Non-VA Medical Care 101 VHA Chief Business Office

1. Non-VA Medical Care 101 VHA Chief Business Office March2014

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

3. 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

4. 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

5. Growth of Non-VA Medical Care Fiscal Veterans Total Cost Per YearServedDisbursedUnique FY 06 534,729$1.798B $3,362 FY 07 615,768$2.227B $3,617 FY 08 821,794$3.029B $3,686 FY 09 920,404$3.820B $4,150 FY 10 951,836 $4.438B $4,664 FY 11970,727$4.594B $4,733 FY 12 983,496 $4.490B $4,565 FY 13 1,065,434 $4.811B $4,516 FY14(YTD) 615,154 $1.733B $2,817 Data depicted based on in-system payments made through VistA Fee As of End of JAN 2014

6. FY 13 Non-VA Expenditures By Program

7. 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

8. Non-VA Medical Care Options

9. Non-VA Care Coordination 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 MedicalCare program VHA-wide.

10. Scope of Non-VA Care Coordination • 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

11. Non-VA Care Coordination Approach • 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

12. Measuring Success • 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

13. 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

14. Alignment With Strategic Goals • 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 • 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.

15. Services Included and Not Included in PC3 Contracts The 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 orlong wait times, or it is an extraordinary distance from the Veteran’s home • 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

16. 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 For the complete contract, including these requirements, please visit http://pccc.hac.med.va.gov/

17. Benefits • 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

18. Benefits, cont. • 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 *Region 6, Alaska, not included in these ranges

19. Six Region PC3 Contract Coverage

21. PC3 Utilization Total PC3 Authorizations * Trend • Health Net • Contract availability: VISN 2, 3, 4, 10, 11, 23 • Authorization Concentrations: Optometry, Physical Therapy, and Neurology • TriWest • Contract 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.