[Federal Register Volume 72, Number 52 (Monday, March 19, 2007)]
[Notices]
[Pages 12783-12784]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E7-4924]


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DEPARTMENT OF DEFENSE

Office of the Secretary


Office of the Secretary of Defense (Health Affairs)/TRICARE 
Management Activity

AGENCY: Department of Defense.

ACTION: Notice of a disease management demonstration project for 
TRICARE Standard beneficiaries.

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SUMMARY: This notice is to advise interested parties of a Military 
Health System (MHS) demonstration project entitled Disease Management 
Demonstration Project for TRICARE Standard Beneficiaries. Although 
there are many similarities between TRICARE Standard and TRICARE Prime 
as to the preventive health care services that may be provided in the 
current benefit, there are services that are expressly excluded under 
TRICARE Standard that may be offered under TRICARE Prime which are the 
essence of a disease management (DM) program. TRICARE currently 
requires the Managed Care Support Contractors (MCSCs) to provide 
``disease management services'' under the current contracts, without 
specific guidance. Based upon the current legal statutes authorizing 
preventive health care services, TRICARE must conduct a demonstration 
under 10 U.S.C. 1092 in order to offer TRICARE Prime benefits to 
TRICARE Standard beneficiaries under the DM program already in 
existence. (Section 734 of the John Warner National Defense 
Authorization Act for Fiscal Year 2007 (henceforth NDAA 2007) does not 
give any broader authority than exists today). Under this 
demonstration, disease management services will be provided to TRICARE 
Standard beneficiaries as part of the current MHS DM programs. The 
demonstration project will enable the MHS to provide uniform policies 
and practices on disease and chronic care management throughout the 
TRICARE network. Additionally, the demonstration will help determine 
the effectiveness of DM programs in improving the health status of 
beneficiaries with targeted chronic diseases or conditions, and any 
associated cost savings.

DATES: Effective Date: April 1, 2007. This demonstration will remain in 
effect until March 31, 2009.

ADDRESSES: TRICARE Management Activity (TMA), Office of the Chief 
Medical Officer, 5111 Leesburg Pike, Suite 810, Falls Church, VA 22041-
3206.

FOR FURTHER INFORMATION CONTACT: CDR Cynthia Gantt, Office of the Chief 
Medical Officer--TRICARE Management Activity, telephone (703) 681-0064.

SUPPLEMENTARY INFORMATION:

A. Background

    The Military Health System (MHS) is a $33 billion dollar 
enterprise, consisting of 76 military hospitals, over 500 military 
health clinics, and an extensive network of private sector health care 
partners, which provides medical care for over 9 million beneficiaries 
and active duty service members. Of these beneficiaries, approximately 
5 million are classified as TRICARE Prime enrollees and 4.2 million are 
TRICARE Standard participants.
    The MHS is facing significant fiscal challenges in the coming years 
due to the rising costs of providing health care, coupled with recent 
expansions to the pool of eligible beneficiaries. The MHS recognizes 
these challenges and has implemented several new initiatives to help 
control costs. Disease management (DM) programs have become popular in 
the private sector as a means to accomplish this goal, with varying 
levels of effectiveness having been documented. The MHS has the 
opportunity to become a leader in DM, due to its population of long 
term or life time eligible beneficiaries and robust information 
systems.

B. MHS Disease Management Program

    On September 1, 2006, the MHS implemented a new DM initiative based 
on a consistent approach across all three managed care regions, 
focusing on asthma and congestive heart failure. These programs run by 
the Managed Care Support Contractors (MCSCs) include beneficiaries from 
military treatment facilities and those seen by civilian healthcare 
providers within the TRICARE network. In this revised uniform approach 
to DM, the Government, with the assistance of a program evaluation 
contractor, provides the MCSCs risk-stratified patient lists and 
conducts a formal evaluation across all three Regions using national 
benchmarks.
    TRICARE's approach to disease management is two-fold: (1) Keep the 
well healthy with a focus on healthy lifestyles, disease prevention and 
health promotion and (2) maintain an active disease management program 
for high risk beneficiaries with specific chronic disease conditions. 
Evidence-based clinical practice guidelines (CPGs) and educational 
resources developed jointly by the Departments of Defense (DoD) and 
Veterans Affairs (VA) are used in both the military treatment facility 
and MCSC DM programs.
    The MHS DM program directly supports the MHS strategic goal of 
effective patient partnerships by advocating the use of evidence-based 
practice guidelines and emphasizing patient self management skills. The 
goals of the DM initiatives are to improve clinical outcomes, increase 
patient and provider satisfaction, and ensure appropriate utilization 
of resources.

C. Current TRICARE Standard Benefit

    Under 10 U.S.C. 1079(a)(13), TRICARE may cost share only services 
or supplies that are medically or psychologically necessary to prevent, 
diagnose, or treat a mental or physical illness, injury, or bodily 
malfunction as assessed or diagnosed by an authorized provider. There 
is additional statutory authority that describes what are preventive 
health care services. Under 10 U.S.C. 1074d, members and former members 
of the uniformed services are entitled to preventive health care 
services including cervical cancer screening, breast cancer screening, 
and screening for colon and prostate cancer, all at intervals and using 
methods the Secretary considers appropriate. These same services are 
available to them and all dependents in MTFs under 10 U.S.C. 
1077(a)(14), and to all covered beneficiaries under TRICARE under 10 
U.S.C. 1079(a)(2). Under 10 U.S.C. 1079(a)(2)(B), other health 
promotion and disease prevention visits for those over six years of age 
are authorized under TRICARE Standard only when done in connection with 
immunizations or with diagnostic or preventive cancer screening tests. 
(See also, 32 CFR 199.4(g)(37)).

[[Page 12784]]

    Additionally, the TRICARE Prime program is authorized by 10 U.S.C. 
1097--1099. The statutes authorize Prime to ``provide better services 
than those provided by [Standard]'', and the Secretary ``shall 
prescribe regulations to carry out this section.'' The regulations that 
directly impact the TRICARE Prime program are 32 CFR 199.17 and 199.18. 
Under 32 CFR 199.18(b)(2), the following services are available under 
TRICARE Prime that are not authorized under TRICARE Standard:
    (1) ``Periodic health promotion and disease prevention exams;
    (2) Appropriate education and counseling services. The exact 
services offered shall be established under uniform standards 
established by the Assistant Secretary of Defense (Health Affairs).
    (3) In addition to preventive care services provided pursuant to 
paragraph (b)(2) of this section, other benefit enhancements may be 
added and other benefit restrictions may be waived or relaxed in 
connection with health care services provided to include the Uniform 
HMO Benefit. Any such other enhancements or changes must be approved by 
the Assistant Secretary of Defense (Health Affairs) based on uniform 
standards.''
    Also, under TRICARE Standard, education and counseling services are 
expressly excluded under 32 CFR 199.4(g)(39).

D. National Defense Authorization Act (NDAA) 2007 Disease Management 
Directives

    The NDAA 2007 section 734 requires the design and development of a 
fully integrated program on disease and chronic care management for the 
military health care system that provides uniform policies and 
practices on disease and chronic care management throughout the TRICARE 
network by October 1, 2007. The NDAA 2007 further states the program 
``shall include strategies for disease and chronic care management for 
all beneficiaries, including beneficiaries eligible for benefits under 
the Medicare program under title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.), for whom the TRICARE program is not the primary 
payer for health care benefits.''
    The purposes of the MHS DM programs, as stated in the NDAA 2007, 
are to facilitate the improvement of the health status of individuals 
under care in the military health care system, to ensure the 
availability of effective health care services for individuals with 
diseases and other chronic conditions, and to ensure the proper 
allocation of health care resources for individuals who need care for 
disease or other chronic conditions. The NDAA 2007 mandates the DM 
program to address, at a minimum, the following chronic diseases and 
conditions: diabetes, cancer, heart disease, asthma, chronic 
obstructive pulmonary disorder, and depression and anxiety disorders.

E. Description of Demonstration Project

    Under this demonstration, DoD will waive, for disease management 
services provided to TRICARE Standard beneficiaries, the provisions of 
10 U.S.C. section 1079(a)(13) and 32 CFR 199.4(g)(39) that expressly 
exclude clinical preventive services for TRICARE Standard beneficiaries 
in the current benefit. The MHS will enroll TRICARE Standard 
beneficiaries in its DM programs. DM services provided to Standard 
beneficiaries will include, but are not limited to: clinical preventive 
examinations, patient education and counseling services, and periodic 
screening exams.
    There will be a cap on MHS DM program costs not to exceed the 
amount approved by the contracting officer. The DM program costs are 
total costs of DM services provided to both Prime and Standard 
beneficiaries. Only those beneficiaries identified by TRICARE 
Management Activity (TMA) for disease management of asthma, congestive 
heart failure, and diabetes are included in the current program, with 
other diseases or conditions to be added in the future as funding 
permits. The beneficiaries identified by TMA are included in the DM 
program unless the beneficiary chooses to opt out.
    This action will directly reduce variation across the system and 
result in improved consistency and quality for beneficiaries with 
targeted chronic illness, regardless of TRICARE classification. 
Furthermore, including TRICARE Standard beneficiaries in current DM 
efforts will inform the MHS about total potential savings and return on 
investment (ROI) associated with DM, a stated requirement for inclusion 
in the Congressional report per the NDAA 2007. The system-wide DM 
program will improve the quality of care by educating patients about 
their disease and helping them manage their symptoms, thereby avoiding 
many complications and possibly slowing the progression of their 
chronic disease, thus resulting in significant cost savings.

F. Implementation

    The demonstration is effective on April 1, 2007.

G. Evaluation

    An independent evaluation of the demonstration will be conducted. 
The evaluation will be designed to use a combination of administrative 
and survey measures of health care outcomes (clinical, utilization, 
financial, and humanistic measures) to provide analyses and comment on 
the effectiveness of the demonstration in meeting its goal of providing 
uniform disease management policies and practices across the MHS.

    Dated: March 13, 2007.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. E7-4924 Filed 3-16-07; 8:45 am]
BILLING CODE 5001-06-P