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Notice

TRICARE Prime Urgent Care Demonstration Project

Document Details

Information about this document as published in the Federal Register.

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This document has been published in the Federal Register. Use the PDF linked in the document sidebar for the official electronic format.

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AGENCY:

Department of Defense.

ACTION:

Notice of demonstration.

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 Prime Urgent Care Demonstration Project. The demonstration project is intended to test whether allowing four visits to an urgent care center without requiring a referral from the Primary Care Manager (PCM) will improve access to urgent care including minor illness or injury for Active Duty Family Members enrolled in TRICARE Prime or TRICARE Prime Remote while reducing the overall costs of such care to the DoD. The Department currently has a demonstration to test this same provision for U.S. Coast Guard personnel. However, this demonstration is being conducted outside of the Coast Guard population in order to be able to evaluate the impact on ADFMs who tend to be a more mobile population than the Coast Guard members and their families. Current data indicates that the ADFMs frequently need urgent care while traveling to new duty stations for permanent orders or training and when traveling to temporary locations while a member is deployed. Under the demonstration, ADFMs who are enrolled in TRICARE Prime or TRICARE Prime Remote 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 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. The ADFMs 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, Section 199.17 (n)(3) may apply. Referral requirements for specialty care and inpatient authorizations will remain as currently required by MHS policy. At the conclusion of the demonstration, data will be analyzed to determine if use of this ability to seek urgent care without a referral is used more or less frequently by a more mobile population than a stable population in order to determine whether the overall costs to the government have decreased due to a reduced usage of emergency care facilities by this same population.

DATES:

This demonstration will be effective 60 days from the date of this notice in the Federal Register for a period of thirty-six (36) months.

ADDRESSES:

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

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FOR FURTHER INFORMATION CONTACT:

For questions pertaining to this Start Printed Page 80908demonstration project, please contact Ms. Shane Pham at (703) 681-0039.

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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 Primary Care Manager (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. Additionally for our ADFMs in transition, the Department has seen a higher incident of ER usage by this population. It appears that the difficulty in contacting the PMS while traveling or in a new location may result in the beneficiary's higher hospital ER services for care that might be suitably be obtained at an urgent care center.

In 2010, we examined the degree to which ADFMs used ERs for the top 14 medical conditions for which they sought care. We found that ADFM military treatment facility enrollees received about 7 percent of their visits from ERs while civilian prime enrollees received 4 percent of their care from emergency rooms. Because many of the top 14 conditions are acute in nature, we consider the ADFMs' use of ERs to be too high.

b. Implementation

This demonstration will be effective 60 days from the date of this notice in the Federal Register for a period of thirty-six (36) 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. The evaluation/analysis of the demonstration would use Fiscal Year 2011 as the base line with follow-up data analysis conducted at each 6-month interval throughout the 36 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.

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Dated: December 21, 2011.

Aaron Siegel,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

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[FR Doc. 2011-33065 Filed 12-23-11; 8:45 am]

BILLING CODE 5001-06-P