meprs what it’s good for …*

MEPRSWhat it’s good for …*

29 July 2010

8:00 – 8:50 a.m.

*And the impact of your data on various programs and metrics

2

Objectives• Identify major programs, applications and

metrics utilizing cost, workload, or manpower data from MEPRS*

• For selected programs, describe how MEPRS data are used

• Discuss examples where “questionable” MEPRS data have an impact on the selected programs, possibly affecting MHS decisions

*NOTE: Presentation is from the viewpoint of those who use centrally available data rather than data from local systems

3

Selected Applications• Inpatient Third Party Collection (TPC) Rates

– Adjusted Standardized Amounts (ASAs) for billing third parties

– MTF expense data pooled with peers to create standardized rates

• US Family Health Plan (USFHP) Capitation Rates– Former USTF/Designated Provider hospitals– Approximately 108,000 enrollees– Direct Care portion of rates based on expense and workload

data from CONUS MTFs

• Practice Management Revenue Model (PMRM)– Army PMRM used in productivity evaluation– “Purple PMRM” with Tri-Service data available from TMA– FTE data from MEPRS input to comparative metrics involving

PPS earnings estimates

4

Selected Applications (continued)• Costs on MDR/M2 Encounter Records

– MEPRS expense data basis for unit costs:• Standard Inpatient Data Records (SIDRs)

• Standard Ambulatory Data Records (SADRs)

• Pharmacy Data Transaction Service (PTDS) dispensing costs

• Lab/Rad

– Resulting encounter record costs used in numerous analyses and metrics

• Metrics– Per Member Per Month (PMPM) costs

• Metric reported to the USD(P&R) level

• Adjusted MEPRS expenses allocated to enrollment categories based on encounter records workload

5

Selected Applications (continued)• Metrics (continued)

– Provider Productivity (RVUs per FTE)• Metric reported to the USD(P&R) level• FTE data from MEPRS

• Prospective Payment System (PPS)– Ratios of PPS earnings to MEPRS cost used to adjust

for programmatic increases or decreases– Starting to use Radiology workload data from MEPRS

• Medicare Eligible Retiree Health Care Fund (MERHCF)– Annual direct care Level of Effort (LOE) and

reconciliation– Rates for future distributions

6

Data Issues Affecting These Applications

• Expenses with no workload• Negative expenses• Unallocated ancillary/support expenses• Erroneous expense data (magnitude;

appropriateness; FCC identification)• “Lumpiness” of expense data across time• Data missing when applications are “due”• Lack of association between FTEs and workload• Differences in Services’ accounting and/or

reporting

7

Costs on SIDRs & SADRs

8

Challenge/Goal• Direct care encounter records — Standard Inpatient

Data Records (SIDRs) and Standard Ambulatory Data Records (SADRs) are not billing/claims data, but contain patient-level clinical (limited) and workload data

• MEPRS captures expense data from financial systems and reports or allocates to clinical and non-clinical functional cost centers (FCCs; e.g., MEPRS-3 treatment clinic service)

• GOAL: Allocate appropriate costs of patient care, support and overhead activities to patient-level encounter records for various reporting and analysis purposes

9

Principles of Allocation• “Interrupt” (undo) the EAS-IV stepdown process

so that various components of expenses may be identified and allocated separately

• Use the most logical (intuitive, literature-based, or tested) basis for unit cost development and for allocating each expense component to individual encounters (SIDRs or SADRs)

• After allocation, test to ensure all expenses have been accounted for

• Perform various analyses to check reasonableness of results (e.g., coefficients of variation for SIDR costs within DRGs)

10

Base Year Data Issues May Affect Encounter Records in Three FYs

• Unit costs are developed from the most recent complete year of MEPRS and encounter data

• Inflation rates are applied to take the unit costs forward for application in future years

• During annual SIDR/SADR retrofit process, record costs are updated so that, in as many years as possible, they are based on that same year’s costs and workload data

SIDR/SADR CostsBased On: FY06 FY07 FY08 FY09 FY10 FY11

After Summer 2010 Retrofit

FY07 FY08 FY09 FY09 FY09

FY06

FY06

Current FY07 FY08 FY08 FY08 N/A

Application Year

Before Summer 2009 Retrofit

FY07 FY07 FY07 N/A N/AFY06

11

Expenses with No Workload

12

Negative Expenses

13

Unallocated Ancillary/Support?

$0

$2,000,000

$4,000,000

$6,000,000

$8,000,000

$10,000,000

$12,000,000

01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12

2007 2008 2009

FY07-FY09 Monthly Total Expenses by MEPRS-1(Selected MTF)

B C D E F

14

Erroneous Expenses? (Note: data were extracted June 2010)

15

Rx Percentage of Ambulatory $

Lumpiness: Pharmacy expenses recorded when drugs purchased rather than when dispensed?

16

Dispensing Costs for Direct Care PDTS

Records

18

Why the Difference?

19

High-Level MHS Metrics

20

MHS Dashboard

*** Denotes Strategic ImperativeImproving Declining Stable X Under development

Casualty Care and Humanitarian Assistance

G Reduced Combat Losses

Case Fatality Ratio (OIF/OEF Combat Casualty)

G

Observed/Expected Survival Rate (Battle Wounds)

G

Mortality Rate Following Massive Transfusions

G

Battle-Injured Medical Complications Rate G

Age of Blood in Theater G

YEffective Medical Transition

and Warrior Care

MEBs Completed Within 30 Days *** R

DES Cases Returned to MTF G

MEB Experience Rating *** G

VA Transition Process R

GImproved Rehabilitation & Reintegration to

Force

Amputee Functional Re-Integration Rate G

TBI Screening and Referral X X

Potential Alcohol Problems and Referral X X

Increased Interoperability with Allies, Other Government Agencies and NGOs

Under Development X X

Reconstitution of Host Nation Medical Capability


Strategic Deterrence for Warfare


Healthy, Fit andProtected Force

Y Reduced Medical Non-Combat Loss

Force Immunization Rate Y

Orthopedic Injuries Rate in Theater

R

Orthopedic Injuries Rate in Garrison (Non-Deployed)

G

Influenza-Like Illness Rate in Theater

R

Influenza-Like Illness Rate in Garrison (Non-Deployed)

G

Psychological Health: In-Theater Evacuations/ Encounters

R

R Improved Mission Readiness

Individual Medical Readiness ***

R

Percentage Unknown Medical Readiness Status

R

Increased Resilience & Optimized Human Performance

Psychological Distress Screens, Referral and Engagement ***

X X

Effectiveness of Care for Complex Medical / Social Problems ***

X X

Healthy and Resilient Individuals, Families and Communities

Y Healthy Communities/Healthy Behaviors

MHS Cigarette Use Rate Y

Active Duty Lost Work Days Rate Y

MHS Body Mass Index Rate G

Alcohol Screening/Assessment Rate G

FAP Substantiated Child/Spouse Abuse Rate G

Influenza Immunization Rate R

Pandemic/Seasonal Influenza Vaccine Coverage Rate ***

X X

Mental Health Demand-Family of Service Members X X

Percent of Patients Advised to Stop Smoking ***

X X

Active Duty Suicide Rate (Probable/Confirmed) R

G Health Care Quality

Enrollee Preventive Health Quality Index (HEDIS) ***

G

Overall Hospital Quality Index (ORYX) *** G

CONUS Ventilator Associated Pneumonia Rate X X

Health Care Personnel Flu Vaccination Rate X X

Hospitalization 30-Day Disease Mortality Rate G

Y Access to Care

Getting Needed Care Rate *** R

Getting Timely Care Rate *** R X

Percent of Visits Where MTF Enrollees See Their PCM ***

Y

Booking Success Rates for Primary Care Appointing Y

Primary Care Third Available Routine Appointment Y

Y Beneficiary Satisfaction

Satisfaction with Provider Communication Y

Satisfaction with Health Care *** Y

Satisfaction with Health Plan G

Education, Research and Performance Improvement

GCapable MHS Work Force and Medical

Force

Mental Health Provider Staffing X X

Staff Satisfaction *** X X

Competitive & Direct Hire Activity (Medical Professionals)

G

Advancement of Global Public Health


Contributions to Medical Science

Product to Practice Success ***

X X

Healing Environments


RPerformance-Based Management

and Efficient Operations

Annual Cost Per Equivalent Life (PMPM) ***

R

Enrollee Utilization of Emergency Services ***

Y

Provider Productivity R

Impact of Deployments on MTFs ***

X X

Bed Day Utilization (Prime Enrollees) X X

RDeliver Information to People so They

Can Make Better Decisions

AHLTA Reliability R

AHLTA Speed Y

User Assessment of EHR Functionality ***

X X

DMHRSi/EAS-IV Transmissions by Service

R

21

Per Member Per Month (PMPM)• What are we measuring? The average percent change

in Defense Health Program annual cost per equivalent life compared to average civilian sector health insurance premium changes

• Why is it important? Metric looks at how well the MHS manages the care for individuals who have chosen to enroll in an HMO-type benefit (Prime). It is designed to capture aspects of three major management issues: 1. How efficiently the Military Treatment Facilities (MTFs)

provide care 2. How effectively the MTFs manage enrollee demand 3. How well the MTFs determine which care should be

provided inside the facility versus purchased from a managed care support contractor

22

PMPM: Impact of Missing MEPRS• Key metric periodically reported to the USD

(P&R)• Source of direct care costs and FTEs is MEPRS• In one update a large Medical Center was

missing Contractor labor; in the same Service, multiple months of MEPRS data were missing at the cutoff date for metric reporting

• Overall PMPM with estimates for missing data were below the goal (green); when data were complete, TMA had to report back to the USD that the Service had failed to meet the goal (red)

23

RVUs per Primary Care Provider Per Day• What are we measuring? Metric computes the Work

RVUs for all the visits of a provider for a specified period attributed to a specific clinical site divided by the available FTEs of that provider in that clinic computed on a per day basis

• Why is it important? It reflects the availability of a specific provider for patient care and the volume/intensity of the associated work. National standards for Primary Care allow for comparison– If providers are below average, process improvement initiatives

may be undertaken for increasing productivity – Practices of providers above average may lead to best practice

dissemination

• Metric assumes a direct correlation between available FTEs and workload reported in a given cost center

24

RVUs per FTE

9.5

11.5

13.5

15.5

17.5

19.5

21.5

23.5FY

06 O

ct Dec

Feb

Apr

Jun

Aug

FY07

Oct De

c

Feb

Apr

Jun

Aug

FY08

Oct De

c

Feb

Apr

Jun

Aug

FY09

Oct De

c

Feb

Apr

Jun

Army Navy Air Force MHS

Good

Civilian Averageis 21.8

25

Ambulatory Available FTEs by MEPRS-2(Selected Major Medical Center)

26

Ambulatory Available FTEs & Visits

27

Medicare-Eligible Retiree Health Care Fund

(MERHCF)

Direct Care Level of Effort (LOE)

28

MERHCF Defined• Established by Congress (2001 NDAA) to

provide mandatory funding for a military retiree health care entitlement

• Covers certain Medicare-eligible DoD beneficiaries (military retirees, retiree family members and survivors - not simply “over-65s”)

• Pays for MTF care, purchased care and pharmacy

• Recognizes DoD’s accrued and future liability for cost of retiree/survivor health care for military service members and their family members based on actuarial analyses and assumptions about population characteristics

29

Overview – MTF LOE• Purpose: To estimate annual DoD expenses

for Military Treatment Facility (MTF) care of Medicare-eligible DoD and other uniformed services retirees, dependents of retirees and survivors

• Results support reconciliation of annual Accrual Fund charges and projection of future MERHCF direct care budget allocations and reimbursement rates

• Level of Effort (LOE) procedures comply with DODI 6070.2 Department of Defense Medicare Eligible Retiree Health Care Fund Operations

30

LOE Methodology• Expense data are taken from the MEPRS

EAS-IV Repository• Workload data are extracted from patient

encounter records in the Military Health System (MHS) Data Repository (MDR)– Inpatient: Standard Inpatient Data Records

(SIDR)– Ambulatory: Standard Ambulatory Data Records

(SADR)– Pharmacy: Pharmacy Data Transaction Service

(PDTS) Records

31

Direct Care Expense Allocation• MEPRS expenses are allocated to beneficiary

categories on the following bases:– Inpatient – Relative Weighted Products (RWP, DRG

based) from SIDRs– Ambulatory – Ambulatory Patient Group (APG)

weighted work units from SADRs– Pharmacy – Prescription counts (for admin costs) and

ingredient costs (for pharmaceuticals) in PDTS

• LOE beneficiary categories used are:– (1) Active Duty, (2) Active Duty Family Member, (3) Non-

Accrual Fund Retiree, (4) Non-Accrual Fund Retiree Family Mbr/Srv, (5) Accrual Fund Retiree, (6) Accrual Fund Retiree Family Mbr/Srv and, (7) All Other MTF patients

32

Identifying Pharmacy – by Program Element Code (PEC)

• 0807701 Pharmaceuticals in Defense Medical Centers, Station Hospitals and Medical Clinics – CONUS– Includes pharmaceuticals specifically identified and measurable

to provision of Pharmacy Services in DoD owned and operated CONUS facilities

– Excludes manpower authorizations, support equipment and other cost directly associated with the production and operation of DoD owned and operated facilities

– This Program Element is designed to specifically collect Pharmaceuticals. It will include all prescription supply items used in the direct patient care by hospitals, dental clinics, veterinary clinics and other clinics such as Occupational Health Clinics…

• 0807901 Pharmaceuticals in Defense Medical Centers, Station Hospitals and Medical Clinics – OCONUS

33

FY09 MERHCF LOEPharmaceutical PEC & SEEC Mismatch

Fiscal Year

Parent DMIS

IDParent Name

DoD PEC

DoD SEEC SEEC Description

Net Month Expense

2009 0033 10th MED GROUP-USAF ACADEMY CO87701 11.10 Civilian Personnel Compensation 387,245$ 2009 0033 10th MED GROUP-USAF ACADEMY CO87701 11.72 Military Personnel Compensation 821,658$

1,208,904$

2009 0045 6th MED GRP-MACDILL87701 11.10 Civilian Personnel Compensation 105,859$ 2009 0045 6th MED GRP-MACDILL87701 11.72 Military Personnel Compensation 421,938$ 2009 0045 6th MED GRP-MACDILL87701 11.74 Borrowed Military Labor 2,093$

529,889$

2009 0055 375th MED GRP-SCOTT87701 11.10 Civilian Personnel Compensation 113,216$ 2009 0055 375th MED GRP-SCOTT87701 11.72 Military Personnel Compensation 816,848$ 2009 0055 375th MED GRP-SCOTT87701 11.74 Borrowed Military Labor 3,752$

933,817$

34

FY07 MERHCF LOEImpact of Incomplete Army MEPRSArmy lost $20.0 million or 3.3% of their FY07-

based MERHCF distribution

Official results submitted 29 April 2008

Updated results computed 13 June 2008

Army Air Force NavyDoD Beneficiaries 609,708,647$ 575,864,963$ 395,999,148$ 1,581,572,758$ Non-DoD Beneficiaries 4,284,678$ 5,003,092$ 8,083,711$ 17,371,482$

613,993,325$ 580,868,055$ 404,082,859$ 1,598,944,239$ Total MERHCF LOE

MERHCF LOE by Providing Military ServiceBeneficiary Service Affiliation

MERHCF LOE Total


634,951,708$ 581,305,267$ 404,819,438$ 1,621,076,413$ Total MERHCF LOE


MERHCF LOE Total

35

FY09 MERHCF LOEImpact of Incomplete Air Force MEPRS


715,157,597$ 602,857,971$ 434,459,771$ 1,752,475,340$ Total MERHCF LOE


MERHCF LOE Total

Official results submitted 21 April 2010


715,591,185$ 626,330,797$ 434,465,006$ 1,776,386,989$ Total MERHCF LOE


MERHCF LOE Total

Updated results computed 24 May 2010

Air Force lost $23.5 million or 3.7% of their FY09-based MERHCF distribution

36

Concluding Thoughts• MEPRS data are used in many programs,

applications and metrics• Uncorrected data problems can affect the

outcome of studies, analyses, metrics, and resulting decisions

• Detection/correction of various MEPRS data problems centrally takes time and is difficult to accomplish systematically

• Local detection/correction of data problems is most effective

• Several tools are available to assist in identification of data problems

Questions?

CONTACT INFORMATION

John A. Coventry, Ph.D.SRA International, Inc.

[email protected]

meprs what it’s good for …*

Documents

available data

tmafte data

data issues

billingclaims data

manpower data

questionable meprs data

partiesmtf expense data

radiology workload data