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NEWS | April 15, 2021

Projects Test New Approaches to Improve Health Care Quality, Outcomes

By MHS Communications

TRICARE has more than a half-dozen pilots and demonstration projects underway that offer new and innovative medical services, treatments, and approaches, and that have the potential to become part of its permanent health care coverage.
“Many of these pilots are value-based initiatives that seek to reward better health outcomes, enhance beneficiary care experiences, and reduce health care costs over time,” said TRICARE Health Plan Deputy Director Curt Prichard. “These include projects for autism care, sexual trauma, and low back pain. These pilots and demonstrations are also looking to improve care through nurse navigators, a referral and appointing center and accountable care organization to make medical care easier for TRICARE beneficiaries.”

Air Force Lt. Col. Donald “Del” Lofton, chief, TRICARE Optimization said: “The use of these pilots and demonstrations allows TRICARE to develop and test innovative approaches and services with the broader TRICARE beneficiary population as well as specific services to targeted groups. The goal is always to provide the most effective, high-quality, value-based health care while seeking to improve the overall health care experience for both beneficiaries and those who provide them care.”

Here's a look at eight initiatives underway:

Comprehensive Autism Care Demonstration

The Department of Defense’s Comprehensive Autism Care demonstration provides reimbursement from TRICARE for applied behavior analysis (ABA) services for beneficiaries diagnosed with autism-spectrum disorder.
Its major goals are to analyze, evaluate, and compare the quality, convenience, efficiency, and cost-effectiveness of ABA services that have not been shown to be proven medical care and are not covered by TRICARE. The pilot, which covers a wide range of TRICARE beneficiaries, began in July 2014 and is scheduled to conclude at the end of 2023.

Sexual Trauma Intensive Outpatient Program Pilot

The Intensive Outpatient Program pilot for sexual trauma aims to treat psychological behavioral health effects of that trauma in active-duty service members (ADSMs) through partnership with public, private, and non-profit organizations in seven locations in the United States.

The pilot is focused on treating ADSMs suffering from post-traumatic stress disorder and other psychological conditions associated with sexual trauma, and determining the feasibility and advisability of using such programs by measuring outcomes and sharing lessons learned. The pilot began last September and is slated to conclude Aug. 31.

TRICARE Select Navigator Pilot

The TRICARE Select Navigator pilot is designed to assess whether providing eligible beneficiaries with one-on-one assistance from nurses identified as health care “navigators” improves health outcomes and the patient experience for those with complex medical conditions.

Those eligible for the pilot must be enrolled in TRICARE Select and have two or more medical conditions requiring coordination of specialties or at least $100,000 in claims per year.
This assistance could lead to reduced use of unnecessary emergency room or urgent care visits due to a beneficiary’s lack of understanding of their options. The pilot also will determine the feasibility of incorporating nurse navigators in available support contracts. The pilot is expected to conclude March 31, 2023.

Low Back Pain and Physical Therapy Demonstration

Another demonstration project deals with physical therapy (PT) for lower back pain (LBP). The purpose is to evaluate whether waiving cost-sharing for up to three PT visits increases TRICARE beneficiary use of PT, decreases low-value care, and/or decreases the overall cost of care for treating patients with LBP. The demonstration, available in 10 states, runs through Dec. 31, 2023.

Referral and Appointing Center Pilot

The Referral and Appointing Center (RAC) pilot will create a RAC at one pilot site that will receive all TRICARE Prime A managed care option available in Prime Service Areas in the United States; you have an assigned primary care manager who provides most of your care. TRICARE Prime referrals written by military medical treatment facility providers in the area. It will determine whether the specialty care will be provided at a Direct Care Direct care refers to military hospitals and clinics, also known as “military treatment facilities” and “MTFs.” direct care facility or will be referred to the TRICARE network. The goal is to determine if using RACs simplifies and improves the process of receiving referrals for specialty care and making appointments for members enrolled in TRICARE Prime.

Accountable Care Organization Demonstration

The Accountable Care Organization (ACO) demonstration offers beneficiaries eligible for TRICARE Prime and TRICARE Select Starting on January 1, 2018, TRICARE Select replaces TRICARE Standard and Extra. TRICARE Select is a self-managed, preferred provider network plan. TRICARE Select is a fee-for-service option in the United States that allows you to get care from any TRICARE-authorized provider.  Enrollment is required to participate. TRICARE Select in the Atlanta metro area the chance to enroll in Kaiser Permanente, a TRICARE Prime option. The demonstration is testing the hypothesis that an integrated delivery model will result in higher levels of efficiency, care effectiveness, and beneficiary satisfaction. The demonstration continues through Dec. 31, 2022.

Buckley Prime Service Area Pilot

Another value-based care-driven pilot is in the Buckley Air Force Base, Colorado, Prime service area. Under this population-based capitation pilot, the regional contractor for this region, Health Net Federal, will provide dedicated, concierge-type service and support to network-enrolled TRICARE Prime beneficiaries in the Denver area. The regional contractor also will target improved quality of care, better experience, and increased satisfaction for both the beneficiaries and providers in the pilot. The goal of the pilot is to determine the effectiveness of a value-based payment model approach versus the current predominantly discounted fee-for-service payment model.

The final demonstration project is the Defense Health Agency's evaluation of non-Food and Drug Administration-approved laboratory-developed tests (LDTs).

According to regulation, DHA may not cost-share LDTs that are not approved by the FDA under its "substantial equivalence" rules. The goal is to improve the quality of health care services for rare diseases by evaluating the feasibility for DOD review of non-FDA approved LDTs to see if they meet TRICARE requirements for safety and efficacy to become a covered benefit under the demonstration.

The demonstration also extends coverage for cystic fibrosis preconception and prenatal carrier screening when provided in accordance with guidelines.

Referral and Appointing Center Pilot

The Referral and Appointing Center (RAC) pilot will create a RAC at one pilot site that will receive all TRICARE Prime referrals written by military medical treatment facility providers in the area. It will determine whether the specialty care will be provided at a direct care facility or will be referred to the TRICARE network. The goal is to determine if using RACs simplifies and improves the process of receiving referrals for specialty care and making appointments for members enrolled in TRICARE Prime.

Photo credit: Deidre Smith, Navy Medicine Readiness and Training Command Jacksonville
Cutline: Health Benefits Advisor Charlene Johnson (left) talks with a retiree in the TRICARE Operations Department at Naval Hospital Jacksonville Nov. 24, 2020.

Accountable Care Organization Demonstration

The Accountable Care Organization (ACO) demonstration offers beneficiaries eligible for TRICARE Prime and TRICARE Select in the Atlanta metro area the chance to enroll in Kaiser Permanente, a TRICARE Prime option. The demonstration is testing the hypothesis that an integrated delivery model will result in higher levels of efficiency, care effectiveness, and beneficiary satisfaction. The demonstration continues through Dec. 31, 2022.

Buckley Prime Service Area Pilot

Another value-based care-driven pilot is in the Buckley Air Force Base, Colorado, Prime service area. Under this population-based capitation pilot, the regional contractor for this region, HealthNet Federal, will provide dedicated, concierge-type service and support to network-enrolled TRICARE Prime beneficiaries in the Denver area. The regional contractor also will target improved quality of care, better experience, and increased satisfaction for both the beneficiaries and providers in the pilot. The goal of the pilot is to determine the effectiveness of a value-based payment model approach versus the current predominantly discounted fee-for-service payment model.

Non-Food and Drug Administration-approved laboratory-developed tests

The final demonstration project is the Defense Health Agency’s evaluation of non-Food and Drug Administration-approved laboratory-developed tests (LDTs).
According to regulation, DHA may not cost-share LDTs that are not approved by the FDA under its “substantial equivalence” rules. The goal is to improve the quality of health care services for rare diseases by evaluating the feasibility for DOD review of non-FDA approved LDTs to see if they meet TRICARE requirements for safety and efficacy to become a covered benefit under the demonstration.
The demonstration also extends coverage for cystic fibrosis preconception and prenatal carrier screening when provided in accordance with guidelines.
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