DOD Health Care:

Further Testing and Evaluation of Case-Managed Home Health Care Is Needed

HRD-93-59: Published: May 21, 1993. Publicly Released: May 21, 1993.

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Pursuant to a congressional request, GAO provided information on the Department of Defense's (DOD) 1986 and 1988 Civilian Health and Medical Program for the Uniformed Services (CHAMPUS) home care demonstration projects, focusing on: (1) whether the projects yielded sufficient information to adequately identify beneficiaries, prevent program abuse, and determine when and how to provide case management; (2) the reasonableness of CHAMPUS cost savings estimates; and (3) potential overlap between CHAMPUS and the DOD Coordinated Care Program.

GAO found that: (1) neither of the demonstration projects provided sufficient case information for early identification of patients requiring home care and permanent high-cost benefits; (2) although CHAMPUS has not yet developed adequate internal controls to prevent program abuse and control access to home care services, the 1986 project's internal controls seemed reasonable; (3) CHAMPUS projects have not developed sufficient information to identify when case management is needed, the type of case management services required, and efficient and effective ways of delivering case management services; (4) although the two CHAMPUS projects have realized some savings, the claimed savings under both projects could be overstated by up to 31 percent because of inappropriate CHAMPUS cost accounting methods, flawed contractor accounting methods, and inaccurate project management cost accounting; and (5) DOD needs to determine the most cost-effective plan of delivering home care benefits and ways of integrating CHAMPUS into its new Coordinated Care Program to avoid potential overlap between the two programs.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In October 1995, DOD published its final rule in the Federal Register implementing a permanent case-managed home care benefit, including preauthorization and preadmission screening, continued stay authorization, and retrospective claims analysis. These elements are also part of managed care support contracts now being awarded.

    Recommendation: The Secretary of Defense should, before implementing a permanent case-managed home care benefit, evaluate alternative identification methods, such as hospital preadmission certification, to target potential recipients of case-managed home care.

    Agency Affected: Department of Defense

  2. Status: Closed - Implemented

    Comments: In October 1995, DOD published its final rule requiring that benefits be certified as medically necessary, appropriate, and cost-effective, with recertification at least every 30 days.

    Recommendation: The Secretary of Defense should, before implementing a permanent case-managed home care benefit, develop specific medical or cost controls to limit access to case-managed home care to patients for whom there is a reasonable likelihood that the care will be cost-effective.

    Agency Affected: Department of Defense

  3. Status: Closed - Implemented

    Comments: In October 1995, DOD published its final rule identifying varying levels of assistance that beneficiaries may need when accessing health care services through CHAMPUS. DOD's guidance includes criteria for onsite versus telephone case management.

    Recommendation: The Secretary of Defense should, before implementing a permanent case-managed home care benefit, determine: (1) when CHAMPUS case management is needed; (2) when on-site rather than telephone case management is appropriate; and (3) the most efficient way to provide case management services.

    Agency Affected: Department of Defense

  4. Status: Closed - Implemented

    Comments: In October 1995, DOD published its final rule in the Federal Register authorizing the Director of CHAMPUS to provide case management at medical treatment facilities. The case management benefit will be included as a program requirement within managed care support contracts.

    Recommendation: The Secretary of Defense should, before implementing a permanent case-managed home care benefit, determine how the administration of the CHAMPUS home care benefit fits into the overall DOD Coordinated Care Program.

    Agency Affected: Department of Defense

 

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