Non-VA Medical Care 101
VHA Chief Business Office
March 2014
Agenda
• Non-VA Medical Care Program Overview
• Non-VA Care Coordination (NVCC) Overview
• Patient-Centered Community Care (PC3) Overview
VETERANS HEALTH ADMINISTRATION
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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
VETERANS HEALTH ADMINISTRATION
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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
VETERANS HEALTH ADMINISTRATION
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Growth of Non-VA Medical Care
Fiscal
Year
FY 06
FY 07
FY 08
FY 09
FY 10
FY 11
FY 12
FY 13
FY14(YTD)
Veterans Total
Served Disbursed
534,729 $1.798B
615,768 $2.227B
821,794 $3.029B
920,404 $3.820B
951,836 $4.438B
970,727 $4.594B
983,496 $4.490B
1,065,434 $4.811B
615,154 $1.733B
Cost Per
Unique
$3,362
$3,617
$3,686
$4,150
$4,664
$4,733
$4,565
$4,516
$2,817
Data depicted based on in-system payments made through VistA Fee
VETERANS HEALTH ADMINISTRATION
As of End of JAN 2014
POI
FY 13 Non-VA Expenditures By Program
FY 13 Fee Expenditures by Major Program Element
Other
Unauthorized,
$126,822,276
$176,706,251
Community Nursing
Home, $616,761,803
Preauthorized
Otpt/Ancillary,
$1,479,095,230
Home Health Services,
$686,465,947
Mill Bill
$396,591,467
Preauthorized
Inpt/Ancillary,
$1,328,665,046
Total = $4,811,108,020
VETERANS
HEALTH ADMINISTRATION
Other= Fee Dental $48.9M, Comp & Pension $77.7M, Fee Pharmacy $.204M
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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
VETERANS HEALTH ADMINISTRATION
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Non-VA Medical Care Options
VETERANS HEALTH ADMINISTRATION
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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 Medical Care program VHA-wide.
VETERANS HEALTH ADMINISTRATION
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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
VETERANS HEALTH ADMINISTRATION
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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
VETERANS HEALTH ADMINISTRATION
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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
VETERANS HEALTH ADMINISTRATION
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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
VETERANS HEALTH ADMINISTRATION
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Alignment With Strategic Goals
VHA’s three strategic goals:
PC3 offers:
 Provide Veterans personalized, proactive,
patient-driven health care;
 Access to care when care is not readily
available within VA;
 Achieve measureable improvements in
health outcomes, and
 Quality, coordinated care ; and
 Align resources to deliver sustained value
to Veterans.
 Standardized purchasing processes,
defined performance metrics, and
favorable rates
VETERANS HEALTH ADMINISTRATION
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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 or long 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
VETERANS HEALTH ADMINISTRATION
•
The contracts do not include:
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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
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Contract Requirements
The collaboration with internal and external stakeholder groups resulted in robust contract
requirements surrounding
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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
VETERANS HEALTH ADMINISTRATION
For the complete contract,
including these requirements,
please visit
http://pccc.hac.med.va.gov/
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Benefits
Ensures clinical quality
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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
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Option to manage high volumes of one type of care
Contractor schedules appointment
Allows for authorization without additional contracting review
Convenient for Veteran
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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
VETERANS HEALTH ADMINISTRATION
– Payment rates are defined by contract
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Benefits, cont.
Supports care coordination
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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
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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
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Return of appointment information supports review of third party payer precertification
Value
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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
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Monitor performance against a Quality Assurance Surveillance Plan
Regular audits
*Region 6, Alaska, not included in these ranges
VETERANS HEALTH ADMINISTRATION
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Six Region PC3 Contract Coverage
VETERANS HEALTH ADMINISTRATION
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PC3 Utilization
Total PC3 Authorizations *
Trend
Total PC3 Authorizations Issued
6487
TriWest
4102
Health Net
2385
7000
6000
5000
4000
3000
2000
1000
0
PC3
TriWest
Healthnet
Health Net
TriWest
Contract availability: VISN 2, 3, 4, 10, 11, 23
Contract availability: All facilities in Region 5 which
includes VISNs 18, 20 (excl. AK), 21, and 22
Authorization Concentrations: Optometry, Physical
Therapy, and Neurology
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
VETERANS HEALTH ADMINISTRATION
tax ID matched that of the PC3 contractor. Data was extracted from the VA Corporate Data Warehouse (CDW) files on 2/28/14.
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