capital region medical directorate market journey...

“Medically Ready Force...Ready Medical Force”

National Capital Region Medical DirectorateEnhanced Multi‐ Service Market JourneyJohn D. O’Boyle, MD, CAPT, MC, USN

Chief Medical Officer NCR MD

March 2017


Disclosures

Presenter has no financial interest to disclose.

2


MHS Governance Reform JourneyDoD Task Force on MHS Governance

September 2011 18th study over 62 years 7th rec “added central authority” DHA model for MHS governance Recommended anEnhanced MSM (eMSM)model providing budgetary and short‐term personnelmanagement authority forMSM

DepSecDefPlanning Memo

March 2012 Directed I‐Planning for MHS Governance Reform—OASD(HA)DHA Shared Services JTF‐CapMed transition eMSMs

DepSecDef“Nine Commandments”

Memo

March 2013 Directed implementation of MHS Governance Reform—OASD(HA) & TMA transitionDHA (as CSA) Shared ServicesNCR Directorate eMSMs

1949 ‐ 2006 17 studies over 57 years8 recs for unified service/unified joint command6 recs for added central authority3 recs “keep separate Service lines

3


Where are the enhanced Multi‐Service Markets (eMSMs)?

eMSM Markets and Service/Department Leads

1. National Capital Region (Defense Health Agency)

2. Colorado Springs, Colorado (rotate Air Force/Army)

3. Tidewater, Virginia (Navy)

4. San Antonio, Texas (rotate Air Force/Army)

5. Puget Sound, Washington (Army)

6. Oahu, Hawaii (Army)

5

2 1

3

4

6

eMSMs provide over 40% of all MHS Healthcare Delivery

4


2005

The Base Realignment and Closure Act (BRAC) of 2005 directed the closure of both National Naval Medical Center (NNMC) and Walter Reed Army Medical Center (WRAMC)

BASE REALIGNMENT AND CLOSURE

2013

A joint, integrated Combat Support Agency that enables the Army, Navy, and Air Force medical services to provide a medically ready force and ready medical force to Combatant Commands in both peacetime and wartime

DEFENSE HEALTH AGENCY (DHA) ESTABLISHED

2007

JTF CapMed was created in 2007 to guide the congressionally mandated consolidation of military medical facilities in the greater Washington D.C. area

JTF CAPMED ESTABLISHED

2011

Walter Reed National Military Medical Center, Bethesda opened on Sep. 15 and on Aug. 31, Fort Belvoir Community Hospital began serving patients with a patient transferred from DeWitt Army Community Hospital

WRNMMC AND FBCH OPEN

20162017

The NCR has 11 military medical treatment facilities with over 246,000 enrolled beneficiaries – focused on sustaining a ready medical force, delivering better care and an improved patient experience at a lower cost

NATIONAL CAPITAL REGION ADVANCES

Future

Title VII, Section 702 of the National DefenseAuthorization Actdirects reform of theadministration of theDefense Health Agency and military medical treatment facilities

NDAA 2017

OUR HISTORYNational Capital Region (NCR)

5


eMSM CONOPS Functional Organizational Structure

Senior Market Manager

Director

Admin/ITSupport

Directorate ofClinical Operations

Appointing andReferral

Management

Direct CareOptimization/Capability

Population Health

Case & DiseaseManagement

Readiness

Health Education & Training Ancillary Services

Directorate ofMarket Analysis & Evaluation

MarketPerformancePlanning &Reporting

Data Analysis &Program Evaluation

Business ProcessReengineering

Directorate ofBusiness Operations

Manpower &Budget

Management

MCSC Operations/Recapture

Management

EmergencyResponse Planning

MOUs/MOAs/Contracting &Venture Capital

IM/IT Telehealth

FederalPartnerships/Community Relations

Market BusinessWorkloadReporting/Enrollment

Strategic Communications/

PatientSatisfaction

** Central CLRProcessing

** Central

Appointing** Expanded Functions

eMSM Functional Organizational Structure

Clinical Standardization

Quality Management

Risk Management

Patient Safety

Research

Logistics

Strategic Planning

6


• Rader AHC• Kimbrough AHC• McNair AHC

• Bolling Clinic• Malcolm GrowMedical Clinic• Pentagon Flight Clinic

• NHC Annapolis• NHC Quantico• WNY Clinic

NCR eMSM

USD(P&R)ASD(HA)

CJCS

Defense Health Agency

WRNMMC FBCH JPC

NCR Medical Directorate

Tri‐Service Dental Clinic

Pentagon(DiLorenzo) Dumfries Fairfax

SEC Navy

CNO

Navy SG

BUMED

NME

MTFs

CSA

SEC Army

Army SG

MEDCOM

ARHC‐A

MTFs

CSAF

SEC Air Force

AF SG

MAJCOMS

MDW

MTFs

Secretary of Defense

Organizational Structure

7

National Capital Region Academic Health and Readiness System

8


Common eMSM Challenges

• Leadership: perspective, maturity, development• Strategy: eMSM Strategy vs Service priorities

– High Reliability Organization principles– The “Service‐led” eMSM

• Performance: Performance Management System– Data overload: MTFs, eMSM, regional HQ, TRO, Services, DHA, etc. = Noisy

• Drivers:– Enrollment….Access to Care…Productivity….Containment/Recapture– Patient Satisfaction– Collision of Compliance, Accreditation, and Governance

• Distribution of Assets:– Integrated manning documents– Movement of personnel, equipment, monies

• Governance Structures and Workflow:– Issue identification, Prioritization, and Decision Making

9

DEFENSE HEALTH AGENCY STRATEGY MAP v2.2The Defense Health Agency (DHA) is a joint, integrated Combat Support Agency that enables the Army, Navy, and Air Force medical services to provide a

medically ready force and ready medical force to Combatant Commands in both peacetime and wartime.

Modernize TRICARE

(W11)

Strengthen Our Role as a Combat Support Agency

Strengthen Our Partnershipwith the Services

Optimize Defense Health Agency Operations

Conduct Health-Related Research (W5)

Support Integrated Training Requirements

(W3)

Deploy Solutions for 21st Century

Battlespace (W1)

Design and Prototype Health

Readiness Solutions (W4)

Respond to

Immediate Mission Needs (W2)

ENDS

WAY

SME

ANS

“I trust the DHA to deliver the support I need for mission

success.” (E2)

“DHA creates greater value through Operational

Excellence.” (E3)

Gather, Develop, and Prioritize Requirements in Support of DHA’s Current and Future Mission (W6)

Deliver and Sustain Electronic Health

Record (W8)

Optimize Existing ESAs (W12)

Improve System of DHA Accountability

(W9)

Support Service Needs for Data, Reporting, and

Analytics (W7)

READINESS

Optimize Critical Internal

Management Processes

(W18)

Implement DHA

Performance Management

System (W16)

Build Robust Improvement

Capability (W13)

Optimize Portfolio of DHA Initiatives (W14)

Strengthen Customer Focus (M1)

Shape Workforce for Success (M2)

Align Resources Against Strategic Priorities and

Ensure Fiscal Accountability (M3)

Advance a Culture of Continuous Learning

(M4)

Ready Medical Force Medically Ready Force

Operational MedicineCONOPS

Health Benefit DeliveryCONOPS

Joint Concept for Health Services

Improve Health

Outcomes and Exp.

in the NCR(W15)

“DHA supports Readiness solutions that meet joint

mission needs.” (E1)

1 March 2017

Leverage Strategic Partnerships (W10)

Maximize Value from

Suppliers and Partners (W17)

Improve Health Outcomes and Experiences in the NCR

W15

• Create an integrated learning health system across the market that brings services to the patient, not vice versa, and delivers highly reliable quality health outcomes

• Fully utilize capability and capacity in both primary and specialty care within the market

• Sustain and improve currency of the total Medical Force (including Uniformed Military, Civilians, and Contractors)

• Create a culture of proactive prevention to engage patients anywhere, anytime, and reduce the need for healthcare

• Continuously improve care processes to be responsive and respectful of our beneficiaries needs and choices

NCR Strategic Initiatives

High Reliability Culture of Quality

Seamless Patient & Team Experience

Optimizing a Fully Engaged Direct Care System

Academic Health & Readiness System

10


OUR VISIONNational Capital Region (NCR)

11

NATIONALCAPITALREGION

ACADEMIC HEALTH

& READINESSSYSTEM

The National Capital Region (NCR) Academic Health &

Readiness System (AHRS) is the preeminent integrated academic health system in America, connecting every federal hospital and clinic in our region to generate and

sustain a ready medical force


OUR PRIORITIESNational Capital Region (NCR)

12


ACADEMIC HEALTH

& READINESSSYSTEM

Build and sustain a high reliability culture of qualitythat permeates throughout our organization and has the paramount goal of zero harm to patients and staff

Infuse input from our patients, caregivers, and staff into high velocity learning and rapid cycle innovation design methods in order to put the NCR AHS at the vanguard for improving caregiver wellbeing and experience, patient experience, quality and safety

Enhance the professional operational readiness of our personnel and teams through the active holistic management of both the direct and purchased care sectors of the TRICARE marketplace across the NCR



ACADEMIC HEALTH

& READINESSSYSTEM

The NCR AHRS is the healthcare system of choice for beneficiaries in the National Capital Region, and the employer of choice for our total workforce, active duty, civil service and contractors

The NCR AHRS leads the Military Health System in

delivering the quadruple aim – the best experience of care at the best value resulting in the best health and maximized readiness

OUR FUTURENational Capital Region (NCR)


NCR MD Critical Focus Areas

• Access to Care• Product Line Integrations and Optimization• Referral Management• Secure Messaging / Nurse Advice Line• Urgent and Emergency Care• Academic Health & Readiness System

14


Data Source: TROSS (Question 32) as of 20 January 2016, TRISS (Question 21) as of 04 January 2016

Inpatient and Outpatient Satisfaction in the NCR remain higher than MHS averages and exceed Inpatient Targets

Patient Satisfaction

15

Inpatient Satisfaction: How would you rate this hospital?

Outpatient Satisfaction with Care Received

92%

76%No data

reported for FY 2014 Q4

TROSS questionnairechanges implemented


MS-DRG RWP LEADERBOARDRANKED BY GROWTH FROM FY13 TO FY16

PROVIDER AGG tRVU LEADERBOARD RANKED BY GROWTH FROM FY13 TO FY16

Top 25 Growth Facilities – FY13‐16

PRODUCTIVITY GROWTH LEADERBOARDS

16Source: MHS MART (M2), February 2017

Rank Parent Name GrowthGrowth

Rate1 FT BELVOIR COMMUNITY HOSP‐FBCH 526,630 25%2 WALTER REED NATL MIL MED CNTR 602,015 21%3 NH CAMP LEJEUNE 242,379 16%4 AF‐C‐59th MDW‐WHASC‐LACKLAND 232,822 14%5 AMC BAMC‐FSH 269,281 7%6 AHC MONCRIEF‐JACKSON 21,140 2%7 AF‐MC‐88th MED GRP‐WRIGHT‐PAT 19,182 2%8 ACH MARTIN‐BENNING 25,258 1%9 NH JACKSONVILLE (11,517) ‐1%10 ACH WINN‐STEWART (26,046) ‐2%11 AMC TRIPLER‐SHAFTER (71,155) ‐2%12 AMC MADIGAN‐LEWIS (116,669) ‐3%13 AMC WILLIAM BEAUMONT‐BLISS (76,093) ‐3%14 AMC WOMACK‐BRAGG (161,735) ‐6%15 NH CAMP PENDLETON (105,101) ‐6%16 AF‐MC‐60th MED GRP‐TRAVIS (61,509) ‐6%17 AMC DARNALL‐HOOD (183,630) ‐7%18 AF‐MC‐99th MED GRP‐NELLIS (73,760) ‐8%19 KIMBROUGH AMB CAR CEN‐MEADE (84,549) ‐8%20 ACH LEONARD WOOD (96,653) ‐8%21 NMC SAN DIEGO (371,661) ‐8%22 JAMES A LOVELL FHCC (94,760) ‐9%23 AHC REYNOLDS‐SILL (101,826) ‐9%24 ACH BLANCHFIELD‐CAMPBELL (181,347) ‐9%25 NMC PORTSMOUTH (458,508) ‐11%

Rank Parent Name GrowthGrowth

Rate1 NH GUANTANAMO BAY 30 35%2 ACH MARTIN‐BENNING 676 20%3 AF‐MC‐88th MED GRP‐WRIGHT‐PAT 813 19%4 ACH LEONARD WOOD 368 17%5 FT BELVOIR COMMUNITY HOSP‐FBCH 782 13%6 NH CAMP LEJEUNE 434 11%7 AF‐H‐31st MED GRP‐AVIANO 22 11%8 NH JACKSONVILLE 273 11%9 AMC WOMACK‐BRAGG 801 10%10 NH CAMP PENDLETON 286 9%11 NH NAPLES 17 8%12 ACH KELLER‐WEST POINT 57 7%13 AMC BAMC‐FSH 1,853 6%14 NH SIGONELLA 8 6%15 AMC MADIGAN‐LEWIS 824 6%16 NH OKINAWA 84 4%17 ACH EVANS‐CARSON 154 4%18 NMC SAN DIEGO 622 3%19 AF‐H‐96th MED GRP‐EGLIN 71 2%20 NH GUAM‐AGANA 25 2%21 WALTER REED NATL MIL MED CNTR 164 1%22 ACH BLANCHFIELD‐CAMPBELL (11) 0%23 AMC WILLIAM BEAUMONT‐BLISS (52) ‐1%24 AMC DARNALL‐HOOD (122) ‐2%25 ACH IRWIN‐RILEY (51) ‐3%


NATIONAL CAPITAL REGION eMSMEmbedded Physical Therapy

17Source: MHS MART (M2),

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

2013Q1

2013Q2

2013Q3

2013Q4

2014Q1

2014Q2

2014Q3

2014Q4

2015Q1

2015Q2

2015Q3

2015Q4

2016Q1

2016Q2

2016Q3

2016Q4

DC En

coun

ter e

MSM

Enrollees

PSC Am

ount Paid eM

SM Enrollees

Purchased Physical Therapy NCR Enrollee Physical Therapy Encounters

Average quarterly PSC down $1.5M FY13 to FY16and down $451K FY15 to FY16

Physical Therapy Product LineMarket Integration

The Problem

• $8M in NCR enrollee PT network care expenses in FY14 and $6.3M in FY15

• Enough referrals for 10‐12 more PTs • Limited space for rehab, no new MILCON• eMSM referral acceptance rates 80‐85%

The Solution

• Added 11 Physical Therapy FTEs across the region to recapture care

• Embedded PTs in the PCMH to maximize space utilization

• Sent the PT to the patient, not the patient to the PT


INCREASED ACCESS IN THE NCRDirect Care Optimization is adding appointments in stages – over 15,000 additional appointments to date

18

Annual additional promised / projected SPEC appointments per wave

38,580 (est.)SPECs

annually

38,580 (est.)SPECs

annually

Wave 1 Wave 2 Wave 3 Wave 4• Allergy• Pediatric subspecialties

• Moved to direct booking without clinic optimization

• Orthopedics• ENT

• Completed optimization

• Reflects actual additional appointments

• Pulmonary• Dermatology• Audiology• Endocrine• Rheumatology• Speech therapy

• Completed optimization

• Reflects actual additional appointments

• Cardiology• Chiropractic• GI• General Surgery• Hem/Onc• Neurology• OB‐GYN• Ophthalmology• Optometry

• Pain• PM&R• Physical Therapy• Podiatry• Sleep• Urology• Vascular surgery• Plastic surgery• Pediatric subspecialties

• Optimization in process• Assumes all providers meet agreed encounter targets

Apr‐Aug 2016Jul‐Dec 2016

Oct ‐ Present

23,400 (est.)9,0486,132 + +

Source: Current data ‐ CHCS SPEC encounter data via Dashboard, Sep 1 – Dec 30, 2016 / Projection and Baseline data – CHCS data, Nov 2, 2016


Data Source: Health Affairs PMPM FY16 Q1 Export file

COMPARATIVE EFFICIENCYCost per Unit by Inpatient Facility – FY2016 Qtr1

19

Portsmouth

Wainwright

Carson

Gordon

Benning

Stewart

Tripler

Riley

Campbell

KnoxPolk

Leonard Wood

West Point

Bragg

Sill

Jackson

Bliss

BAMC

Hood

Lewis

Irwin

Elmendorf

Travis

Eglin

Mt Home

Keesler

Nellis

Wright‐Pat

Eustis

PendletonSan Diego

29 Palms

Pensacola

Jacksonville

Lejeune

Beaufort

Bremerton

Oak Harbor

WRNMMC

FBCH

WRNMMC (FY13)FBCH (FY13)

$K

$5K

$10K

$15K

$20K

$25K

$30K

$35K

$30 $40 $50 $60 $70 $80 $90 $100 $110 $120 $130 $140 $150 $160

Cost per M

S DRG

RWP

Cost per RVU


• From FY12 – FY16 Total Obligations reduced by 4.8%

5 Year Execution Trend for NCR MD (WRNMMC & FBCH)

TOTAL GROSS OBLIGATIONSSpending Less on Direct Care

20


NCRMD–FY2016

NCRMD–FY2013

MHS Navy

MCSC

ArmyAF

‐15.0%

‐10.0%

‐5.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

$200 $250 $300 $350 $400 $450 $500 $550 $600 $650

PMPM

Market Successes

FBCH / MGMC OB CarePer Member Per Month (PMPM)

Embedded Physical Therapy

LOWER

ISBE

TTER

Growth

Rate

0

50

100

150

200

250

300

350

400

450

500

$0K

$100K

$200K

$300K

$400K

$500K

$600K

$700K

2014 2014 2014 2014 2015 2015 2015 2015Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Southern Maryland Costs

Southern Maryland Admissions

Live Births at FBCH

Eliminated$2M PSC ERSA

NCR MD Supporting MarketNeeds with 11 new PTProviders

• Improved Patient Satisfaction• Improved PTAccess• Improved OrthoAccess• FY16 ‐ Expected $2.5M PSC

Reduction from FY14 levels

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

2014

Q1

2014

Q2

2014

Q3

2014

Q4

2015

Q1

2015

Q2

2015

Q3

2015

Q4

2016

Q1

2016

Q2

2016

Q3

2016

Q4

Average quarterly PSC$ down $852K FY14 to FY16

and down$453K FY15 to FY16

21


Top Five Successes

1. Market Management & Empowered Market Leaders

– Market Initiative Champions

2. Quality of Care– Institute for Healthcare Improvement

Leadership Alliance– Partnership for Patients (PfP) – Ambulatory

Settings

3. Academic Health & Readiness System

– Tri‐Federal Cancer Initiative, an alliance between the Walter Reed Murtha Cancer Center, Uniformed Service University of Health Sciences, and the National Cancer Institute to standardize Clinical Practice Guidelines for cancer treatment

4. Operational Support & Readiness– Provided over 300 medical personnel to support

Joint Forces Headquarters National Capital Region– 46% of all Army GME programs and 28% of all

Army trainees– 34% of all Navy GME programs and 23% of all Navy

GME trainees

5. Stewardship– Reduced obligations by 6% from an FY12 base of

$1.37 billion to an FY15 base of $1.29 billion.– Decreased professional care purchased for our

enrollees by a third in the NCR eMSM, from $90M in FY13 to $64.5 M in FY15

22


What’s Next

• Single market strategyo How to continue transformation to an HRO.o Distribution of Assets

• Synergy with MHS Reviewo Leadership, Safety, Performance Managemento Quality, Access, Production, Containment/Recapture

• Refining our Governance Processeso NCR as the 4th service.o Unified Department Chairso Streamlined Product lines

2323


National Defense Authorization Act (NDAA) 2017

A single Agency with oversight of an integrated system of health and readiness delivered through the direct management of each MTF and regional market, utilizing standardized processes and centralized budget accountability to promote transparency to the Department, beneficiaries, Services and Combatant Commands.

Section 702 ‐DHA leading

the way

24


Questions

2525


National Defense Authorization Act (NDAA) 2017

• Readiness and Operational Support linked

• Health Benefit is means to an end, not the end itself

Readiness

Health Benefit

Operational Support

26


Guiding Principles for Implementing the NDAA

• Readiness is primary

• Services are ultimately responsible for readiness supported by DHA

• DHA is responsible for the health benefit supported by the Services who will use this as a means to enable and sustain readiness

• The direct care services will be first choice to support

readiness• DHA creates healthcare

direction, policies and procedures for the direct care system

• DHA is the single source budget authority for the direct care system

• All Active Duty Personnel are tied to an operational requirement

27

capital region medical directorate market journey...

Documents