[Federal Register Volume 76, Number 248 (Tuesday, December 27, 2011)]
[Notices]
[Pages 80907-80908]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-33065]


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DEPARTMENT OF DEFENSE

Office of the Secretary


TRICARE Prime Urgent Care Demonstration Project

AGENCY: Department of Defense.

ACTION: Notice of demonstration.

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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.

FOR FURTHER INFORMATION CONTACT: For questions pertaining to this

[[Page 80908]]

demonstration project, please contact Ms. Shane Pham at (703) 681-0039.

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.

    Dated: December 21, 2011.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2011-33065 Filed 12-23-11; 8:45 am]
BILLING CODE 5001-06-P