81_FR_17218 81 FR 17159 - TRICARE Bundled Payment for Lower Extremity Joint Replacement or Reattachment (LEJR) Surgeries Based on Centers for Medicare and Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) Model

81 FR 17159 - TRICARE Bundled Payment for Lower Extremity Joint Replacement or Reattachment (LEJR) Surgeries Based on Centers for Medicare and Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) Model

DEPARTMENT OF DEFENSE
Office of the Secretary

Federal Register Volume 81, Issue 59 (March 28, 2016)

Page Range17159-17161
FR Document2016-06859

This notice is to advise interested parties of a Military Health System (MHS) demonstration project under the authority of Title 10, United States Code, Section 1092, entitled TRICARE Bundled Payment for Lower Extremity Joint Replacement or Reattachment (LEJR) Surgeries that will test bundled payment and quality measurement on an ``episode of care'' basis to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery. This demonstration is being conducted in compliance with Section 726 of the National Defense Authorization Act (NDAA) for 2016. This particular TRICARE demonstration will be based on Centers for Medicare and Medicaid Services' (CMS) Comprehensive Care for Joint Replacement (CJR) Model, which will be implemented in 67 metropolitan statistical areas (MSAs) beginning April 1, 2016. CMS's CJR Model is designed to promote better and more efficient care for beneficiaries undergoing LEJR surgery (DRG 469 (major joint replacement or reattachment of lower extremity with major complications or comorbidities) or 470 (major joint replacement or reattachment of lower extremity without major complications or comorbidities)). Participant hospitals in the CMS model will be held financially accountable for the quality and cost of the entire episode of care, which begins with hospital admission of a beneficiary and ends 90 days post-discharge in order to cover all related costs for the complete recovery period. This ``bundled'' episode includes all related items and services paid under Medicare Part A and Part B for all Medicare fee-for-service beneficiaries. The TRICARE demonstration project will test this value-based payment model in the Tampa-St. Petersburg MSA for DRG 470 only (including 90 days of related post-operative care) to assess whether value-driven bundled payment incentives will result in a reduction in the rate of increase in health care spending and improvements in health care quality, patient experience of care, and overall health of TRICARE beneficiaries. All network and non-network hospitals with at least 20 TRICARE admissions for DRG 470 over the three years of Fiscal Year (FY) 2013, 2014, and 2015 shall be required to participate in the demonstration project (excluding admissions for beneficiaries with primary Other Health Insurance (OHI), Active Duty Service Members (ADSMs), and Medicare-TRICARE dual eligible beneficiaries). Once selected for participation, hospitals will remain in the project throughout the duration of this demonstration (regardless of actual TRICARE utilization) unless the Government directs otherwise.

Federal Register, Volume 81 Issue 59 (Monday, March 28, 2016)
[Federal Register Volume 81, Number 59 (Monday, March 28, 2016)]
[Notices]
[Pages 17159-17161]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2016-06859]


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DEPARTMENT OF DEFENSE

Office of the Secretary


TRICARE Bundled Payment for Lower Extremity Joint Replacement or 
Reattachment (LEJR) Surgeries Based on Centers for Medicare and 
Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) 
Model

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, United States Code, Section 1092, entitled TRICARE Bundled Payment 
for Lower Extremity Joint Replacement or Reattachment (LEJR) Surgeries 
that will test bundled payment and quality measurement on an ``episode 
of care'' basis to encourage hospitals, physicians, and post-acute care 
providers to work together to improve the quality and coordination of 
care from the initial hospitalization through recovery. This 
demonstration is being conducted in compliance with Section 726 of the 
National Defense Authorization Act (NDAA) for 2016. This particular 
TRICARE demonstration will be based on Centers for Medicare and 
Medicaid Services' (CMS) Comprehensive Care for Joint Replacement (CJR) 
Model, which will be implemented in 67 metropolitan statistical areas 
(MSAs) beginning April 1, 2016. CMS's CJR Model is designed to promote 
better and more efficient care for beneficiaries undergoing LEJR 
surgery (DRG 469 (major joint replacement or reattachment of lower 
extremity with major complications or comorbidities) or 470 (major 
joint replacement or reattachment of lower extremity without major 
complications or comorbidities)). Participant hospitals in the CMS 
model will be held financially accountable for the quality and cost of 
the entire episode of care, which begins with hospital admission of a 
beneficiary and ends 90 days post-discharge in order to cover all 
related costs for the complete recovery period. This ``bundled'' 
episode includes all related items and services paid under Medicare 
Part A and Part B for all Medicare fee-for-service beneficiaries. The 
TRICARE demonstration project will test this value-based payment model 
in the Tampa-St. Petersburg MSA for DRG 470 only (including 90 days of 
related post-operative care) to assess whether value-driven bundled 
payment incentives will result in a reduction in the rate of increase 
in health care spending and improvements in health care quality, 
patient experience of care, and overall health of TRICARE 
beneficiaries. All network and non-network hospitals with at least 20 
TRICARE admissions for DRG 470 over the three years of Fiscal Year (FY) 
2013, 2014, and 2015 shall be required to participate in the 
demonstration project (excluding admissions for beneficiaries with 
primary Other Health Insurance (OHI), Active Duty Service Members 
(ADSMs), and Medicare-TRICARE dual eligible beneficiaries). Once 
selected for participation, hospitals will remain in the project 
throughout the duration of this demonstration (regardless of actual 
TRICARE utilization) unless the Government directs otherwise.

DATES: Effective Date: This demonstration is mandated by Section 726 of 
the National Defense Authorization Act for Fiscal Year 2016, with an 
implementation deadline of May 23, 2016. This demonstration authority 
will remain in effect until December 31, 2019.

ADDRESSES: Defense Health Agency, Health Plan Execution and Operations, 
7700 Arlington Boulevard, Suite 5101, Falls Church, Virginia 22042.

FOR FURTHER INFORMATION CONTACT: For questions pertaining to this 
demonstration, please contact Ms. Debra Hatzel at (303) 676-3572.

SUPPLEMENTARY INFORMATION: 

A. Background

    Section 726 of the National Defense Authorization Act (NDAA) for 
Fiscal Year 2016 directed the Department of Defense to conduct a 
demonstration project on incentives to improve health care provided 
under the TRICARE program, also known as paying for value rather than 
for volume or value-based reimbursement. Innovative health care payment 
models are being tested and implemented by the CMS and a variety of 
commercial health care programs and insurers. This demonstration will 
assess whether value-driven incentives will result in a reduction in 
the rate of increase in health care spending and improvements in health 
care quality, patient experience of care, and overall health of TRICARE 
beneficiaries.
    This demonstration program is based on the Medicare Program for 
Comprehensive Care for Joint Replacement (CJR) Payment Model for Acute 
Care Hospitals Furnishing Lower Extremity Joint Replacement Services, 
under the authority of the Center for Medicare and Medicaid Innovation 
(CMMI) pursuant to section 1115A of the Social Security Act, and as 
implemented by CMS. A copy of the Final Rule published by CMS on 
November 24, 2015, may be found at https://www.federalregister.gov/articles/2015/11/24/2015-29438/medicare-program-comprehensive-care-for-joint-replacement-payment-model-for-acute-care-hospitals. In general, 
CMS sought to target high expenditure, high utilization procedures for 
which there were significant regional variation in spending. Acute care 
hospitals, as the site of surgery, will be held accountable for 
spending during the entire episode of care. This model seeks to promote 
the alignment of financial and other incentives for all health care 
providers and suppliers caring for a beneficiary during an LEJR 
episode, thereby improving quality and increasing efficiency in the 
provision of care. It is also anticipated the CJR model will benefit 
Medicare beneficiaries by improving coordination and transition of care 
by incentivizing more efficient service delivery and higher value care 
across the inpatient and post-acute care spectrum spanning the episode 
of care. The CMS CJR model will be implemented in 67 metropolitan 
statistical areas (MSAs) beginning April 1, 2016. Under Medicare, this 
episode-based payment model is mandatory for all hospitals in the 
designated MSAs.
    The Department of Defense elected to conduct a demonstration 
project to adapt, in general, and test this value-based incentive 
program to assess whether a reduction in the rate of increase in health 
care spending can be achieved while simultaneously improving the 
experience and quality of health care provided to our beneficiaries by 
providing financial incentives for high-quality, efficient care. 
Consistent with the CJR model, TRICARE demonstration hospitals will be 
held accountable for the costs and quality of the entire episode of 
care and will be afforded the opportunity to earn performance-based 
payments by appropriately reducing expenditures and meeting certain 
quality metrics.
    An analysis of LEJR surgeries in the TRICARE beneficiary population 
was conducted. This analysis revealed some of the Metropolitan Service 
Areas (MSAs) participating in the CMS Comprehensive Care for Joint 
Replacement (CJR) model have a substantial number of TRICARE-eligible 
beneficiaries. These locations include the Killeen-Temple TX MSA, the 
Seattle-Tacoma WA MSA, and the Tampa-St. Petersburg FL MSA. Both the 
Killeen-Temple MSA and the Seattle-Tacoma MSA are associated with large 
inpatient military treatment facilities

[[Page 17160]]

(MTFs); however, there are not any inpatient MTFs associated with the 
Tampa-St. Petersburg MSA. Based on FY 2015 data, there are 74,133 
TRICARE eligibles residing in the Tampa-St. Petersburg area, and 128 
joint replacement or reattachment surgeries for TRICARE beneficiaries 
were performed in FY 2015. Due to co-location with CMS's MSA (which 
makes hospital participation mandatory), the significant number of 
TRICARE eligible beneficiaries receiving joint replacement or 
reattachment surgeries, and the lack of MTF inpatient resources, Tampa-
St. Petersburg was selected for this demonstration project. 
Additionally, it was determined only one to two percent of all TRICARE 
LEJR patients are in DRG 469 (major joint replacement or reattachment 
of lower extremity with major complications or comorbidities). As a 
result, the TRICARE demonstration project will exclude DRG 469 
admissions since there are insufficient volumes for setting target 
episode prices for these procedures.

B. Description of the Demonstration Project

    All network and non-network hospitals in the Tampa-St. Petersburg 
area will be required to participate in the demonstration if they had 
at least 20 TRICARE admissions for DRG 470 over the three years of FY 
2013, FY 2014, and FY 2015 (excluding admissions for beneficiaries with 
Other Health Insurance (OHI), Active Duty Service Members (ADSMs), and 
Medicare-TRICARE dual eligible beneficiaries). Once selected for 
participation, demonstration hospitals will remain in the program 
throughout the duration of this NDAA demonstration (regardless of 
actual TRICARE utilization) unless the Government directs otherwise. 
Demonstration hospitals will be accountable for quality and cost of 
care for an inpatient stay that results in DRG 470, along with all 
related care provided during the 90-day period following discharge.
    The Defense Health Agency (DHA) will prospectively establish target 
episode prices for each demonstration hospital at least 30 days prior 
to the start of each demonstration year. This target episode price 
shall be based on TRICARE claims for DRG 470 admissions and associated 
post-operative care for FY 2013, FY 2014, and FY 2015, and shall be a 
blend of hospital-specific and market-wide historical episode costs. 
This historical data period shall be used for the duration of the 
demonstration, with annual adjustments for inflation. In Demonstration 
Years one and two, the blended rate for the target episode price shall 
be developed with two-thirds hospital-specific data and one-third 
market-wide data; in Demonstration Year three, the target episode price 
shall be developed with one-third hospital-specific data and two-thirds 
market-wide data.
    Although the CMS CJR Model incorporates an automatic cost savings 
of 3percent into their target episode prices, DHA will not deduct an 
automatic cost savings amount when developing TRICARE target episode 
prices. Instead, target episode pricing will take historical network 
discounts, DRG and CPT pricing adjustments, and annual inflation 
factors into consideration. Additionally, the value of any care 
provided in the direct care system will not be considered in developing 
target prices. This will permit local military treatment facilities to 
recapture, where appropriate, post-surgery outpatient care under 
existing TRICARE procedures based on the MTF's capability and capacity 
without affecting incentive calculations. The target episode price will 
clearly indicate the cost build-up calculations for each component of 
care within the episode. These target episode prices will become the 
basis for calculating any incentive payments or penalties.
    For purposes of this demonstration, Demonstration Year one will 
commence for admissions on May 23, 2016, and will include all completed 
episodes with an end date continuing through September 30, 2017 
(including the full 90 days post-discharge period). Subsequent 
demonstration years will be conducted on a fiscal year basis (i.e., for 
episodes ending October 1st through September 30th). The target episode 
price in effect on the date of hospital admission shall be used for 
incentive calculation purposes, even if a portion of post-discharge 
care is delivered in the subsequent demonstration year.
    During each demonstration year, all hospital, physician, and post-
acute care claims will be paid under the normal TRICARE reimbursement 
methodologies. At the end of each demonstration year, the total costs 
of all completed episodes for the year will be compared to the 
aggregate target episode price for each demonstration hospital to 
determine whether actual costs were less than, equal to, or greater 
than the target episode price. In order to ensure all costs are 
properly attributed to each demonstration hospital, actual cost 
calculations shall occur no sooner than 90 calendar days following the 
end of the demonstration year to allow adequate time for claims 
processing. In order to encourage use of the direct care system and 
because the managed care support contractor processing the episode 
calculations will not have access to direct care cost data, costs for 
direct care shall be excluded (consistent with the target cost 
development).
    In addition to performing these cost calculations, DHA will utilize 
the composite quality score (as determined by CMS) for each 
demonstration hospital as the basis for determining eligibility for 
gain-sharing. This composite quality score is a hospital-level summary 
quality score reflecting performance and improvement on the quality 
measures adopted for the Medicare CJR model (Total Hip Arthroplasty 
(THA)/Total Knee Arthroplasty (TKA)) complications measure and the 
Hospital Consumer Assessment of Healthcare Providers and Systems 
(HCAHPS) patient experience survey measure. TRICARE will use Hospital 
Compare as the source for these data. Hospitals that do not achieve and 
maintain a favorable CJR composite quality score for the full 
demonstration year are not eligible for incentive payments, regardless 
of whether cost savings are achieved. TRICARE is following the same 
approach as Medicare in order to ensure hospitals are not reducing the 
quality of care offered to beneficiaries or reducing patients' overall 
perception of their hospital experience.
    Incentive payments will be calculated using the CMS gain/loss 
sharing model; beginning in Demonstration Year one, positive incentive 
payments will be made to hospitals who achieve and maintain a favorable 
CJR composite quality score for the full demonstration year and who 
demonstrate cost savings as compared to the target episode price. 
``Downside'' risk (negative financial incentives) will not be phased 
into the payment model until the second demonstration year. Gain/Loss 
sharing will increase over time, from no loss sharing in Demonstration 
Year one (only gain sharing), to higher levels in later years (gain 
sharing of 5 percent in Demonstration Years one and two, and 10 percent 
in Demonstration Year three). Loss sharing is 0 in Demonstration Year 
one, 5 percent in Demonstration Year two, and 10 percent in 
Demonstration Year three.
    On a quarterly basis, demonstration hospitals will receive feedback 
from the MCSCs on their current quality performance (as identified in 
Hospital Compare), episode of care costs to date, and projected 
eligibility for incentives (based on TRICARE claims and Medicare's 
composite quality scores for each hospital). To facilitate effective 
communication with demonstration

[[Page 17161]]

hospitals, these quarterly reports shall mirror the format and detail 
of CMS's feedback reports to the extent feasible. Active Duty Service 
Members (ADSMs), Medicare-TRICARE Dual Eligible (TDEFIC) beneficiaries, 
and beneficiaries with Other Health Insurance (OHI) are excluded from 
this demonstration.

C. Communications

    The DHA will proactively educate beneficiaries, providers, and 
other stakeholders about this change.

D. Evaluation

    This demonstration project will assist the Department in evaluating 
whether value-driven incentives will result in a reduction in the rate 
of increase in health care spending and improvements in health care 
quality, patient experience of care, and overall health of TRICARE 
beneficiaries. Regular status reports and a full analysis of 
demonstration outcomes will be conducted consistent with the 
requirements in Section 726 of the 2016 NDAA. Future expansions of the 
demonstration project to additional locations may be considered based 
on DHA data analysis for the Tampa-St. Petersburg market. Details of 
any future expansions will be announced via Federal Register notice 
prior to implementation.

    Dated: March 22, 2016.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2016-06859 Filed 3-25-16; 8:45 am]
 BILLING CODE 5001-06-P



                                                                           Federal Register / Vol. 81, No. 59 / Monday, March 28, 2016 / Notices                                             17159

                                             [FR Doc. 2016–06937 Filed 3–25–16; 8:45 am]             incentives will result in a reduction in              the Social Security Act, and as
                                             BILLING CODE 5001–06–C                                  the rate of increase in health care                   implemented by CMS. A copy of the
                                                                                                     spending and improvements in health                   Final Rule published by CMS on
                                                                                                     care quality, patient experience of care,             November 24, 2015, may be found at
                                             DEPARTMENT OF DEFENSE                                   and overall health of TRICARE                         https://www.federalregister.gov/articles/
                                                                                                     beneficiaries. All network and non-                   2015/11/24/2015-29438/medicare-
                                             Office of the Secretary                                 network hospitals with at least 20                    program-comprehensive-care-for-joint-
                                                                                                     TRICARE admissions for DRG 470 over                   replacement-payment-model-for-acute-
                                             TRICARE Bundled Payment for Lower
                                                                                                     the three years of Fiscal Year (FY) 2013,             care-hospitals. In general, CMS sought
                                             Extremity Joint Replacement or
                                                                                                     2014, and 2015 shall be required to                   to target high expenditure, high
                                             Reattachment (LEJR) Surgeries Based
                                                                                                     participate in the demonstration project              utilization procedures for which there
                                             on Centers for Medicare and Medicaid
                                                                                                     (excluding admissions for beneficiaries               were significant regional variation in
                                             Services (CMS) Comprehensive Care
                                                                                                     with primary Other Health Insurance                   spending. Acute care hospitals, as the
                                             for Joint Replacement (CJR) Model
                                                                                                     (OHI), Active Duty Service Members                    site of surgery, will be held accountable
                                             AGENCY:   Department of Defense.                        (ADSMs), and Medicare-TRICARE dual                    for spending during the entire episode
                                             ACTION:   Notice of demonstration.                      eligible beneficiaries). Once selected for            of care. This model seeks to promote the
                                                                                                     participation, hospitals will remain in               alignment of financial and other
                                             SUMMARY:    This notice is to advise                    the project throughout the duration of                incentives for all health care providers
                                             interested parties of a Military Health                 this demonstration (regardless of actual              and suppliers caring for a beneficiary
                                             System (MHS) demonstration project                      TRICARE utilization) unless the                       during an LEJR episode, thereby
                                             under the authority of Title 10, United                 Government directs otherwise.                         improving quality and increasing
                                             States Code, Section 1092, entitled                                                                           efficiency in the provision of care. It is
                                                                                                     DATES: Effective Date: This
                                             TRICARE Bundled Payment for Lower                                                                             also anticipated the CJR model will
                                                                                                     demonstration is mandated by Section
                                             Extremity Joint Replacement or                                                                                benefit Medicare beneficiaries by
                                                                                                     726 of the National Defense
                                             Reattachment (LEJR) Surgeries that will                                                                       improving coordination and transition
                                                                                                     Authorization Act for Fiscal Year 2016,
                                             test bundled payment and quality                                                                              of care by incentivizing more efficient
                                                                                                     with an implementation deadline of
                                             measurement on an ‘‘episode of care’’                                                                         service delivery and higher value care
                                                                                                     May 23, 2016. This demonstration
                                             basis to encourage hospitals, physicians,                                                                     across the inpatient and post-acute care
                                             and post-acute care providers to work                   authority will remain in effect until
                                                                                                     December 31, 2019.                                    spectrum spanning the episode of care.
                                             together to improve the quality and                                                                           The CMS CJR model will be
                                             coordination of care from the initial                   ADDRESSES: Defense Health Agency,
                                                                                                                                                           implemented in 67 metropolitan
                                             hospitalization through recovery. This                  Health Plan Execution and Operations,                 statistical areas (MSAs) beginning April
                                             demonstration is being conducted in                     7700 Arlington Boulevard, Suite 5101,                 1, 2016. Under Medicare, this episode-
                                             compliance with Section 726 of the                      Falls Church, Virginia 22042.                         based payment model is mandatory for
                                             National Defense Authorization Act                      FOR FURTHER INFORMATION CONTACT: For                  all hospitals in the designated MSAs.
                                             (NDAA) for 2016. This particular                        questions pertaining to this                             The Department of Defense elected to
                                             TRICARE demonstration will be based                     demonstration, please contact Ms. Debra               conduct a demonstration project to
                                             on Centers for Medicare and Medicaid                    Hatzel at (303) 676–3572.                             adapt, in general, and test this value-
                                             Services’ (CMS) Comprehensive Care for                  SUPPLEMENTARY INFORMATION:                            based incentive program to assess
                                             Joint Replacement (CJR) Model, which                                                                          whether a reduction in the rate of
                                                                                                     A. Background
                                             will be implemented in 67 metropolitan                                                                        increase in health care spending can be
                                             statistical areas (MSAs) beginning April                  Section 726 of the National Defense                 achieved while simultaneously
                                             1, 2016. CMS’s CJR Model is designed                    Authorization Act (NDAA) for Fiscal                   improving the experience and quality of
                                             to promote better and more efficient                    Year 2016 directed the Department of                  health care provided to our beneficiaries
                                             care for beneficiaries undergoing LEJR                  Defense to conduct a demonstration                    by providing financial incentives for
                                             surgery (DRG 469 (major joint                           project on incentives to improve health               high-quality, efficient care. Consistent
                                             replacement or reattachment of lower                    care provided under the TRICARE                       with the CJR model, TRICARE
                                             extremity with major complications or                   program, also known as paying for value               demonstration hospitals will be held
                                             comorbidities) or 470 (major joint                      rather than for volume or value-based                 accountable for the costs and quality of
                                             replacement or reattachment of lower                    reimbursement. Innovative health care                 the entire episode of care and will be
                                             extremity without major complications                   payment models are being tested and                   afforded the opportunity to earn
                                             or comorbidities)). Participant hospitals               implemented by the CMS and a variety                  performance-based payments by
                                             in the CMS model will be held                           of commercial health care programs and                appropriately reducing expenditures
                                             financially accountable for the quality                 insurers. This demonstration will assess              and meeting certain quality metrics.
                                             and cost of the entire episode of care,                 whether value-driven incentives will                     An analysis of LEJR surgeries in the
                                             which begins with hospital admission of                 result in a reduction in the rate of                  TRICARE beneficiary population was
                                             a beneficiary and ends 90 days post-                    increase in health care spending and                  conducted. This analysis revealed some
                                             discharge in order to cover all related                 improvements in health care quality,                  of the Metropolitan Service Areas
                                             costs for the complete recovery period.                 patient experience of care, and overall               (MSAs) participating in the CMS
                                             This ‘‘bundled’’ episode includes all                   health of TRICARE beneficiaries.                      Comprehensive Care for Joint
                                             related items and services paid under                     This demonstration program is based                 Replacement (CJR) model have a
                                             Medicare Part A and Part B for all                      on the Medicare Program for                           substantial number of TRICARE-eligible
Lhorne on DSK5TPTVN1PROD with NOTICES




                                             Medicare fee-for-service beneficiaries.                 Comprehensive Care for Joint                          beneficiaries. These locations include
                                             The TRICARE demonstration project                       Replacement (CJR) Payment Model for                   the Killeen-Temple TX MSA, the
                                             will test this value-based payment                      Acute Care Hospitals Furnishing Lower                 Seattle-Tacoma WA MSA, and the
                                             model in the Tampa-St. Petersburg MSA                   Extremity Joint Replacement Services,                 Tampa-St. Petersburg FL MSA. Both the
                                             for DRG 470 only (including 90 days of                  under the authority of the Center for                 Killeen-Temple MSA and the Seattle-
                                             related post-operative care) to assess                  Medicare and Medicaid Innovation                      Tacoma MSA are associated with large
                                             whether value-driven bundled payment                    (CMMI) pursuant to section 1115A of                   inpatient military treatment facilities


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                                             17160                         Federal Register / Vol. 81, No. 59 / Monday, March 28, 2016 / Notices

                                             (MTFs); however, there are not any                      blended rate for the target episode price             system and because the managed care
                                             inpatient MTFs associated with the                      shall be developed with two-thirds                    support contractor processing the
                                             Tampa-St. Petersburg MSA. Based on                      hospital-specific data and one-third                  episode calculations will not have
                                             FY 2015 data, there are 74,133 TRICARE                  market-wide data; in Demonstration                    access to direct care cost data, costs for
                                             eligibles residing in the Tampa-St.                     Year three, the target episode price shall            direct care shall be excluded (consistent
                                             Petersburg area, and 128 joint                          be developed with one-third hospital-                 with the target cost development).
                                             replacement or reattachment surgeries                   specific data and two-thirds market-                     In addition to performing these cost
                                             for TRICARE beneficiaries were                          wide data.                                            calculations, DHA will utilize the
                                             performed in FY 2015. Due to co-                           Although the CMS CJR Model                         composite quality score (as determined
                                             location with CMS’s MSA (which makes                    incorporates an automatic cost savings                by CMS) for each demonstration
                                             hospital participation mandatory), the                  of 3percent into their target episode                 hospital as the basis for determining
                                             significant number of TRICARE eligible                  prices, DHA will not deduct an                        eligibility for gain-sharing. This
                                             beneficiaries receiving joint replacement               automatic cost savings amount when                    composite quality score is a hospital-
                                             or reattachment surgeries, and the lack                 developing TRICARE target episode                     level summary quality score reflecting
                                             of MTF inpatient resources, Tampa-St.                   prices. Instead, target episode pricing               performance and improvement on the
                                             Petersburg was selected for this                        will take historical network discounts,               quality measures adopted for the
                                             demonstration project. Additionally, it                 DRG and CPT pricing adjustments, and                  Medicare CJR model (Total Hip
                                             was determined only one to two percent                  annual inflation factors into                         Arthroplasty (THA)/Total Knee
                                             of all TRICARE LEJR patients are in                     consideration. Additionally, the value of             Arthroplasty (TKA)) complications
                                             DRG 469 (major joint replacement or                     any care provided in the direct care                  measure and the Hospital Consumer
                                             reattachment of lower extremity with                    system will not be considered in                      Assessment of Healthcare Providers and
                                             major complications or comorbidities).                  developing target prices. This will                   Systems (HCAHPS) patient experience
                                             As a result, the TRICARE demonstration                  permit local military treatment facilities            survey measure. TRICARE will use
                                             project will exclude DRG 469                            to recapture, where appropriate, post-                Hospital Compare as the source for
                                             admissions since there are insufficient                 surgery outpatient care under existing                these data. Hospitals that do not achieve
                                             volumes for setting target episode prices               TRICARE procedures based on the                       and maintain a favorable CJR composite
                                             for these procedures.                                   MTF’s capability and capacity without                 quality score for the full demonstration
                                                                                                     affecting incentive calculations. The                 year are not eligible for incentive
                                             B. Description of the Demonstration                     target episode price will clearly indicate            payments, regardless of whether cost
                                             Project                                                 the cost build-up calculations for each               savings are achieved. TRICARE is
                                               All network and non-network                           component of care within the episode.                 following the same approach as
                                             hospitals in the Tampa-St. Petersburg                   These target episode prices will become               Medicare in order to ensure hospitals
                                             area will be required to participate in                 the basis for calculating any incentive               are not reducing the quality of care
                                             the demonstration if they had at least 20               payments or penalties.                                offered to beneficiaries or reducing
                                             TRICARE admissions for DRG 470 over                        For purposes of this demonstration,                patients’ overall perception of their
                                             the three years of FY 2013, FY 2014, and                Demonstration Year one will commence                  hospital experience.
                                             FY 2015 (excluding admissions for                       for admissions on May 23, 2016, and                      Incentive payments will be calculated
                                             beneficiaries with Other Health                         will include all completed episodes                   using the CMS gain/loss sharing model;
                                             Insurance (OHI), Active Duty Service                    with an end date continuing through                   beginning in Demonstration Year one,
                                             Members (ADSMs), and Medicare-                          September 30, 2017 (including the full                positive incentive payments will be
                                             TRICARE dual eligible beneficiaries).                   90 days post-discharge period).                       made to hospitals who achieve and
                                             Once selected for participation,                        Subsequent demonstration years will be                maintain a favorable CJR composite
                                             demonstration hospitals will remain in                  conducted on a fiscal year basis (i.e., for           quality score for the full demonstration
                                             the program throughout the duration of                  episodes ending October 1st through                   year and who demonstrate cost savings
                                             this NDAA demonstration (regardless of                  September 30th). The target episode                   as compared to the target episode price.
                                             actual TRICARE utilization) unless the                  price in effect on the date of hospital               ‘‘Downside’’ risk (negative financial
                                             Government directs otherwise.                           admission shall be used for incentive                 incentives) will not be phased into the
                                             Demonstration hospitals will be                         calculation purposes, even if a portion               payment model until the second
                                             accountable for quality and cost of care                of post-discharge care is delivered in the            demonstration year. Gain/Loss sharing
                                             for an inpatient stay that results in DRG               subsequent demonstration year.                        will increase over time, from no loss
                                             470, along with all related care provided                  During each demonstration year, all                sharing in Demonstration Year one (only
                                             during the 90-day period following                      hospital, physician, and post-acute care              gain sharing), to higher levels in later
                                             discharge.                                              claims will be paid under the normal                  years (gain sharing of 5 percent in
                                               The Defense Health Agency (DHA)                       TRICARE reimbursement                                 Demonstration Years one and two, and
                                             will prospectively establish target                     methodologies. At the end of each                     10 percent in Demonstration Year
                                             episode prices for each demonstration                   demonstration year, the total costs of all            three). Loss sharing is 0 in
                                             hospital at least 30 days prior to the                  completed episodes for the year will be               Demonstration Year one, 5 percent in
                                             start of each demonstration year. This                  compared to the aggregate target episode              Demonstration Year two, and 10 percent
                                             target episode price shall be based on                  price for each demonstration hospital to              in Demonstration Year three.
                                             TRICARE claims for DRG 470                              determine whether actual costs were                      On a quarterly basis, demonstration
                                             admissions and associated post-                         less than, equal to, or greater than the              hospitals will receive feedback from the
                                             operative care for FY 2013, FY 2014,                    target episode price. In order to ensure              MCSCs on their current quality
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                                             and FY 2015, and shall be a blend of                    all costs are properly attributed to each             performance (as identified in Hospital
                                             hospital-specific and market-wide                       demonstration hospital, actual cost                   Compare), episode of care costs to date,
                                             historical episode costs. This historical               calculations shall occur no sooner than               and projected eligibility for incentives
                                             data period shall be used for the                       90 calendar days following the end of                 (based on TRICARE claims and
                                             duration of the demonstration, with                     the demonstration year to allow                       Medicare’s composite quality scores for
                                             annual adjustments for inflation. In                    adequate time for claims processing. In               each hospital). To facilitate effective
                                             Demonstration Years one and two, the                    order to encourage use of the direct care             communication with demonstration


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                                                                           Federal Register / Vol. 81, No. 59 / Monday, March 28, 2016 / Notices                                                   17161

                                             hospitals, these quarterly reports shall                ADDRESSES:   To access and review all the               Type of Review: An extension of an
                                             mirror the format and detail of CMS’s                   documents related to the information                  existing information collection.
                                             feedback reports to the extent feasible.                collection listed in this notice, please                Respondents/Affected Public: State,
                                             Active Duty Service Members (ADSMs),                    use http://www.regulations.gov by                     Local, and Tribal Governments; Private
                                             Medicare-TRICARE Dual Eligible                          searching the Docket ID number ED–                    Sector.
                                             (TDEFIC) beneficiaries, and                             2016–ICCD–0009. Comments submitted                      Total Estimated Number of Annual
                                             beneficiaries with Other Health                         in response to this notice should be                  Responses: 2,072.
                                             Insurance (OHI) are excluded from this                  submitted electronically through the                    Total Estimated Number of Annual
                                             demonstration.                                          Federal eRulemaking Portal at http://                 Burden Hours: 11,397.
                                                                                                     www.regulations.gov by selecting the                    Abstract: The collection of
                                             C. Communications                                                                                             information is necessary under section
                                                                                                     Docket ID number or via postal mail,
                                               The DHA will proactively educate                      commercial delivery, or hand delivery.                485 of the Higher Education Act of
                                             beneficiaries, providers, and other                     Please note that comments submitted by                1965, as amended, with the goal of
                                             stakeholders about this change.                         fax or email and those submitted after                increasing transparency surrounding
                                                                                                     the comment period will not be                        college athletics for student, prospective
                                             D. Evaluation                                                                                                 students, parents, employees and the
                                                                                                     accepted. Written requests for
                                               This demonstration project will assist                information or comments submitted by                  general public. The survey is a
                                             the Department in evaluating whether                    postal mail or delivery should be                     collection tool to compile the annual
                                             value-driven incentives will result in a                addressed to the Director of the                      data on college athletics. The data
                                             reduction in the rate of increase in                    Information Collection Clearance                      collected from the individual
                                             health care spending and improvements                   Division, U.S. Department of Education,               institutions by ED and is made available
                                             in health care quality, patient                         400 Maryland Avenue SW., LBJ, Room                    to the public through the Equity in
                                             experience of care, and overall health of               2E–103, Washington, DC 20202–4537.                    Athletics Data Analysis Cutting Tool as
                                             TRICARE beneficiaries. Regular status                                                                         well as the College Navigator.
                                             reports and a full analysis of                          FOR FURTHER INFORMATION CONTACT:      For
                                                                                                     specific questions related to collection                Dated: March 23, 2016.
                                             demonstration outcomes will be                                                                                Kate Mullan,
                                             conducted consistent with the                           activities, please contact Ashley
                                                                                                     Higgins, 202–219–7061.                                Acting Director, Information Collection
                                             requirements in Section 726 of the 2016                                                                       Clearance Division, Office of the Chief Privacy
                                             NDAA. Future expansions of the                          SUPPLEMENTARY INFORMATION:       The                  Officer, Office of Management.
                                             demonstration project to additional                     Department of Education (ED), in                      [FR Doc. 2016–06890 Filed 3–25–16; 8:45 am]
                                             locations may be considered based on                    accordance with the Paperwork                         BILLING CODE 4000–01–P
                                             DHA data analysis for the Tampa-St.                     Reduction Act of 1995 (PRA) (44 U.S.C.
                                             Petersburg market. Details of any future                3506(c)(2)(A)), provides the general
                                             expansions will be announced via                        public and Federal agencies with an
                                                                                                                                                           DEPARTMENT OF ENERGY
                                             Federal Register notice prior to                        opportunity to comment on proposed,
                                             implementation.                                         revised, and continuing collections of                [FE Docket No. 16–29–LNG]
                                               Dated: March 22, 2016.                                information. This helps the Department
                                                                                                     assess the impact of its information                  Cheniere Marketing, LLC; Application
                                             Aaron Siegel,                                                                                                 for Blanket Authorization To Export
                                                                                                     collection requirements and minimize
                                             Alternate OSD Federal Register Liaison                                                                        Previously Imported Liquefied Natural
                                             Officer, Department of Defense.
                                                                                                     the public’s reporting burden. It also
                                                                                                     helps the public understand the                       Gas on a Short-Term Basis
                                             [FR Doc. 2016–06859 Filed 3–25–16; 8:45 am]
                                                                                                     Department’s information collection                   AGENCY:   Office of Fossil Energy, DOE.
                                             BILLING CODE 5001–06–P
                                                                                                     requirements and provide the requested                ACTION:   Notice of application.
                                                                                                     data in the desired format. ED is
                                                                                                     soliciting comments on the proposed                   SUMMARY:   The Office of Fossil Energy
                                             DEPARTMENT OF EDUCATION                                 information collection request (ICR) that             (FE) of the Department of Energy (DOE)
                                                                                                     is described below. The Department of                 gives notice of receipt of an application
                                             [Docket No.: ED–2016–ICCD–0009]                         Education is especially interested in                 (Application), filed on March 7, 2016,
                                                                                                     public comment addressing the                         by Cheniere Marketing, LLC (CMI),
                                             Agency Information Collection                           following issues: (1) Is this collection              requesting blanket authorization to
                                             Activities; Submission to the Office of                 necessary to the proper functions of the              export liquefied natural gas (LNG)
                                             Management and Budget for Review                        Department; (2) will this information be              previously imported into the United
                                             and Approval; Comment Request;                          processed and used in a timely manner;                States from foreign sources in an
                                             Campus Equity in Athletics Disclosure                   (3) is the estimate of burden accurate;               amount up to the equivalent of 500
                                             Act (EADA) Survey                                       (4) how might the Department enhance                  billion cubic feet (Bcf) of natural gas on
                                             AGENCY: Office of Postsecondary                         the quality, utility, and clarity of the              a short-term or spot market basis for a
                                             Education (OPE), Department of                          information to be collected; and (5) how              two-year period commencing on June 7,
                                             Education (ED).                                         might the Department minimize the                     2016.1 CMI seeks authorization to
                                                                                                     burden of this collection on the                      export the LNG from the Sabine Pass
                                             ACTION: Notice.
                                                                                                     respondents, including through the use                LNG terminal owned by Sabine Pass
                                             SUMMARY:  In accordance with the                        of information technology. Please note                LNG, L.P. located in Cameron Parish,
                                                                                                     that written comments received in                     Louisiana, to any country with the
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                                             Paperwork Reduction Act of 1995 (44
                                             U.S.C. chapter 3501 et seq.), ED is                     response to this notice will be                       capacity to import LNG via ocean-going
                                             proposing an extension of an existing                   considered public records.                            carrier and with which trade is not
                                             information collection.                                    Title of Collection: Campus Equity in
                                                                                                                                                             1 CMI’s current blanket authorization to export
                                             DATES: Interested persons are invited to                Athletics Disclosure Act (EADA)
                                                                                                                                                           previously imported LNG, granted in DOE/FE Order
                                             submit comments on or before April 27,                  Survey.                                               No. 3442 on June 6, 2014, extends through June 6,
                                             2016.                                                      OMB Control Number: 1840–0827.                     2016.



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Document Created: 2016-03-26 00:12:57
Document Modified: 2016-03-26 00:12:57
CategoryRegulatory Information
CollectionFederal Register
sudoc ClassAE 2.7:
GS 4.107:
AE 2.106:
PublisherOffice of the Federal Register, National Archives and Records Administration
SectionNotices
ActionNotice of demonstration.
ContactFor questions pertaining to this demonstration, please contact Ms. Debra Hatzel at (303) 676-3572.
FR Citation81 FR 17159 

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