2011-4863. TRICARE Access to Care Demonstration Project

AGENCY:

Department of Defense.

ACTION:

Notice of demonstration project.

SUMMARY:

This notice is to advise interested parties of a Military Health System (MHS) Demonstration project under the authority of Title 10, U.S. Code, Section 1092, entitled Department of Defense TRICARE Access to Care Demonstration Project. The demonstration project is intended to improve access to urgent care including minor illness or injury for Coast Guard beneficiaries enrolled in TRICARE Prime or TRICARE Prime Remote while decreasing emergency room visits and healthcare costs. Under the demonstration, Coast Guard active duty service members (ADSMs) and their family members who are enrolled in TRICARE Prime or TRICARE Prime Remote in the South Region would be allowed to self-refer, without an authorization, to a TRICARE network provider such as an Urgent Care Clinic (UCC) or Convenience Center for up to four urgent care visits per year. No referral from their Primary Care Manager (PCM) or authorization by a Health Care Finder will be required and no Point of Service (POS) deductibles and cost shares shall apply to these four unmanaged visits. Additionally, when outside of the South region, these Coast Guard TRICARE Prime or Prime Remote enrollees may use any TRICARE authorized provider or UCC without incurring POS deductibles and cost shares. The ADSM and family member will be required to notify their PCM of any urgent/acute care visits to other than their PCM within 24 hours of the visit and schedule any follow-up treatment that might be indicated with their PCM. If more than the four (4) authorized urgent care visits are used, or if the beneficiary seeks care from a non TRICARE network or non TRICARE authorized provider, POS deductibles and cost shares as required by Title 32, Code of Federal Regulations (CFR), 199.17(n)(3) may apply. Referral requirements for specialty care and inpatient authorizations will remain as currently required by MHS policy.

DATES:

This demonstration will be effective 60 days from the date of this notice for a period of twenty-four (24) months.

ADDRESSES:

TRICARE Management Activity (TMA), Health Plan Operations, 5111 Leesburg Pike, Suite 810, Falls Church, VA 22041.

FOR FURTHER INFORMATION CONTACT:

For questions pertaining to this demonstration project, please contact Ms. Shane Pham at [phone].

SUPPLEMENTARY INFORMATION:

a. Background

Access for acute episodic primary care continues to be in high demand by TRICARE Prime beneficiaries. The current regulations require that if a Prime beneficiary seeks care from a provider other than their PCM, they must first obtain a referral. Otherwise, the care will be covered under the point-of-service option at greater out-of-pocket cost to the Prime beneficiary. This includes urgent care which TRICARE defines as medically necessary treatment for an illness or injury that would not result in further disability or death if not treated immediately but that requires professional attention within 24 hours. On the other hand, emergency care defined as a medical, maternity or psychiatric condition that would lead a “prudent layperson” (someone with average knowledge of health and medicine) to believe that a serious medical condition existed, or the absence of medical attention would result in a threat to his or her life, limb or sight and requires immediate medical treatment or which has painful symptoms requiring immediate attention to relieve suffering, does not require an authorization. Often when a Prime beneficiary needs urgent care after hours or when the PCM does not have available appointments, the Prime beneficiary will seek care from civilian sources such as emergency rooms (ER). While many Prime beneficiaries pay no out-of pocket costs for ER services, the average cost for an ER visit is much higher than an urgent care visit. In many cases, using the ER is not necessary, and a patient's condition can be treated through urgent care. However, TRICARE has found it difficult to enforce the required point-of-service charges when an ER visit was for urgent care and not a true medical emergency.

There are 25,781 Coast Guard active duty service members and their family members enrolled in TRICARE Prime in the South Region. In the South Region, beneficiary ER visits are currently averaging 197 ER visits/1,000 beneficiaries per year and that number is slowly increasing. Analysis indicates much of the care rendered in these ER visits is for acute or chronic conditions that are not true life threatening emergencies and may have been better suited for care by the PCM or in an urgent care setting.

b. Implementation

This demonstration will be effective 60 days from the date of this notice for a period of twenty-four (24) months.

c. Evaluation

The results of this Demonstration will allow a focused study of the impact of this process on: (1) The reduction of ER utilization and resulting costs, (2) assessment of the availability and accessibility of less expensive acute care services such as UCCs, (3) reduction of administrative processes, and (4) impact on Coast Guard active duty service members and their families. The evaluation/analysis of the demonstration would use Fiscal Year 2008 as the base line with follow-up data analysis conducted at each 6-month interval throughout the 24 month period to monitor of ER and TRICARE authorized UCC utilization workload and cost (claims data). Success of the demonstration would be determined by consistent shifts in health care utilization from ERs to a TRICARE authorized UCCs by 15-20%. A less than 5% shift in utilization from the ER to a TRICARE authorized UCCs would be considered insignificant.

Dated: March 1, 2011.

Morgan F. Park,

Alternate OSD Federal Register Liaison Officer, Department of Defense.