TRICARE Retired Reserve• TRICARE Young Adult• TRICARE Pharmacy• TRICARE Dental Plans

Serving 9.5 million beneficiaries•1.41 Active Duty•1.91 Active Duty Family Members•5.37 Retirees & Family Members•0.85 Guard/Reserve & Family Members

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TRICARE Today – A Week in the Life of TRICARE

• 2.47M prescriptions– 882,000 direct care– 616,000 retail pharmacy– 98,000 home delivery– 876,000 TFL 

• 94,000 behavioral health outpatient visits– 60,000 direct care– 34,000 purchased care

• 74,000 emergency room visits– 27,000 direct care– 47,000 purchased care

• 20,000 inpatient admissions– 4,900 direct care– 15,100 purchased care

• 1.818M outpatient visits – 744,000 direct care – 1,074,000 purchased care

• 2,360 births– 960 direct care– 1,400 purchased care

• 5.2M claims processed

based on FY 2014 data

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MHS Spending Over Time

Includes Normal Cost contributions to the Medicare Eligible Retiree Health Care Fund (MERHCF)

Military Health System Expenditures

Drivers of Healthcare Costs•Health care inflation (5.7% projected between 2013-23)•Demographics (age, lifestyle, chronic conditions)•Emerging (and often expensive) new treatments

Drivers of Healthcare Savings•Standardization across the enterprise•Optimization of direct care system•Integration across direct and purchased care systems•Health of the Force

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MHS Quadruple Aim and Supporting Lines of Effort

1. Eliminate unnecessary duplication of effort, inefficiency and suboptimal performance by modernizing enterprise management

2. Continually improve medical capabilities and capacity to provide contemporary health care

3. Ensure that a ready medical force is balanced to meet Combatant Commanders’ requirements

4. Develop and support strategic partnerships

5.  Reform the Tricare Benefit program to ensure the program’s long term viability

6. Better define and develop the MHS core resources and competencies needed to support Global Health Engagement

18 “Medically Ready Force…Ready Medical Force”

Multi-Service Markets

The Eight Largest Markets (and Service/Department Leads)

= eMSM

= Single Service

National Capital Region (DHA)

Tidewater, Virginia (Navy)

Ft. Bragg (Army)

San Antonio, Texas (rotate Air Force/Army)

Oahu, Hawaii (Army)

San Diego (Navy)

Puget Sound, Washington (Army)

Colorado Springs, Colorado (rotate Air Force/Army)

19 “Medically Ready Force…Ready Medical Force”

Obtaining CME/CE Credit

If you would like to receive continuing education credit for this activity, please visit:  

http://amsus.cds.pesgce.com