Inactive

The Defense Health Agency (DHA) seeks information about the methods DHA may use to perform clinical quality management activities for healthcare it provides both in its own military medical treatment ... The Defense Health Agency (DHA) seeks information about the methods DHA may use to perform clinical quality management activities for healthcare it provides both in its own military medical treatment facilities (MTFs) and that it purchases in the private sector. To accomplish the goal of ensuring the provision of the highest quality healthcare possible for all Military Health System (MHS) beneficiaries, DHA continually seeks to improve how it administers its quality oversight program to obtain maximum impact and value to taxpayers. In particular, DHA seeks comments regarding which approaches it should consider to assess various aspects of clinical quality. DHA will consider approaches that the public identifies would best achieve the goals of the MHS's Clinical Quality Management Program. This RFI requests comment from members of the public about how DHA can best assess clinical quality across both the direct and purchased care sectors. DHA will use the information received in response to this RFI for market research to develop its acquisition strategy and to achieve its program objectives for upcoming requirements for quality oversight functions. Specific program requirements and additional detailed information about the Program are below: TRICARE manuals are available at https://manuals.health.mil/, for specific references search the TRICARE manuals site, using TRICARE Quality Monitoring Contract (TQMC). Defense Health Agency Procedural Manual 6025.13 Clinical Quality Management: https://health.mil/Reference-Center/Policies?query=6025.13&isDateRange=0&broadVector=000&newsVector=0000000&refVector=000000000100000&refSrc=1 BACKGROUND: TRICARE is a Department of Defense (DoD) healthcare program which serves active duty and retired military personnel, other uniformed service personnel, and their family members. DHA is accountable for the management and operation of the TRICARE program, which provides care to over 9.5 million beneficiaries worldwide in DoD MTFs and private sector healthcare facilities obtained through Managed Care Support Contracts (MCSCs). The MHS maintains effective organizational structures and active programs to ensure quality in healthcare throughout the MHS. Clinical quality management activities include patient safety, healthcare risk management, credentialing and privileging, accreditation, clinical measurement, and clinical quality improvement. DHA currently has a contract, TRICARE Quality Monitoring Contract (TQMC), in place to assist in performing oversight of the quality of healthcare provided to beneficiaries in accordance with Title 32 Code of Federal Regulations Part 199.15 (32 CFR 199.15). The contract performs the following services: Healthcare Effectiveness Data and Information Set (HEDIS) data analysis and an annual HEDIS measures methodology compliance audit, Joint Commission ORYX hospital quality measures data collection, submission and reporting, Center for Medicare and Medicaid Services Hospital Compare measures data collection submission and reporting, Standard of care (SOC) and quality of care (QOC) case reviews by clinical peers, Medical record reviews for utilization and quality of care, Medical Necessity (Reconsideration) Reviews (Second Level Appeals), Internal/External Case Reviews for Office of General Counsel (OGC) Appeals and Hearings, DHA, and provide Clinical/Expert Witnesses for medical appeal administrative hearings and proceedings, Assessment of Evolving Practices, Devices, Medicines, Treatments and Procedures, Initial fee calculation for facilities requesting TRICARE authorization, to be a network provider as a Residential Treatment Center (RTC), Partial Hospitalization Program (PHP), and Substance Use Disorder Rehabilitation Facility (SUDRF) Focused studies for clinical quality improvement, Educational webinars and meeting support focused on clinical quality management activities. The TQMC is responsible for TRICARE quality monitoring accomplished through a variety of tasks supporting the direct care and purchased care systems. A summary of the tasks include: Joint Commission ORYX® Core Measures (Direct Care): The TQMC collects, displays, reports and submits data on selected Joint Commission ORYX® core measures for all 48 DoD inpatient MTFs. MTF-specific patient level data created from these measures is available to authorized users and Service Quality Leaders. The secure web-based access includes drill down capability to the patient level and data analysis with display (i.e. statistical process control charts, bar graphs, line charts) on each participating MTF. The data are provided with national comparative benchmarks and MTF trends, and opportunities for improvement are identified. Best practices are noted and shared across the MHS. For measures in which any MTF is significantly below the national benchmark as identified in quarterly reports, the MHS TQMC Contractor reviews the literature to identify best practices and provide the information to the Clinical Support Division (CSD), Service representatives, and the MTF(s). The TQMC reviews and reports on newly developed Joint Commission hospital measures to determine applicability to DoD MTFs. The MHS TQMC Contractor facilitates the MHS's transition to new Joint Commission hospital measure as appropriate. At the completion of the contract, all MTF data collected to meet the Joint Commission ORYX® requirements will be transitioned per CSD's direction. Hospital Compare Measures (Direct and Purchased Care) The TQMC collects, displays, reports and submits data on selected Hospital Compare Experience of Care and Timely and Effective measures for 35 DoD inpatient facilities located in the United States. This data is incorporated with purchased care inpatient network provider data for a system view of performance. On a quarterly basis, the TQMC downloads, analyzes, displays and reports, as posted on the Hospital Compare website, National Hospital Quality Measure data from MHS purchased care and Designated Provider (DP) network hospitals. The data includes comparable national benchmarks for average and top performing hospitals, along with trends noted and opportunities for improvement. Facility-level data created from these measures are provided to DHA users and Service Quality Leaders. The TQMC posts the National Hospital Quality Measures work products on a secure web portal. This includes data analysis with display (i.e. statistical process control charts, bar graphs, line charts) stratified by Service, Contract Region, DP and MHS levels. Reports, presentations and a user's guide to support new users of the site are also included. The volume of patient records meeting the specifications for the past year, and the proposed data collection process. In Fiscal Year 2019, approximately 100,000 direct care records were abstracted for Joint Commission and Hospital Compare measures. Electronic access to health records and scanned document was utilized for data collection. Quality of Care and Utilization Reviews (Purchased Care) The TQMC provides DHA with an independent, impartial evaluation of the care provided to MHS beneficiaries in the Purchased Care System. As a part of TRICARE's Quality and Utilization Peer Review Organization Program, in accordance with 32 CFR 199.15, TQMC reviews care provided under the MCSCs and the Uniformed Services Family Health Plan (USFHP) DPs. The USFHP consists of six DP programs that care for about 111,000 beneficiaries. The six DP programs are Johns Hopkins, St Vincent, Martin's Point, Brighton Marine, Christus Health and Pacific Medical Centers. The TQMC also reviews records from other TRICARE Contractors such as the TRICARE Medicare Eligible Program (TMEP) formerly, TRICARE Dual-Eligible Fiscal Intermediary Contract (TDEFIC), TRICARE Overseas Contract, and the TRICARE Pharmacy Contract (TPharm) on a limited basis. The TQMC measures and reports on the quality of health care services and provides tools for making informed decisions; insight for targeting quality improvement activities; information that allows for external comparisons of health care services against civilian benchmarks, between regions and DP service areas, and against the Direct Care System; and information that promotes medical care that is consistent with clinical guidelines. It measures, evaluates, and identifies superior quality health care services and recommends means to transfer successes throughout the MHS. Medical Reviews (Purchased Care) The TQMC reviews medical, surgical, and mental health cases to determine the medical necessity and appropriateness of care of the services provided and to ensure the MCSCs and DPs are performing preauthorizations and retrospective and prepayment reviews. The TQMC also identifies cases of inappropriate medical care, preventable admissions, care that is not a TRICARE benefit, and potential cases of fraud and abuse. The TQMC applies appropriate quality screens and medical judgment to identify quality issues. These quality reviews utilize both process and outcome measures that focus on deficiencies in the delivery of health care that result in an adverse effect on the patient and also identify superior healthcare services. Any quality issues that are identified are confirmed by a board certified, licensed physician, who is actively practicing in the clinical area being reviewed. Medical Necessity Reconsideration Reviews (Direct and Purchased Care) The TQMC conducts medical necessity reconsideration reviews and issue decisions per TOM Chapters 12 and 24. These reviews and decisions are in accordance with the waiver of liability provisions in TPM Chapter 1, Section 4.1. These reviews include medical necessity appeals from the purchased care Contractors and MTFs. Appeals & Hearings Internal and External Reviews and Hearing Support (Direct and Purchased Care) The TQMC conducts internal and external case reviews to assist the OGC, DHA, with the appeals and hearings process. TQMC Contractors provide pre- and post-hearing support, including transcription. The TQMC provides clinical/expert witnesses as needed for medical appeal administrative/trial attendance, discovery, and DHA appeal subject manner conference calls in support to the OGC, DHA, Appeals and Hearings. Standard of Care and Quality of Care Reviews (Direct and Purchased Care) The TQMC conducts external Standard of Care (SOC) reviews of paid malpractice claim cases in which the Military Service's preliminary determination is that the malpractice payment was not caused by failure of any practitioner to meet the standard of care. The TQMC also reviews selected cases involving injury to active duty soldiers, including those resulting in a payment of a disability and/or death benefit. When the case involves a physician, the case is reviewed by a licensed physician who is board-certified in the same clinical specialty as the physician who provided the care. Additionally, the physician reviewer has an active clinical practice in the same clinical area being reviewed. If the case involves a provider other than a physician, a reviewer who is similarly qualified conducts the review. When a case involves more than one specialty, a separate report is issued for each specialty. For all cases, the TQMC (1) summarizes the facts of the case, (2) discusses the allegations, (3) determines whether the standard of care at the time the care was provided was met for each involved provider, (4) provides the rationale for that finding (standard text, practice guidelines, any evidence-based medical citations from the literature relevant at the time of the incident, etc.), and (5) determines whether the care provided caused the patient's injury. In addition, if the case was identified as a system problem, the TQMC includes rationale for agreeing or disagreeing with the identified system issue. The TQMC conducts a quality of care review when DHA identifies a quality concern regarding care provided within the MHS. The reviews are completed in the same fashion as SOCs. Initial Fees Calculations (Purchased Care) The TQMC is responsible for calculating the initial fees for RTCs, SUDRFs, and PHPs to confirm TRICARE requirements for authorized provider status in accordance with the provisions of 32 CFR 199.6 and the TRICARE Policy Manual. Evolving Practices, Devices, Medicines, Treatments, and Procedures Assessments (Direct and Purchased Care) The TQMC reviews the hierarchy of reliable evidence, as defined in 32 CFR 199.2, and recommends to the DHA devices, medical treatments, or procedures which the TQMC believes have moved from unproven to proven. The assessments include a review of published, refereed scientific literature and studies on topics such as individual health care technologies, to include the full range of medical or surgical devices, practices or procedures; behavioral health devices, practices or procedures; dental health devices, practices or procedures; or the use of pharmaceuticals for purposes other than that approved by the U.S. Food and Drug Administration. The TQMC provides a written report for DHA to utilize is analysis of benefits provided. DHA furnishes the data contained in the MHS population health portal to the TQMC to validate through a Healthcare Effectiveness Data and Information Set (HEDIS) certified vendor. The TQMC reviews National Coverage Determinations from Centers for Medicare and Medicaid (CMS) to determine their applicability as potential benefits in the TRICARE program. Quality Improvement Studies (Direct and Purchased) The TQMC conducts studies (collect, measure, synthesize, analyze, report findings and formulate recommendations based on prevailing healthcare standard and evidence based practice) focused on evaluating and improving health care and reducing variation in the MHS. The work performed is comparable to the quality of studies presented in professional medical research literature. The TQMC proposes studies for consideration based on a thorough review and analysis of information gathered from DHA leadership, health plan network providers; current trends in the healthcare industry with reference to the application to the MHS; the findings of past MHS studies/outcome measures and congressionally mandated reviews. The TQMC conducts focused studies that allow DHA to understand critical risks to design recommendations to improve the quality of care. The studies selected are those with a potential to significantly impact beneficiary health, functional status, satisfaction, and utilization. RFI RESPONSE FORMAT: DHA requests RFI responses in the form of a white paper in Microsoft Word (Times New Roman, 12-point font). Please submit responses in the following format: Section I. Company name, mailing address; and the name, phone number, fax number, and email of the designated point of contact. Section II. The name and contact information for the business or other organization whose views are represented in the paper if that contact information is different from that provided in Section I. Section III (NO MORE THAN 15 PAGES). Please provide responses to each of the questions listed below. QUESTIONS: Respondents should review the Background information above prior to answering the questions. Respondents are asked to draw their responses from objective, empirical, and actionable evidence and to cite this evidence within their responses. DHA is particularly interested in the findings from research in the areas of healthcare services delivery, public policy and/or the administration of complex policy programs, innovation diffusion, change management, community organization/mobilization, industrial engineering or manufacturing, operations research, and other disciplines that can inform the quality improvement of services delivered in health care systems or the promotion of health through community-based organizations. While some of the goals of the clinical quality oversight program are directed by statute, the overall goal of the program is to ensure the MHS delivers the highest quality care possible to its eligible beneficiaries. DHA may use responses in designing the future direction of the MHS Clinical Quality Program. DHA asks that respondents address each of the following questions as it pertains to utilizing a single contract to provide program support for all quality oversight functions throughout the MHS: 1. Given the background information provided, what do you believe is the best approach to assessing the quality of care rendered in both the inpatient and outpatient settings for direct and purchased care that would deliver maximum program value to beneficiaries? (Respondents are reminded that all requirements listed in 32 CFR 199.15 must be met.) 2. What advantages would the program expect to realize by adopting the approach you articulated in your response to Question 1? 3. How would utilization of the approach articulated in your response to Question 1 allow DHA to ensure the most impact to the delivery of safe, quality care for patients? 4. What are some important factors for DHA to consider if it were to adopt your recommended approach (including any alternative approaches you suggest in your response) in organizing its quality oversight program in this way? What else should DHA think about as it makes its decision? 5. a. Considering solicitation characteristics such as contract type, options, multiple vs single award, performance incentives, what specific solicitation characteristics would encourage your organization to submit an offer/proposal in response to a solicitation for these services? Why? b. What solicitation characteristics would discourage or prevent your organization from submitting a offer/proposal? 6. a. What solicitation characteristics would attract small business participation? b. What solicitation characteristics would discourage/prevent small business participation? 7. a. Would your organization provide most services in-house? If yes, which services would be performed in-house? b. What services would your company be most likely to outsource? Why? 8. a. How are these services typically priced? For example, which services are typically fixed price, which are typically cost reimbursed? For fixed price what is the unit of measure? For example hourly labor rates? Price per study? b. For cost-reimbursed contracts, what are the major cost drivers? 9. What are the major risk factors associated with these services? 10. a. What are the biggest challenges and frustrations facing your industry? b. What is the cost impact of these challenges? 11. What incentives are typical for these services? 12. Are there benchmarks/standards or industry "best practices" that your company uses to assess the quality of the services provided? If yes, please describe them. 13. DHA is considering the NAICS codes below for this requirement. Which does your company recommend and why? Is there a NAICS code not listed that is more suitable? Why? a. 541611, Administrative Management and General Management Consulting Services (Medical office management consulting services or consultants) b. 813920, Professional Organizations (Peer review boards, professional standards review boards, professional standards review committees) c. Other: 14. Description of recent (within the last 3 years), relevant contract experience (Government and Commercial) performing all of the TQMC requirements above. Please include the following for each contract: a. Name of company or organization which awarded the contract; b. POC name and contact information; c. Length of the contract; d. Dollar value and number of labor hours required/year; e. Description of the requirement, including NAICS code, contract type, tasks performed f. Magnitude (number of medical facilities supported, number/type of reviews, total dollar value) g. Place of performance 15. Provide a description of your business’s background, technical expertise, experience, staffing, financial resources and other capabilities that demonstrate the capacity, capability and experience to perform as the prime contractor for the TQMC requirements listed above. Please reference each paragraph that you discuss. Also, please include in the discussion of the size (number of facilities, reviews, and total dollar value) and complexity of the contracts/projects. 16. How long your company has been involved in this type of work? 17. Does your company have the capability and/or the desire to function as the prime on a contract of this size and complexity? 18. Would you intend to partner with another firm? If so, will your firm be capable of providing a minimum of 51% of the work? 19. Do you have a current GSA Schedule that could be used for a requirement such as this? If so, please provide the Contract Schedule #. 20. Based on the requirements described above, specify current available medical peer reviewers by specialty, their experience, certifications, and credentials. 21. Based on the requirements described above, specify current experience, certifications, and credentials for behavioral health facility certifications. 22. Specify current experience, qualifications, certifications, and credentials for collecting, submitting and presenting the Joint Commission (TJC) ORYX® National Hospital Quality Measures data for comparative analysis with healthcare organizations nationwide and to support the accreditation of DoD hospitals. 23. Specify current experience, qualifications, certifications, and credentials for collecting, analyzing, submitting and presenting HEDIS® measures and trends. 24. Specify current experience, qualifications, certifications, and credentials for conducting independent medical peer reviews. 25. If a small business, what contractual or other factors that would discourage you from submitting a proposal in response to a Solicitation for these TQMC requirements? THIS IS AN RFI ONLY. This RFI is issued solely for market research. It does not constitute a Request for Proposal. Interested firms shall not send proposals in response to this Notice nor shall they contact any other individuals about this Notice or the requirement. Any information provided to DHA is strictly voluntary and given with no expectation of compensation and is clearly provided at no cost to the Government. A solicitation will not be issued at this time, and this Notice shall not be construed as a commitment by the Government to issue a solicitation nor does it restrict the Government to a particular acquisition approach. The Government may issue a formal solicitation on the Federal Business Opportunities (fbo.gov) website at a future date. If the Government issues a solicitation, the Government will conduct any source selection in accordance with the Federal Acquisition Regulation (FAR), as supplemented. Any future information on this acquisition (statement of work, specifications, solicitation, etc.) will be posted on www.fbo.gov. It is the responsibility of the prospective offeror to review this site regularly for updates and/or changes. DHA will not respond to questions about the policy issues raised in this RFI. Please email white papers to the primary point of contact listed in this notice. Please state "DHA-RFI-20-TQMC Response" in the email subject line.