TRICARE Launches Urgent Care Pilot, Simplifies EHR Sharing

by U.S. Medicine

August 7, 2016

By Annette M. Boyle

Vice Admiral Raquel Bono, director of DHA

Vice Admiral Raquel Bono, director of DHA

WASHINGTON— The Defense Health Agency (DHA) launched two programs this summer to ease access to care and improve communication between military and civilian healthcare providers. The Urgent Care Demonstration enables TRICARE Prime beneficiaries to receive medical care at civilian urgent care centers for the first time, while the Virtual Lifetime Electronic Record simplifies medical record sharing.

The three-year pilot urgent care program, mandated by the 2016 National Defense Authorization Act, allots patients up to two urgent care visits per year without requiring prior authorization or referral, or incurring deductibles or co-pays. TRICARE Overseas enrollees do not face a cap on the number of visits to domestic urgent care facilities.

The program aims to keep TRICARE members out of the emergency department (ED) when they could be more quickly—and less expensively—treated elsewhere. “We recognize there are some times when our patients don’t really need an emergency room, but they do need access to urgent care,” said Vice Admiral Raquel Bono, director of DHA.

Previously, visits to civilian urgent care clinics required authorization, while care provided in an ED did not. The program “will reduce the burden for beneficiaries who need medical care after-hours or while traveling,” explained Shane Pham, a member of the DHA Policy and Operations Directorate.

For servicemembers based overseas, “it’s a huge benefit. They had such a problem getting a primary care manager referral when they came back to the U.S.,” Pham added.

In 2014, TRICARE spent $4.9 million on primary care provided through EDs, compared to many times that for actual emergencies. “That’s not much, compared to the $6 billion in patients seen,” said Regina Julian, MHA, MBA, DHA’s chief of Patient-Centered Integrated Care, Experience and Access.

“People had an idea that a lot more of our patients were going to network emergency rooms than actually were. Based on industry standards, we found that our patients do a good job of not going to the emergency room when not warranted in a prudent layperson’s opinion,” she noted.

Nurse Advice Line

The Nurse Advice Line, which launched in 2014, helps beneficiaries evaluate whether they need to go to an urgent care center or emergency room or instead wait to see their primary care provider the following day. The line fields 1,800 calls per day, and the numbers continue to rise each month. In an emergent situation, the nurse activates the emergency medical system and remains on the line until an ambulance arrives.

If the nurse recommends urgent care, he or she will locate a civilian network clinic or attempt to book an appointment either with the patient’s primary care manager at a military treatment facility (MTF), if open, or an MTF urgent care center. The Nurse Advice Line successfully secures same-day or next-day appointments at local MTFs about 60% of the time, according to Julian.

For MTF Prime enrollees, urgent care visits recommended by the Nurse Advice Line do not count against the two-visit limit. Network Prime members, on the other hand, need to contact their primary care manager after the visit to ensure it does not count as a self-referred visit.

Some issues will likely arise in the early stages of implementation, but Bono asserted that DHA would make the urgent care program work. “It will be right in line with what the Military Health System, Congress, and DHA have worked hard to achieve, being responsive to the needs of patients,” she told U.S. Medicine and other media on a conference call earlier this year.

Medical Record Sharing

Another initiative launched in June enables providers in the Military Health System (MHS) to share TRICARE beneficiary medical data with other federal and private healthcare providers through a health information exchange (HIE). Part of the Virtual Lifetime Electronic Record (VLER) Health Initiative, the program is designed to “ensure continuity of care by providing a comprehensive look at a patient’s medical record,” regardless of where they receive medical care, Bono said.

The close collaboration of the VA and DoD already allows more than 75,000 providers in both agencies to view individual medical records in the counterpart system through the Joint Legacy Viewer. VLER will increase interoperability to include TRICARE network partners who provide more than half the care provided to the population, Bono said at a legislative hearing this spring.

As of June 1, MHS began sharing non-active duty TRICARE beneficiary data as well. Currently, 11 large provider networks are connected to the MHS, including Innova and Centara.

Active duty personnel cannot opt out of VLER, but non-active duty enrollees can do so and request to opt back in later. The DHA encourages all beneficiaries to enable sharing of their medical data with other providers, as it can improve the speed, quality, safety and cost of care.

“Imagine a scenario where a provider in the emergency room in the private sector needs access to your medical history to provide the safest and right care,” Julian said. MHS could not share that information, for a beneficiary who opted out. The benefits of data sharing go both directions. “If you’re treated in the private sector, your primary care team may need to see your test results to provide appropriate care in the MTF,” she noted.

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