military health system: the defense health agency in...

Military Health System: The Defense Health Agency in 2016

VADM (Dr) Raquel Bono

Director, Defense Health Agency December 1, 2015

“Medically Ready Force…Ready Medical Force”

Presenter

Presentation Notes

Shift in leadership Building on FOC that Gen Robb brought us to Imperative to address what DHA was to established to accomplish 10 shared services as that prism not only as support and products we give to medical services, but also our ability to help commands in their missions Medical education and training Health plan itself: some of objectives at IOC were on the margins, but how much about future/where we’re going?

The Defense Health Agency Fully Operational / Continuity of Mission

1 “Medically Ready Force…Ready Medical Force”

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“The imperative of successful MHS Governance reform requires a sustained

commitment by all components to adapt an enterprise focus, including the renewed

priority of quality, patient safety and access throughout the entire MHS and the challenge

of transitioning to a new, state-of-the-art electronic health record. Jointness, cost effectiveness and healthcare integration

remain the guiding vision.” -DepSecDef Work September 2015


The Defense Health Agency Fully Operational / Continuity of Mission

Why We Are Here

• It’s on every slide… • Medically Ready Force

• Ready Medical Force


Presenter

Presentation Notes

Most important - everything we do is tied to these two outcomes. Everything.

Our 2016 Priorities

• Support to the Services

• Support to Combatant Commanders

• Optimizing the DHA for the Future


Defense Health Agency Leadership Team

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Vice Admiral Raquel Bono Director

Mr. Guy Kiyokawa Deputy Director

CMSgt Vottero Acting Sr. Enlisted Advisor

MG Richard Thomas Director

Healthcare Operations

RADM Bruce Doll Director

Research & Development

Brig Gen Robert Miller Director

Education & Training

MG Jeffrey Clark Acting Director

NCR-Medical Directorate

Mr. David Bowen Director

Health IT

Mr. Darrell Landreaux Acting Director

Business Support


Defense Health Agency Global Operations / Global Support

TRO West TRO South METC Health IT

DHA - Aurora

TRO North Defense Health Agency

TRICARE Pacific TRICARE Europe:

MMSO Great Lakes

“Medically Ready Force…Ready Medical Force” 7

Armed Forces Med Examiner

Armed Forces Hlth Surveillance Center Natl Museum of Hlth and Medicine Walter Reed Natl Mil Med Center Ft Belvoir Cmty Hospital

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DHA as a Combat Support Agency


DHA Shared Services

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TRICARE Health Plan FOC 29 Sep 15

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Pharmacy Programs FOC 29 SEP 15

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Medical Education & Training * Pending 90-Day Review

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Research, Development & Acq FOC 29 SEP 15

Health Information Technology FOC 29 SEP 15

Facilities FOC 3 March 15

Budget & Resource Management FOC 29 SEP 15

Medical Logistics FOC 3 March 15

Procurement/Contracting FOC 29 SEP 15

Public Health FOC 29 SEP 15

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Presenter

Presentation Notes

Updated slide?

Pharmacy

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Presentation Notes

Pharmacy is one of our first fully mature shared services Shows the full capability of the Agency being able to work agency to agency enhances our ability to actually address these issues

Note: DHP Compound Pharmacy Expense represented by under age 65 beneficiaries

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Compound Drugs Cost Trend and Impact from Screening

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Presentation Notes

We saw a problem creeping up in 2014 Alerted policy leaders as well as Congress Started to inform stakeholders of our plans to make changes


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Presenter

Presentation Notes

Industry saw our initial steps and draft rule-making Some tried to take advantage of that to profiteer in this period There wasn’t breakthrough drugs – this was simple profiteering, and – in some cases – potential criminal activity



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May 1-May 11 (Initial Screen): $75M May 12-May 31 (Enhanced Screen) : $5M

Spend peaked in April 2015 - $545M Last week in April alone over $200M

Presenter

Presentation Notes

We lowered the boom Much more stringent policies, working in close collaboration with our Rx partner, ExpressScripts Dramatic reduction in Rx and costs that were

Addressed Fraud; Assisted Criminal Activity Justice Dept will prosecute fraud


Shared Service: Pharmacy Programs Implementing Home Delivery

• Enterprise effort to move patients to the right source for prescription medications at the lowest cost to the patient and the government • TRICARE For Life – seamless migration to Home Delivery

for chronic medications in February 2014 • All TRICARE beneficiaries – began migration on October 1

of this year • Introduced ability for civilian providers to electronically

request prescription drugs from nearby MTF • Continued to adjust Rx co-pays to incentivize quality, cost-

effective options 15

TRICARE

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Presentation Notes

Updated slide?

TRICARE 2017

• Comprehensive reassessment of how we deliver / coordinate care -- more than just “the benefit”

• How we organize and administer TRICARE – to include TRICARE contracts • Patient-centered: Modernization and

simplification of contracts and service • Expand contemporary means to access

health services beyond the physical office visit


Acute Care Campaign April 2015

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DHA: Listening to Our Customers


Based on our [NMFA] findings, we ask that the Defense Health Agency and Congress consider the following steps to improve access to acute care for military families:

• Develop and implement metrics that accurately assess acute appointment demand

• Expand clinic hours and the number of acute appointments

• Monitor progress on access initiatives

• Standardize the network urgent care referral process and monitor compliance at the MTF level

• Waive the network urgent care preauthorization requirement for a limited number of urgent care visits

• Limit the policy of directing beneficiaries to MTF emergency rooms

• Re-examine the referral policy

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DHA: Listening to Our Customers


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Access 3rd Available Appt - 24hr

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Target MHS NCRMD

LOW

ER IS BETTER


TRICARE Reform Transparency - Internal & External • The Secretary of Defense demanded it; the MHS committed to it; the law

(NDAA 2016) now describes exactly what is expected

• CMS / Hospital Compare requires it • Tied to Medicare reimbursement • VA participates in it, and shares it on its website

• Leading high reliability organizations embody it, even when it is below

benchmarks, and can rapidly drive improvement

• The media has access to the data, without needing to “ask” us (and if they ask, we are obligated to share it)

• Patients expect it


Presenter

Presentation Notes

Part of TRICARE Reform is also about transparency SECDEF demanded, and the NDAA just signed is more explicit Let me give you an example of what this looks like

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For Official Use Only

MHS Transparency…It’s Coming!

Presenter

Presentation Notes

Here is a hospital in Washington, DC They put their numbers up on Hospital Compare – and also on Leapfrog �Even when the quality needs improvement DHA will be supporting our transparency efforts through www.health.mil and www.tricare.mil

Health IT

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Shared Service: Health IT DoD Electronic Health Record

• July: Announcement of next generation Electronic Health Record (Leidos / Cerner / Accenture)

• Strategic enabler for the military medical mission

• Innovation built in to acquisition. Commercial off-the-shelf (COTS) product with 10 years of upgrades at no additional cost.

• Interoperability with federal and private sector health systems – where over 60% of our health care is delivered.

• Research support tool. EHR expands opportunity for DoD to engage in large-scale / big data research


Shared Service: Health IT DoD Electronic Health Record

• DHA will serve critical role in ensuring infrastructure, security, and clinical needs.

• RADM (Ret) Dr Bill Roberts is Functional Champion -- Important all perspectives are represented in deployment: clinicians, business leaders, support staff, and patients.


• My focus – ensuring that the EHR supports the clinical practice of medicine and enhances access, quality and safety!

Facilities

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Presenter

Presentation Notes

Updated slide?

• Standardized demand signal and prioritization process for Medical Construction requirements

• Standardized the Sustainment, Restoration, and Modernization programming models

• Providing facilities support to e-MSMs for future capital requirements

Shared Service: Health Facilities

“Medically Ready Force...Ready Medical Force” 27

• DHA onsite project management of Rhine Ordinance Barracks replacement project (Above right)

• BUILDER implementation (Enterprise-wide Facility Condition Assessment)

MedLog

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Presenter

Presentation Notes

Updated slide?

• Expanding Defense Medical Materiel Standardization Program from supply/consumables to include equipment/medical devices.

• Increasing coordination with Uniformed Services and DLA focused on improved efficiency and lower delivered material costs

• Coordinating with DHMSM Deputy PMO on medical device/equipment interface and standardization policy.

• Reducing purchase card usage, materiel costs, and risk by increasing product lines to DLA’s Electronic Catalog (ECAT).

Shared Service: Medical Logistics


• Good MEDLOG practices support Services and COCOMS!

Budget & Resource Management

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• Implementing ABACUS • Third Party Collections (TPC) for

outpatient and Medical Affirmative Claims (MAC)

• Initial implementation of guidance for a new common cost accounting structure (CCAS) to support consistent & transparent accounting transactions

Shared Service Budget & Resource Management

“Medically Ready Force...Ready Medical Force”

• Standardize medical record coding policies/procedures for all three Military Services & continue development of a HIPAA-compliant remote medical record coding capability

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Procurement/Contracting

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Presentation Notes

Updated slide?

Shared Service Procurement/Contracting

• Integrated contract service to support the full range of products and services needed throughout the organization

• Key Enablers • Simplified processes for customers • Accelerated timelines for everyone • Increased transparency for vendors • Enhanced professional acquisition workforce


Research, Development and Acquisition (RDA)

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Presentation Notes

Updated slide?

• Integrated Joint Program Committees for oversight of $2.2B medical research enterprise

• Established Clinical Investigation Research Office for multiservice clinical studies

• Integrated Armed Forces Medical Examiner System (AFMES) and Natl Museum of Health and Medicine

Shared Service Research Development & Acquisition


Public Health

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Presenter

Presentation Notes

Updated slide?

• Standardized Periodic Health Assessment…~$210M annual cost avoidance

• New Joint Staff Surgeon Quarterly Health Surveillance Report… Evolution of DHA/PHD Combat Support Agency role


Shared Service Public Health

• Collaborated w/ DLA to redistribute ~ 48.4K Doses of “expiring” Japanese Encephalitis Vaccine to MTFs with immediate need…averted $3M loss

• Armed Forces Health Surveillance Center (AFHSC) became part of DHA in August 2015

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Presenter

Presentation Notes

There have been three failed attempts over the last 10 years to standardize the PHA; through, MHS Governance, the PHD, PHA Optimization Working Group, and Public Health Collaboration & Coordination WG are collaborating to achieve ~$210M annually in cost avoidance by implementing an integrated and optimized PHA across the DoD. The optimized PHA incorporates NDAA mandated Mental Health Assessment into annual PHA. The alpha test successfully completed in July; beta test planned for early 2016. The PHA optimization provides standardization across the Services; future inclusion in DHMSM (EHR); increases analytic capabilities/health surveillance. Overall, this improves the data quality and timely reporting to executive military leaders. 2. Answered the JSS request by introducing the JSS Qtrly Health Surv Report, designed to provide strategic/operational military medical indicators of health and medical readiness to Joint Staff/COCOM SGs. The report highlights disease burden for DoD/GCC AD populations; incidence rates of mental health conditions (AD); IMR for total force; AOR vaccination compliance by GCC; etc. to enhance prevention efforts. Strengths of the report are to ID potential SM health improvement areas/cost savings; ID shortfalls/gaps in current data collection platforms/Health IT for strategic planning/policies; facilitates collaborative PH mitigation strategies among OJSS, CCMD SGs and the DHA. 3. PHD facilitated an increase in JE vaccination rates in high-risk areas, by reducing the financial cost of the vaccine to PACOM MTFs, while also reducing vaccine waste at DLA.

Education and Training

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• One Stop Learning Management System • Joint Knowledge Online (JKO) new home

for on-line tools • Joint Executive Skills Institute complete

• METC Strategic Partnerships • Bridge programs with 43 schools in 23

states that recognize military training for credit (WH Initiative)

• “Military Combat Medic to RN” in 13 months a reality

Education and Training Shared Service Highlights


Multi-Service Markets: 2 or more Services, large beneficiary population, 45% direct care dollars, large GME & readiness platforms

The Eight Largest Markets (and Service/Department Leads)

= eMSM

= Single Service

National Capital Region (DHA)

Tidewater (Navy)

Ft. Bragg (Army)

San Antonio, Texas (rotate Air Force/Army)

Oahu, Hawaii (Army)

San Diego (Navy)

Puget Sound, Washington (Army)

Colorado Springs, Colorado (rotate Air Force/Army)


DHA Support to Markets

• Analytic support for decision-making • Dashboard • Performance

• Tools and resources to advance • Access • Quality • Safety

• Important center of gravity for TRICARE Reform


MHS Performance Dashboard STRATEGIC ALIGNMENT

PERFORMANCE MEASURE DEV. STATUS MHS PERFORMANCE

THRESHOLDS COMPONENT PERFORMANCE

AIM OBJECTIVE RED GREEN BLUE A N AF NCR MD PSC AS OF DATA ENTRY

Readiness

Medically Ready Force (PLS1) Individual Medical Readiness (IMR) I 87% <75% ≥85% 90% 84% 90% 89% N/A N/A Jun 15 Sept 15

Ready Medical Force (PLS2) TBD --- --- --- --- --- --- --- --- --- --- ---

Better Health

Healthy People (PLS3) TBD --- --- --- --- --- --- --- --- --- --- ---

Improve Healthy Behaviors (IP5) HEDIS Cancer Screening Index I 63% 50% 70% 90% 88% 94% 73% 79% 36% May 15 Sept 15

Better Care

Improve Clinical Outcomes and Consistent Patient Experience (PLS4)

▼ Risk Adjusted Mortality (All Cause) E .82 TBD TBD TBD .89 .74 .63 .98 Mar 15 Sept 15 Inpatient: Recommend Hospital (Satisfaction) I 75% <71% ≥73% ≥75% 71% 75% 80% 85% 73% Mar 15 Sept 15

Overall Satisfaction w/Healthcare (Outpatient) I 94% Service Specific Service Specific Service Specific 92% 95% 96% 93% 92% Mar 15 Sept 15

Improve Safety (IP9)

▼ **HAI (CLABSI) I 14 N/A N/A 0 9 4 1 0 N/A Jun 15 Sept 15

▼ **PSI 5 - Retained Surgical Item or Unretrieved Device Fragment Count (Per Year) I 11 N/A N/A 0 10 1 0 0 N/A Dec 14 Jun 15

▼

National Surgical Quality Improvement Program (NSQIP) (30 Day) All Case Morbidity Index I 82% of

MTFs green 10th percentile 11th - 89th percentile 90th percentile Multiple scores per service N/A Dec 14 Sept 15

CAUTI 14 TBD TBD TBD 12 1 1 0 N/A Jun 15 Sept 15 Wrong Site Surgery 11 TBD TBD TBD 7 0 1 3 N/A Jun 15 Sept 15

Improve Condition-Based Quality Care (IP7)

**HEDIS Diabetes Index I 54% 50% 70% 90% 68% 80% 76% 80% 20% May 15 Sept 15 **HEDIS Appropriate Care Index (Low Back Pain, Pharyngitis, URI) I 47% 50% 70% 90% 41% 67% 63% 61% 31% May 15 Sept15

▼ NPIC Post-Partum Hemorrhage* E 3.9% 2σ above NPIC avg.(3.3%)

within 2σ of NPIC avg. (3.3%)

2σ below NPIC avg.(3.3%) 3.8% 3.6% 4.3% 5.6% N/A Dec 14 Sept 15

▼ NPIC Vaginal Deliveries w/Coded Shoulder Dystocia Linked to a Newborn ≥ 2500 grams w/Birth Trauma* I 10.9.% 2σ above NPIC

avg.(12.5%) within 2σ of NPIC

avg. (12.5%) 2σ below NPIC

avg.(12.5%) 11.2% 7.1% 16.7% 0% N/A Dec 14 Sept 15

HEDIS (30-Day) Mental Health Follow-Up I 79% 50th percentile (74%)

75th percentile (81%)

90th percentile (85%) 87% 86% 78% 85% 61% May 15 Sept 15

▼ HEDIS All Cause Readmission E 1.45 50th percentile (0.79)

75th percentile (0.73)

90th percentile (0.68) 1.46 1.39 1.27 1.80 N/A Nov 14 Jun 15

ORYX Transition of Care Index (Asthma, VTE, Inpt Psy(2)) I 50% 60% 75% 100% 44% 56% 50% 63% N/A Sept 14 Jun 15

AHRQ Prevention Quality Indicator (PQI) Index I 94% 70% 80% 90% 94% 94% 94% 94% N/A Dec 14 Sept 15

Improve Comprehensive Primary Care (IP8)

PCM Continuity I 61% 55% 65% 81% 61% 63% 61% 54% N/A Apr 15 Jun 15 PCM Empanelment E <1,100:1 1,100:1 >TBD

▼ Primary Care Leakage I 25.3% >24% 24% to > 20% ≤ 20% 22.8% 26.6% 27.5% 26.3% N/A May 15 Sept 15

▼ **Avg. No. of Days to Third Next Available Future Appointment (Primary Care) I 7.6d >7d 7.0d 2.2d 6.4d 6.8d 8.8d 11.0d N/A Aug 15 Sept 15

▼ **Avg. No. of Days to Third Next Available 24 Hour Appointment (Primary Care) I 1.7d >1d 1.0d 0.8d 1.9d 0.9d 2.0d 2.5d N/A Aug 15 Sept 15

Optimize & Standardize Access & Other Care Support Processes (IP10)

**Percent of Direct Care Enrollees in Secure Messaging I 37% <50% ≥50% ≥60% 29% 45% 42% 40% N/A July 15 Sept 15

**Satisfaction with Getting Care When Needed (Service Surveys) I 86% Service Specific Service Specific Service Specific 83% 90% 91% 83% 90% Mar 15 Sept 15

Lower Cost

Improve Stewardship (PLS5)

▼ PMPM I $370 10.6%

>2.8% yearly growth

2.8% to > 0% yearly growth ≤ 0% yearly growth 13.2% 5.4% 9.4% -3.9% 11.6% Mar 15 Sept 15

▼ Total Purchased Care Cost E $-47.7M -2.5% Service Specific Service Specific Service Specific -7.0% -0.8% 0.3% -3.6% N/A Dec 14 Mar 15

▼ Private Sector Care Cost per Prime Enrollee I $194 17.3%

>2.8% yearly growth

2.8% to > 0% yearly growth ≤ 0% yearly growth 33.0% 22.2% 17.3% 2.8% 13.2% Mar 15 Sept 15

OR Utilization E

**Total Enrollment I 3.58M -0.1% <0% yrly growth 0% to < 5% yrly

growth ≥ 5% yrly growth -0.9% 3.1% -2.0% 1.4% N/A Aug 15 Sept 15

▼ Pharmacy Percent Retail Spend I 54.7% >40% 40% to > 35% ≤35% 57.1% 57.4% 51.3% 41.0% N/A Apr 15 Sept 15 Productivity Targets I 93% Service Specific Service Specific Service Specific 94% 93% 93% 80% N/A Jun 15 Sept 15

Report as of 10 SEPT 2015

Developmental Status: A = Accountability; I = Improvement; E = Exploratory *NPIC calculates + provides the MHS w/ MHS, Service + MTF status relative to the NPIC database average

**Indicates Process Improvement Priority ▼ Lower is better Indicates measure

under development

The DHA in 2016

• Driving Value to Services and COCOMS

• Demonstrable service and support to the mission

• I Need Your Feedback and Input


Defense Health Agency


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military health system: the defense health agency in...

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