Governance Implementation Planning Team
Pre-Decisional deliberative matter – For official use only within DoD
Institute of Medicine
Moving to a More Integrated Health System
Assistant Secretary of Defense for Health Affairs
March 20, 2013
The Military Health System
Dr. Jonathan Woodson
The Military Health System
A global organization with medical readiness at the center of the mission
– Integral component of a military fighting force – ensuring a medically ready force
and a ready medical system to respond to the full spectrum of military operations
– A comprehensive, integrated Healthcare delivery system including:
• A hospital system - 56 hospitals world-wide
• An integrated outpatient care system – 363 medical clinics, 282 dental clinics
• A health insurance plan – 9.6 million covered lives, 380,000 participating
providers…70% of our care is purchased from civilian sources
• A global public health system – providing community health, global health and
environmental surveillance
• An education and training system – including a University with an accredited
medical school and graduate programs, a large scale accredited graduate
medical education, enlisted and medical officer training platforms
• Comprehensive medical research and development (R&D) programs
A unique, indispensable, $53 billion per year military medical enterprise
3
The MHS is measured against each of the roles for which it is responsible –
warfighter support, employer, provider, insurer, educator, and researcher
The Quadruple Aim
4
Improved Readiness Ensuring that the total
military force is medically
ready to deploy and that the
medical force is ready to
deliver health care anytime,
anywhere in support of the
full range of military
operations, including
humanitarian missions.
Better Care Providing a care
experience that is patient
and family centered,
compassionate,
convenient, equitable,
safe and always of the
highest quality.
Better Health Reducing the generators
of ill health by
encouraging healthy
behaviors and decreasing
the likelihood of illness
through focused
prevention and the
development of increased
resilience.
Lower Cost Creating value by
focusing on quality,
eliminating waste, and
reducing unwarranted
variation; considering the
total cost of care over
time, not just the cost of
an individual health care
activity.
A Ready Medical Force Survival Rates on Battlefield Against Expected Outcomes
70%
75%
80%
85%
90%
95%
100%
2007 2008 2009 2010 2011
% S
urv
ive
d (
30
Day O
utc
om
e)
Observed Survival Expected Survival 5
An Employer’s Perspective
Health Budget as Percent of Defense Budget
5.9%
7.5%
8.1% 8.1%
8.9% 9.3% 9.4%
9.1% 8.7%
9.4% 9.3%
10.0% 9.6%
10.0% 10.2% 10.4%
10.7%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
$-
$10
$20
$30
$40
$50
$60
$70
FY 2001
FY 2002
FY 2003
FY 2004
FY 2005
FY 2006
FY 2007
FY 2008
FY 2009
FY 2010
FY 2011
FY 2012
FY 2013
FY 2014
FY 2015
FY 2016
FY 2017
% o
d D
oD
To
plin
e
$B
Unified Medical Budget % of DoD Topline Projections
6
Military Health: A Learning Organization
• We have been a learning,
innovative organization on the
battlefield
• We know how to reduce
errors, improve processes and
save lives in the most austere
environments imaginable
7
Military Health: A Learning Organization
• We inform, and are informed
by, the broader American
medical community
• Our advances did not occur in
isolation, but in partnership
with our federal and civilian
colleagues
• Now, we are extending this
integrated approach to our
entire health system
8
9
Better Health OPERATION LIVE WELL/ Healthy Base Initiative
Quadruple Aim
National Prevention Strategy • Health and Safe
Community Environments
• Clinical and Community Preventive Services
• Empowered People
• Elimination of Health Disparities
• Readiness
• Population Health
• Experience of Care
• Per Capita Cost
Objectives
• Active Living
• Healthy Eating
• Tobacco Free Living
• Mental & Emotional Well Being
Operation Live Well
Expected Outcomes
•Improve readiness – retention
and recruitment
•Improve quality of life for all
•Reduce costs
•Help the military model ideal
health behaviors for the nation
Military Health System: New Governance Model
Stronger, Better, and More Relevant for Future • Deputy Secretary of Defense has directed major change in future organization
– Establishing an integrated organization in 2013 – Defense Health Agency:
• Management/oversight of Shared Services: Health IT, Medical Logistics, Medical
Facilities, Health Plan, Pharmacy Operations, Medical R&D, Public Health,
Resource Management, Contracting – Multi-Service Markets (MSMs):
• Major medical markets with multiple military facilities; central to our readiness
mission and maintenance of clinical skills for wartime
• Move from facility-based perspective to five-year, market-based performance
plans
• Central to our efforts for standardizing clinical and business processes – National Capital Region:
• A unique model that sustains our primary casualty-receiving medical center
(Walter Reed National Military Medical Center) and a local military community
hospital (Fort Belvoir) as joint medical facilities
• Implementation is underway – initial stand-up of Defense Health Agency is slated for
October 1, 2013; fully operational by October 1, 2015…and Congress is watching.
10
Overhead and Governance Headquarters Only Part of the Story
11
Private Sector
$16,377M
Direct Care
$8,149M
Consolidated
Health
$2,194M
Edu. and
Train.
$705M
Base
Operations
$1,743M
Info Mgt
$1,423
Management
Activity
$312M
Concluding Perspectives
• The Military Health System is a high-performing organization, operating under conditions unimagined 11 years ago
• Even with conclusion of engagement in Iraq and drawdown in Afghanistan, global environment – political / military / global health / humanitarian risks remain highly unpredictable
• Still, federal spending is not going to grow…it’s going to shrink, even(particularly) in defense spending
– Across-the-board cuts will not save money in health spending
– Better Health and Better Care are critical to our strategy
– Federal and civilian partnerships will grow; we welcome them and seek them
• Our continued strength and relevance will be achieved by our sustained focus on readiness, greater integration within our system and with external partners, moving from healthcare to health, and an enduring commitment to quality and safety
12
The Goal: Deliver Value
14
Creating a high value Military Health System is
predicated on defining and measuring value.
Value =
Readiness Experience
of Care
Population
Health + +
Cost (Over a Span of Time)
Value =
Outcomes
Cost
Simultaneous Transformation of Care and Payment Can
Help Reduce Costs while Improving Care/Health
The Past
Transition
Ideal
Delivery System
Level 2/3 Medical
Homes
Fully Integrated
Delivery System
Volume-driven
Fragmented Care
Bundled/Episode
Payment, Full
Prepayment
Outcome measures
large % of total
payment
Primary Care Sub-
Capitation; FFS for Specialty/IP
Care coordination and
intermediate outcome
measures (moderate %
of total payment)
Fee-for-service
Simple process and
structure measures
(small % of total
payment)
Payment
Bundling
P4P Design
Adapted from “From Volume to Value: Better Ways to Pay for Health Care,” Health Affairs, Sep/Oct 2009. 15
16
Medically Ready Force – Occupational Medicine
Resource Perspective
Healthy and Resilient Individuals, Families and Communities
Ready Medical Force – Operational Medicine
Achieving better system integration from the ground up.
Primary Execution Structure
Research and
Development
Education and
Training
(METC, GME, USUHS)
Shared Services (IM/IT, Contracting, Logistics, HR
Mgmt, Facilities, Fin Mgmt, etc)
Shared and Support Services – The Defense Health Agency
Health Plan
Management
Community
Hospitals
and Clinics
Major Multi-Service
Market MTFs (NCA,
SA, SD, Tidewater,
Madigan, Tripler, CO)
Operational
Medicine
Tricare
Network of
Providers
Developing Our Integrated Delivery System – The MHS
Portfolio of Strategic Initiatives • Foundational Elements
– Strengthened Governance – Defense Health Agency supporting Military Medicine
– Culture of continuous improvement –leadership development, process based mgmt
– Optimizing resources – 10 Enterprise shared services with five year business plans
– Information for better decisions – IT Strategic Alignment
• Readiness
• Sustaining a Ready Medical Force (currency) and Medically Ready Force (IMR)
• Population Health
• Annual health assessment; Healthy Base Initiative; lowering obesity and tobacco use
• Care delivery priorities
– Shared decision making - Patient Centered Medical Home 2.0 (2.5M enrollees)
– Integrated care - Market Management / Medical Neighborhood
– Patient Safety and Quality– Standard workflow embedded in EHR (low back pain,
metabolic syndrome, depression); P4P
– Targeted services –Meeting the needs generated by 11 years of war
• Reliability and feedback –
– Embedded safeguards – Patient safety center, simulation, comparative effectiveness
– Internal transparency – Partnership with GAO to demonstrate success through
public accountability
17
Reference: Ten strategies to lower costs, improve quality, and engage patients …, Health Affairs, Feb 2013, 32:2.
Strategic Imperative
Exec
Sponsor Performance Measure
Development
Status
Previous
Performance
Current
Performance Change
FY2012
Target
FY2014
Target
FY2016
Target MHS Strategic Initiatives
Readin
ess
Improve Individual
and Family Medical
Readiness
FHPC Medically Ready to Deploy 82% 84% +2% 82% 85% 85%
Implement Policies, Procedures &
Partnerships to Meet Individual Medical
Readiness Goals
Optimize Healthcare Markets to Support
GME and Readiness TBD Measure of Family Readiness (i.e., PHA for families) -
Enhance
Psychological
Health & Resiliency
FHPC PTSD Screening, Referral (R) and Treatment (T) 52%/73% 49%/72% -3%/-1% 50%/75% 50%/75% 50%/75%
Integrate & Optimize Psychological Health
Programs to Improve Outcomes and
Enhance Value
FHPC Depression Screening, Referral (R) and Treatment (T) 71%/75% 67%/76% -4%/+1% 50%/75% 50%/75% 50%/75%
Popula
tion
Health
Engage Patients in
Healthy Behaviors
CPSC MHS Cigarette Use Rate (Active Duty 18-24) 21% 20% -1% 18% 16% TBD
Improve Measurement and Management
of Population Health to Accelerate the
Shift from Healthcare to Health
CPSC Adults with Diagnosis of Overweight or Obese 7%/28% 8%/30% +1%/+2% 50%/90% 100%/100% 100%/100%
CPSC Adolescents & Children with Diagnosis of Overweight or
Obese 11%/30% 9%/31% -2%+1% 50%/75% 100%/100% 100%/100%
CPSC Exclusive Breastfeeding During Newborn Hospitalization 60% 63% +3% 70% 80% 80%
CPSC HEDIS Index: Preventive Cancer Screens & Well Child Visits
(DC/PC) 8/6 10/5 +2/-1 12/10 15/12 15/16
Experience o
f C
are
Deliver Evidence-
Based Care
CPSC HEDIS Index: Cardiovascular, Diabetic & Mental Health Care
(DC/PC) 28/5 24/4 -4/-1 36/12 50/16 50/21
Implement Evidence Based Practices
Across the MHS to Improve Quality and
Safety
Optimize Pharmacy Practices to Improve
Quality and Reduce Cost
Implement Patient Centered Medical
Home Model of Care to Increase
Satisfaction, Improve Care and Reduce
Per Capita Costs
CPSC Direct Care Readmission Rate (Medical/Surgical) - - - -
CPSC Wrong Site Surgery and Procedures (Direct Care) 1 1 - 0 0 0
CPSC Antibiotic Received Within 1 Hour Prior to Surgical Incision 96% 97% +1% 98% 98% 98%
Excel in Wounded,
Ill and Injured Care
CPSC Medical Evaluation Board Stage Timeliness – Integrated
Disability Evaluation System (IDES) 85 77 -8 35 35 35
CPSC Percent of Service Members Rating Medical Evaluation Board
Experience as Favorable 53% 47% -6% 70% 75% TBD
Optimize Access to
Care
JHOC Primary Care 3rd Available Appointment (Routine/Acute) 72%/51% 68%/49% -4%/-2% 78%/62% 86%/68% 94%/75%
JHOC Satisfaction with Getting Timely Care Rate 77% 76% -1% 80% 82% TBD
JHOC Potentially Recapturable Primary Care Workload for MTF
Enrollment Sites 27% 22% -5% 24% 22% TBD
Promote Patient-
Centeredness
JHOC Percent of Visits Where MTF Enrollees See Their PCM 56% 57% +1% 60% 65% 70%
JHOC Satisfaction with Health Care 59% 60% +1 62% 64% TBD
Per
Capita
Cost
Manage Health
Care Costs
CFOIC Annual Percent Increase in Per Capita Costs 1.8% 4.3% +2.5% 9.5% - -
Implement Alternative Payment
Mechanisms to Pay for Value CFOIC Emergency Room Visits Per 100 Enrollees Per Year 44 45 +1 30 28 26
Learn
ing &
Gro
wth
Enable Better
Decisions CPSC EHR Usability - - - - Deliver information for better decisions
(Clinical Enterprise Intelligence)
Implement Modernized iEHR to Improve
Outcomes and Enhance Interoperability
Improve Governance to Achieve Better
Quadruple Aim Performance
Foster Innovation CFOIC Effectiveness in Going from Product to Practice (Translational
Research) -
Develop Our People
CFOIC Human Capital Readiness / Build Skills & Currency -
CFOIC Primary Care Staff Satisfaction 58% 58% - 62% 65% 71%
MHS Strategic Imperatives Scorecard
Concept Only Measure Algorithm
Developed
Current Performance Known
and Current Target Approved Out-Year Targets
Approved Design Phase Approved Funded
18
Health Care Management Model Logic Structure
Increasing Resource Requirements
State 1:
Free of Disease,
Low risk
State 2:
Free of Disease,
High risk
State 3:
Has Disease,
Uncomplicated
State 4:
Has Disease,
Complicated
Health Care Management Model Conceptual Structure
•Population Data •Allocation Policy •Access Barriers •Resource Capacities
Scenario Data
HMM • Disease States • Clinical Programs
– Resource Consumption Rates – Disease State Transition
Probabilities
Clinical Data
Disease Profile over time
Workload over time
Futures-Based Agile Thinking
• Implemented Scenario-Based Methodology (Alternative Futuring)
• Identified 4 Transformational/Environmental Issues
• Developed 8 Strategic Themes from 854 Strategic Implications
• Postulated 5 axioms --- Evolved 6 Pathways to the future
• 3 integrative thrusts : leadership development; wisdom; resource stewardship
•
• Framework for mapping the present to the future –Vector to White House summit on creating wellness
–Summits as fast-moving pacing events
–Learning Labs and Focused Meetings
–Support Team / SMEs
Inspiration Phase – (2010-2011)
Ideation Phase – (2011-2012)
Implementation – (2012-2013)
Strategic Themes
• Strategic Themes
– Strategic Planning and Alliances
– Healthcare Diplomacy
– Recruiting and Training
– Translational Research
– Disaster Response
– Information Assurance
– Patient Centric Healthcare
– Surveillance, Prevention and
Control
– Meaningful Measures
– Challenging Ethics
• Backcasting
– Reach back (2027) to a more
definable waypoint
– Define archetypes for
consideration to address
themes in 2027
203
5
202
7
20
15
AFMS Vector
or String
204
5
Federal Health Strategy Map
•Identify common priorities
•Identify common principles
•Outline common objectives
Federal Health Strategic Matrix
Leade
rship
Devel
opme
nt Wisd
om
Gene
ratio
n Reso
urce
Stewa
rdshi
p
Leadership Readiness Value Quality
Optimize
Healthiness
Team
Effectiveness
Agility
Resiliency
Prioritize
Investment
Excellence in
Execution
Increase Access
Cost Efficiency
Collaborative Partnership Federal Collaboration
Research and Development Innovation, Science, Technology
Education and Training Health as a Team Sport
Knowledge, Data Management, and Analytics
Humanitarian Response
Knowledge
Access
Situational
Awareness
Strengthen
Communications
Focused
Acquisition
Interagency
Initiatives
Choice/Options
Standardization
Continuous Care
Accountability
Risk Taking
Transform
Management
Strengthen
Systems
Recapture Care
Manage Cost
Facility Renewal
Fiscal
Stewardship
National
Quality
Strategy
Value Stream of the WIN Initiative Human Flourishing
National
Prevention
Strategy
↑Growth
Disparity↓ Grow
Connect
Live
Survive
↑Quality
Cost↓
↓ National Debt
↓ National Medical Bill
Productivity ↑
Preparedness↑
Prosperity ↑
← Value Proposition →
Wellness Initiative
for the Nation
Environment
Beneficent Purpose
Health Care
Pyramid of Prosperity Core Components
Proposed Incentive Measures
• Readiness: • **IMR – Indeterminate Rate
• Currency - Further study.
• Health: • ** Self reported health status (Use of Tri-service work flow standard
question)
• ** Depression Symptom Prevalence – PHQ 2 (Use of Tri-service
work flow)
• ** Activity Level - (Use of Tri-service work flow standard question)
• ** HEDIS Preventive Measures
– Breast, Cervical, and Colorectal CA , Well Child Visits
• Lost duty days due to injury or illness - Further Study
32
** = Measure to be included in initial set of incentive
measures
Proposed Incentive Measures (Con’t)
• Healthcare:
– Service to Market Measures:
• ** Safety - Partnership for Patients Index (Harm events, readmissions)
• **HEDIS Disease management Measures (Cardio Vascular Disease,
Diabetes)
• **Average Daily Patient Load / Occupancy Rate
• **Operating Room Utilization Rate
• **Primary Care Manager Continuity
• ** 3rd Available Appointment (acute, routine) Subject to revision of measure
• **Satisfaction with Care
Further Study
• Low Back Pain CPG (Diagnostic imaging in LBP) - development
• ORYX inpatient measures
• CPGs for Specialty Care (Ortho, Mental Health)
• Ambulatory care sensitive admission rate
• Perinatal Care (NPIC Index)
• Administrative Cost Efficiency (Support Costs / Direct Care Costs)
33
** = Measure to be included in initial set of incentive
measures
Proposed Incentive Measures (Con’t)
• Cost:
– ** Private Sector Care Cost (Market specific)
– ** ER Utilization Rate
– ** Bed Days per Thousand
– ** % Retail Pharmacy
– ** Referrals accepted by MTFs (ROFR) (Market Specific)
– **% Specialty done in Private Sector
– Note: Cost measures relate to cost management at the population level, not
primarily at the hospital or clinic level. We have included some measures of care
efficiency in the “better care” section of measures.
34
• People (All measures in development)
– Staff Engagement
– Staff Safety
– PC Staff Satisfaction
** = Measure to be included in initial set of incentive
measures
2012 MHS Performance Report Card
2012 *
Improving Target Current
Readiness
1 Medically Ready to Deploy 82% 84%
2 PTSD Screening, Referral (R) and Treatment (T) 50%/75% 49%/72% /
3 Depression Screening, Referral (R) and Treatment (T) 50%/75% 67%/76% /
Population Health
4 MHS Cigarette Use Rate (Active Duty 18-24) ($) 18% 20%
5 Adults with Diagnosis of Overweight or Obese 50%/90% 8%/30% /
6 Adolescents & Children with Diagnosis of Overweight or Obese 50%/75% 9%/31% /
7 Exclusive Breastfeeding During Newborn Hospitalization 70% 63%
8 HEDIS Index: Preventive Cancer Screens & Well Child Visits (DC/PC) 12/10 10/5 /
Experience of Care
9 HEDIS Index: Cardiovascular, Diabetic & Mental Health Care (DC/PC) 36/12 24/4 /
10 Direct Care Readmission Rate (Medical/Surgical) --
11 Wrong Site Surgery and Procedures (Direct Care) 0 1 NC
12 Antibiotic Received Within 1 Hour Prior to Surgical Incision 98% 97%
13 Medical Evaluation Board Stage Timeliness – Integrated Disability Evaluation System (IDES) ($) 35 77
14 Percent of Service Members Rating Medical Evaluation Board Experience as Favorable 70% 47%
15 Primary Care 3rd Available Appointment (Routine/Acute) 78%/62% 68%/49% /
16 Satisfaction with Getting Timely Care 80% 76%
17 Potentially Recapturable Primary Care Workload for MTF Enrollment Sites ($) 24% 22%
18 Percent of Visits Where MTF Enrollees See Their PCM 60% 57%
19 Satisfaction with Health Care 62% 60%
Per Capita Cost
20 Annual Percent Increase in Per Capita Costs ($) 9.5 4.3%
21 Emergency Room Visits Per 100 Enrollees Per Year ($) 30 45
22 Primary Care Staff Satisfaction 62% 58% NC
($) Denotes lower is better * Data lag 3-6months No Yes 35