Military Health System Strategy Update

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Military Health SystemStrategy Update
From Strategy to Action 31 August 2009 Dr.
Mike Dinneen
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Military Health System Mission
Our team provides optimal Health Services in
support of our nations military missionanytime,
anywhere.
Healthy, Fit and Protected Force
Casualty Care Humanitarian Assistance
Education, Training Research
This represents the value the MHS delivers for
our investors
It is all about health readiness! Of the Health
Team Of the Force Of all of our beneficiaries
Healthy and Resilient Individuals, Families and
Communities
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MHS Value Measures Dashboard
Casualty Care and Humanitarian Assistance Casualty Care and Humanitarian Assistance
? Reduced Combat Losses
? Effective Medical Transition
? Improved Rehabilitation Reintegration to Force
X Increased Interoperability with Allies, Other Government Agencies and NGOs
X Reconstitution of Host Nation Medical Capability
X Strategic Deterrence for Warfare
Healthy, Fit and Protected Force Healthy, Fit and Protected Force
? Reduced Medical Non-Combat Loss
? Improved Mission Readiness
X Increased Resilience Optimized Human Performance
Healthy and Resilient Individuals, Families and Communities Healthy and Resilient Individuals, Families and Communities
? Healthy Communities/Healthy Behaviors
? Health Care Quality
? Access to Care
? Beneficiary Satisfaction
Education, Research and Performance Improvement Education, Research and Performance Improvement
? Capable MHS Work Force and Medical Force
X Advancement of Global Public Health
? Advancement of Medical Science
X Healing Environments
? Performance-Based Mgmt. and Efficient Operations
? Deliver Information to People so They Can Make Better Decisions
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MHS Value Measures Dashboard (Status, Trends and
Top 10)
Casualty Care and Humanitarian Assistance Casualty Care and Humanitarian Assistance Casualty Care and Humanitarian Assistance Casualty Care and Humanitarian Assistance
G Reduced Combat Losses Reduced Combat Losses Reduced Combat Losses
Case Fatality Ratio (OIF/OEF Combat Casualty) Case Fatality Ratio (OIF/OEF Combat Casualty) G ?
Observed/Expected Survival Rate-Battle Wounds Observed/Expected Survival Rate-Battle Wounds G ?
Mortality Rate Following Massive Transfusions Mortality Rate Following Massive Transfusions G ?
Battle-Injured Medical Complications Rate Battle-Injured Medical Complications Rate G ?
Age of Blood in Theater Age of Blood in Theater Y ?
R Effective Medical Transition Effective Medical Transition Effective Medical Transition
MEBs Completed Within 30 Days MEBs Completed Within 30 Days R ?
DES Cases Returned to MTF DES Cases Returned to MTF G ?
MEB/PEB Experience Satisfaction Rate MEB/PEB Experience Satisfaction Rate R ?
VA Transition Process (Satisfaction with Records Availability) VA Transition Process (Satisfaction with Records Availability) R ?
G Improved Rehabilitation Reintegration to Force Improved Rehabilitation Reintegration to Force Improved Rehabilitation Reintegration to Force
Amputee Functional Re-Integration Rate Amputee Functional Re-Integration Rate G ?
Psychological Distress Screening, Referral and Engagement Psychological Distress Screening, Referral and Engagement X X
PTSD Screening, Referral and Engagement PTSD Screening, Referral and Engagement X X
PTSD Intensity of Care PTSD Intensity of Care X X
TBI Screening and Referral TBI Screening and Referral X X
Potential Alcohol Problems and Referral Potential Alcohol Problems and Referral X X
Increased Interoperability with Allies, Other Government Agencies and NGOs Increased Interoperability with Allies, Other Government Agencies and NGOs Increased Interoperability with Allies, Other Government Agencies and NGOs
Under Development Under Development X X
Reconstitution of Host Nation Medical Capability Reconstitution of Host Nation Medical Capability Reconstitution of Host Nation Medical Capability
Under Development Under Development X X
Strategic Deterrence for Warfare Strategic Deterrence for Warfare Strategic Deterrence for Warfare
Under Development Under Development X X
Healthy, Fit and Protected Force Healthy, Fit and Protected Force Healthy, Fit and Protected Force Healthy, Fit and Protected Force
Y Reduced Medical Non-Combat Loss Reduced Medical Non-Combat Loss Reduced Medical Non-Combat Loss
Force Immunization Rate Force Immunization Rate Y ?
Orthopedic Injuries Rate in Theater Orthopedic Injuries Rate in Theater R ?
Orthopedic Injuries Rate in Garrison (Non-Deployed) Orthopedic Injuries Rate in Garrison (Non-Deployed) G ?
Influenza-Like Illness Rate in Theater Influenza-Like Illness Rate in Theater R ?
Influenza-Like Illness Rate in Garrison (Non-Deployed) Influenza-Like Illness Rate in Garrison (Non-Deployed) G ?
Psychological Health In-Theater Evacuations/ Encounters Psychological Health In-Theater Evacuations/ Encounters R ?
R Improved Mission Readiness Improved Mission Readiness Improved Mission Readiness
Armed Forces Personnel Without Deployment Limiting Medical Conditions Armed Forces Personnel Without Deployment Limiting Medical Conditions R ?
Undetermined Medical Readiness Status Undetermined Medical Readiness Status R ?
Increased Resilience Optimized Human Performance Increased Resilience Optimized Human Performance Increased Resilience Optimized Human Performance
Under Development Under Development X X
Healthy and Resilient Individuals, Families and Communities Healthy and Resilient Individuals, Families and Communities Healthy and Resilient Individuals, Families and Communities Healthy and Resilient Individuals, Families and Communities
Y Healthy Communities/Healthy Behaviors Healthy Communities/Healthy Behaviors Healthy Communities/Healthy Behaviors
MHS Cigarette Use Rate MHS Cigarette Use Rate Y ?
Active Duty Lost Work Days Rate Active Duty Lost Work Days Rate R ?
MHS Body Mass Index Rate MHS Body Mass Index Rate Y ?
Alcohol Screening/Assessment Rate Alcohol Screening/Assessment Rate G ?
FAP Substantiated Child/Spouse Abuse Rate FAP Substantiated Child/Spouse Abuse Rate G ?
Influenza Immunization Rate Influenza Immunization Rate R ?
Mental Health Demand-Family of Service Members Mental Health Demand-Family of Service Members X X
Active Duty Suicide Rate (Probable/Confirmed) Active Duty Suicide Rate (Probable/Confirmed) R ?
Y Health Care Quality Health Care Quality Health Care Quality
Enrollee Preventive Health Quality Index (HEDIS) Enrollee Preventive Health Quality Index (HEDIS) Y ?
Overall Hospital Quality Index (ORYX) Overall Hospital Quality Index (ORYX) Y ?
CONUS Ventilator Associated Pneumonia Rate CONUS Ventilator Associated Pneumonia Rate X X
Health Care Personnel Flu Vaccination Rate Health Care Personnel Flu Vaccination Rate X X
Hospitalization 30-Day Disease Mortality Rate Hospitalization 30-Day Disease Mortality Rate G ?
R Access to Care Access to Care Access to Care
No Problem Getting Needed Care Rate No Problem Getting Needed Care Rate Y ?
Percent of Time MTF Enrollees See Their PCM When PCM in Clinic Percent of Time MTF Enrollees See Their PCM When PCM in Clinic R ?
Booking Success Rates for Primary Care Appointing Booking Success Rates for Primary Care Appointing R ?
Primary Care Third Available Routine Appointment Primary Care Third Available Routine Appointment R ?
Y Beneficiary Satisfaction Beneficiary Satisfaction Beneficiary Satisfaction
Satisfaction with Provider Communication Satisfaction with Provider Communication Y ?
Satisfaction with Health Care Satisfaction with Health Care Y ?
Satisfaction with Health Plan Satisfaction with Health Plan G ?
Education, Research and Performance Improvement Education, Research and Performance Improvement Education, Research and Performance Improvement Education, Research and Performance Improvement
G Capable MHS Work Force and Medical Force Capable MHS Work Force and Medical Force Capable MHS Work Force and Medical Force
Mental Health Provider Staffing Mental Health Provider Staffing X X
Competitive Direct Hire Activity Medical Professionals Competitive Direct Hire Activity Medical Professionals G ?
Advancement of Global Public Health Advancement of Global Public Health Advancement of Global Public Health
Under Development Under Development X X
Y Advancement of Medical Science Advancement of Medical Science Advancement of Medical Science
Peer-Reviewed Journal Article Publication Rate Peer-Reviewed Journal Article Publication Rate Y ?
Healing Environments Healing Environments Healing Environments
Under Development Under Development X X
R Performance-Based Mgmt. and Efficient Operations Performance-Based Mgmt. and Efficient Operations Performance-Based Mgmt. and Efficient Operations
Annual Cost Per Equivalent Life (PMPM) Annual Cost Per Equivalent Life (PMPM) R ?
Enrollee Utilization of Emergency Services Enrollee Utilization of Emergency Services R ?
Provider Productivity Provider Productivity R ?
Bed Day Utilization (Prime Enrollees) Bed Day Utilization (Prime Enrollees) X X
R Deliver Information to People so They Can Make Better Decisions Deliver Information to People so They Can Make Better Decisions Deliver Information to People so They Can Make Better Decisions
AHLTA Reliability AHLTA Reliability R ?
AHLTA Speed AHLTA Speed Y ?
AHLTA Satisfaction AHLTA Satisfaction X X
DMHRSi/EAS-IV Transmissions by Service DMHRSi/EAS-IV Transmissions by Service R ?
Denotes Recommended Tactical Imperatives
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Strategy to Action Addressing our Performance
Gaps
Performance Gap
Actions
Mission Outcome Value Measure for Tactical Imperative FY09 Current Perf FY10 Target FY12 Target FY14 Target Root Cause of Performance Gap Strategic Initiatives Action Steps
Effective Medical Transition MEBs Completed within 30 Days 40 80 Expansion of DES Pilot Continuous Process Improvement efforts
Effective Medical Transition MEB/PEB Experience Satisfaction Rate 46 80 Expansion of DES Pilot Continuous Process Improvement efforts
Improved Mission Readiness Deployment Limiting Medical Conditions 84 92
Health Care Quality Enrollee Preventive Health Quality Index (HEDIS) 18 20 Patient Centered Medical Home (PCMH) Family Health Initiative (FHI) MHS Quality Program
Health Care Quality Overall Hospital Quality Index (ORYX) 81 80 Patient Centered Medical Home (PCMH) Family Health Initiative (FHI) MHS Quality Program
Access to Care No Problem Getting Needed Care 74 75 PCMH FHI
Access to Care Percent of Time MTF Enrollees See their PCM When PCM in Clinic 45 70 PCMH FHI
Beneficiary Satisfaction Satisfaction with Health Care 57 60 PCMH FHI WII Programs
Performance Based Management Increase in Annual Cost per Equivalent Life (PMPM) 12.7 5.0 PCMH FHI Mini QDR Driving Home Delivery IIP
Performance Based Management Enrollee Utilization of Emergency Services 80 40 PCMH FHI Mini QDR Driving Home Delivery IIP
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Over-Arching Strategy Health Care to Health

• Build a team committed to health
• Earn trust by being trustworthy
• Engage our military family in being healthy
• Enhance healthy behaviors
• Achieve the Triple Aim plus Readiness
• Quality first cost will follow
• But, what is the current reality?

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Percent of Time MTF Enrollees See Their PCM When
PCM in Clinic
R
Target
Although the trend lines appear flat, linear
regression reveals significant but small
improvement in all three Services (R2 gt 0.50)
each month, approximately 8,000 additional visits
are linking patients with their PCM.
Measure Advocate Dr. Mike Dinneen HA-OSM (703)
681-1712 Monitoring Weekly Data Source TOC /
CHCS/AHLTA Other Reporting None (Available on
MHS Insight)
Good
Data Source CHCS extract
What are we measuring? This is a retrospective
look at the percentage of time an MTF enrollee
sees their assigned PCM when that provider is
working in the clinic on that particular day.
This measure reflects all appointment types for
primary care. Why is it important? We want to
know if people are seeing their personal
provider. Our hypothesis is that if people have
an ongoing relationship with a single provider
they will be more satisfied, they will be more
likely to become effective partners in their
health and costs will be lower because we will
avoid rework. What does our performance tell us?
For the 10 months of data captured the MHS
average is remaining fairly constant at 44.
Pilot tests of the Patient Centered Medical Home
have been in place since mid-2008 and early
reports indicate an increase in PCM continuity
with the PCMH.
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No Problem Getting Needed Care Rate
Y
Civilian Benchmark (Long Term Goal)
Measure Advocate Dr. Rich Bannick TMA-HPAE
[phone] Monitoring Quarterly Data
Source Health Care Survey of DoD
Beneficiaries Other Reporting None
Near Term Goal
Good
Although enrollees to MCSC continue to rate
satisfaction with getting needed care 5 above
MTF enrollees, we are continuing to see
improvement across the enterprise change in
version of survey could be affecting results.
Assessment Criteria
R
lt 68
Status
What are we measuring? This is a composite of 4
questions from Consumer Assessment of Healthcare
Providers and Systems (CAHPS) (1) How much of a
problem, if any, was it to get a personal MD or
RN you are happy with? (2) In the last 12
months, how much of a problem, if any, was it a)
to see a specialist that you needed to see, b) to
get the care, tests or treatment you or a doctor
believed necessary?, or c) delays in healthcare
while you waited for plan approval? Why is it
important? This measures provides insight into
beneficiary perceptions regarding ability to get
needed care. If the percentage is low, managers
can take action to pinpoint and resolve wherever
the problems are. . What does our performance
tell us?. The lowest measure in the set is
problems in getting a personal MD or RN that
patient is happy with. Lack of administrative
delays almost meets the civilian benchmark. 95
confidence interval for all TRICARE users are 1,
for Air Force Prime enrollees /-2 for Army,
Navy, MCSC they are /-3..
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Percentage of Beneficiaries Satisfied With Health
Care
Y
Current goal is 10 below median performance of
the 250 health systems that participate in CAHPS
survey. Should we raise the target since we are
focusing a great deal of effort on becoming more
patient centered?
Civilian Benchmark
Measure Advocate Dr. Rich Bannick TMA-HPAE
[phone] Monitoring Quarterly Data
Source Health Care Survey of DoD
Beneficiaries Other Reporting Status of
Forces/ Well Being of the Force
Good
Short Term Goal
Assessment Criteria
What are we measuring? Measures beneficiaries
answers to question Using 0 to 10, where 0 is
the worst possible and 10 is the best, how would
you rate all your health care? Responses of 8,
9, or 10 indicate patient satisfaction.
Benchmark comes from Consumer Assessment of
Health Plans Study (CAHPS) (average of 250 health
plans). Why is it important? This measures
provides insight into beneficiary perceptions
regarding health care satisfaction. What does
our performance tell us? As a mark of progress
toward the civilian benchmark, we have a short
term goal of 60. During the 3rd quarter of this
year satisfaction has fallen and additional
effort needs to be made in working towards the
civilian benchmark.
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Enrollee Preventative Health Quality Index (HEDIS)
Y
Service led pay for performance initiatives
appear to have had a positive effect since Army
Navy have seen consistent gains AF has remained
stable.
Measure Advocate COL John Kugler TMA-OCMO (703)
681-0064 Monitoring Quarterly Data Source
Population Health Portal Other Reporting None
Good
What are we measuring? This composite index
scores each Service for their Prime enrollee
population for compliance with Healthcare
Effectiveness Data and Information Set (HEDIS)
measures on seven treatment protocols (three
diabetes measures are combined into one index).
The selected HEDIS measures indicate the
pervasiveness of routine screening or treatment
in an enrolled population for five chronic or
common diseases. Scores for each Service and DoD
were assigned based on their percentile rank
using the 2006/2007 NCQA Civilian Benchmarks.
Index points are assigned for each protocol as
depicted in the table to the right and summed in
the chart above to create a total HEDIS quality
index score. Why is it important? The selected
measures support an evidence-based approach to
population health and quality assessment. It
also provides a direct comparison with civilian
health plans and a means of tracking improvements
in disease screening and treatment. Improved
scores in this measure should translate directly
to a healthier beneficiary population, reduced
acute care needs, and reduced use of integrated
health system resources. What does our
performance tell us? The MHS is experiencing a
positive affect from focus on preventative
measures and the pay for performance initiatives
and is on track to meet goal of overall score of
20 by Jan 2010. Army and Navy both report a
continued upward trend in performance with Navy
exceeding the Jan 2010 goal. A review of
individual measures reveals that process measures
(HgA1c screening) are improving in advance of
outcomes measures but both are improving.
gt 90 5
lt90th and gt75th 4
lt75th gt50th 3
lt50th and gt25th 2
lt25th and gt10th 1
lt10th 0
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Enrollee Utilization of Emergency Services
R
Measure Advocate Dr. Bob Opsut HA-HBFP (703)
681-1724 Monitoring Monthly Data Source M2
TED-NI/DC SADR/Relationship Detail Other
Reporting None
Target
Good
What are we measuring? This measure is derived
using EM codes 99281 through 99285. Purchased
care is limited to the non-institutional program
indicator code and place of service being an
emergency room or hospital outpatient treatment.
Direct care parameters were limited to the MEPRS3
code BIA (emergency room). Enrollees were
restricted to those in regions North, South,
West and Alaska. The expected rate of
utilization is based on the National Hospital
Ambulatory Care Survey (2006) Emergency
Department Utilization, adjusted for the MHS
population constituting each Service. Why is it
important? Measuring emergency room utilization
enables us to determine if our enrollees are
appropriately using this service or is this being
used as a fall back because of access issues.
What does our performance tell us? Utilization
of ER services among TRICARE Prime enrollees is
increasing over time. Prime enrollees are using
these services 1.7 times more than the national
utilization rate.
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R
Average Percent Defense Health Program Annual
Cost Per EquivalentLife Increase Compared to
Average Private Sector Increase
Measure Advocate Dr. Bob Opsut HA-HBFP (703)
681-1724 Monitoring Monthly Data Source
M2 (SIDR/SADR/HCSR-I/HCSR-NI PDTS) Other
Reporting Services, Well Being of the Force
Good
Note Enrollees adjusted for age/gender current
as of Aug 09 measure reported through Mar 09
(portions of value are projected due to missing
expense data from MTFs)
What are we measuring? The average percent
Defense Health Program annual cost per equivalent
life increase compared to average civilian sector
premium increase. Why is it important? This
metric looks at how well the Military Health
System manages the care for those individuals who
have chosen to enroll in a health maintenance
organization-type of benefit. It is designed to
capture aspects of three major management issues
(1) how efficiently the Military Treatment
Facilities (MTF) provides care (2) how
efficiently the MTF manages the demand of its
enrollees and (3) how well the MTF determines
which care should be produced inside the facility
versus that purchased from a managed care support
contractor. What does our performance tell us?
Direct Care units cost for Inpatient and
Outpatient are major drivers. Additionally,
there has been a rise in Outpatient utilization.
Majority of increase for NADD has occurred in the
last year. Army and Navy are the highest cost
per equivalent life and percentage increase. Air
Force data this year is overstated due to issues
with their financial system. (Note Still
missing 7 Army sites for at least 1 month, and
accordingly project with a penalty for the
missing data).
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Aspirational, Achievable Vision A Fully
Integrated Military Health System That Can
Achieve the Triple Aim Readiness

• By Focusing on the Triple Aim the MHS will
• Implement a true medical home
• Use data in a transparent manner to measure and
  create value
• Align incentives with health outcomes
• Foster innovation that serves population health
• Reduce costs by focusing on quality (helping our
  customers do the job they need to do better)

Readiness
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Longer Term Initiatives Comprehensive Health
Care Reform

• Knowledge Management / Best Practice Transfer
• Incentives for Health
• Pay for Value

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Three Domains
Care Delivery Domain
Knowledge Domain
PayerDomain

• Examples
• NIH
• USU
• DCoE

• Examples
• Mayo Clinic
• Kaiser
• Cleveland Clinic
• MHS

• Examples
• Blue Cross/Blue Shield
• Government
• GM
• TRICARE / MHS

In USA 17 years
? No reimbursementfor product offering
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Three Domains
Care Delivery Domain
Knowledge Domain
PayerDomain

• Examples
• NIH
• USU
• DCoE

• Examples
• Mayo Clinic
• Kaiser
• Cleveland Clinic
• MHS

• Examples
• Blue Cross/Blue Shield
• Government
• GM

In USA 17 years
? No reimbursementfor product offering
Insurance for AllFEHBP Model Or TRICARE
Science ofHealth CareDelivery
Create Value
Payfor Value
IndividualizedMedicine
Coordinated/Integrated Care
Great Book The Innovators Prescription by
Clayton Christensen