0. Non-VA Medical Care 101 VHA Chief Business Office
March 2014

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

2. Overview of Non-VA Medical Care
Insert date on slide master
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

3. Reasons VHA Purchases Care from Non-VA Providers
Insert date on slide master
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

4. Growth of Non-VA Medical Care
Fiscal Veterans Total Cost Per
Year Served Disbursed Unique
FY ,729 $1.798B $3,362
FY ,768 $2.227B $3,617
FY ,794 $3.029B $3,686
FY ,404 $3.820B $4,150
FY ,836 $4.438B $4,664
FY ,727 $4.594B $4,733
FY ,496 $4.490B $4,565
FY ,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

5. FY 13 Non-VA Expenditures By Program

6. 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

7. Non-VA Medical Care Options

8. 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.

9. 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

10. 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

11. 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

12. 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
To start, PC3 is a nationwide program that offers health care contracts to give eligible Veterans access to coordinated, timely, and quality health care.  

13. Alignment With Strategic Goals
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.
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 has 3 strategic goals set by Under Secretary of Health, Dr. Petzel. PC3 aligns to these goals by offering access to quality, coordinated care.

14. 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:
The contracts do not include:
Inpatient specialty care
Primary care
Outpatient specialty care
Dental care
Including Skilled Home Health and Home Infusion Therapy
Nursing home care
Long Term Acute Care Hospitals (LTAC)
Mental health care
Homemaker and home health aide services
Limited emergency care
Limited newborn care for enrolled female Veterans after delivery
Chronic dialysis treatments
Compensation and pension examinations
The Denver Acquisition and Logistics Center awarded the PC3 contracts in early September to Health Net and TriWest.
The contracts are options for VA Medical Centers to use when a Veteran needs specialty care that is not available in house, at other VA Medical Centers, through sharing agreements or with Academic Affiliates.
PC3 is also an option if wait times for specialty care are too long or the site of care is too far away from a Veteran’s home.
These contracts offer inpatient and outpatient specialty care (including skilled home health and home infusion therapy), mental health care, limited emergency care and limited newborn care for enrolled female Veterans’ after the birth of a child.
We did not incorporate primary care for inclusion into the contract because Primary care is considered a core competency of VHA.
There are other types of care that are not included in the contracts for various reasons or because they are already covered by other contracts, such as dialysis.

15. 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
In the process of developing the contract requirements, many internal and external stakeholder groups were consulted. The collaboration resulted in an extensive set of requirements. Some of them are listed here.

16. Benefits Ensures clinical quality Efficient Convenient for Veteran
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 – 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
The contract requirements led to a contract vehicle that offers benefits real for Veterans and the VA.
First and foremost, the contract requirements ensure the care Veterans receive meets VA-established quality requirements. We also have two committees per contract to ensure clinical quality – one for oversight and one that conducts peer reviews.
It is efficient for the VA Medical Centers. It provides an option to manage high volumes of one type of care. The contractors will be setting the appointments. And PC3 authorizations over $10,000 do not require additional contracting review.
It’s convenient for the Veterans, with appointments set and held in a timely manner and held within established commute distances.
And it will help decrease improper payments, as rates are defined by the contract

17. Benefits, cont. Supports care coordination Standardizes processes
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
Medical documentation is returned in a timely manner, supporting VA’s care coordination role.
It helps us standardize our processes across the VA Medical Centers.
Reimbursement is supported by the contractor providing appointment information back to the VAMC.
The pricing is competitive, providing VA great value for the care we buy through this contract.
And the PMO will help ensure contractor quality through monitoring performance against specific goals and conducting regular audits.
*Region 6, Alaska, not included in these ranges

18. Six Region PC3 Contract Coverage
Here is the map of the PC3 regions. The regional model helps with centralized management and oversight of the contracts and leverages contractor’s networks where the contractor is the strongest.
Health Net serves:
Region 1 which includes VISNs 1, 2, 3, 4
Region 2 which includes VISNs 5, 6, 7, 8
Region 4 which includes VISNs 10, 11, 12, 19, 23
TriWest serves:
Region 3 which includes VISNs 9 , 15, 16, 17
Region 5 A which includes VISNs 18, 22, 20 (excluding Alaska ), 21 (excluding Hawaii and Pacific Islands and Philippines*)
Region 5 B  which includes VISN 21 – Hawaii and Pacific Islands
Region 6 which includes VISN 20 – Alaska 
The Philippines are not covered by PC3 contracts

20. PC3 Utilization Total PC3 Authorizations * Trend Health Net TriWest
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
Total PC3 Authorizations Issued
6487
TriWest
4102
Health Net
2385
*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.