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25 September 2014

Army Medicine: Linking Strategy , Resources , and Performance Assessment. Army Medicine Health Law Symposium. Robert L. Goodman, SES Deputy Chief of Staff Resources, Infrastructure & Strategy US Army Medical Command & Office of The Surgeon General. 25 September 2014. UNCLASSIFIED

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25 September 2014

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  1. Army Medicine:Linking Strategy, Resources, and Performance Assessment Army Medicine Health Law Symposium Robert L. Goodman, SES Deputy Chief of Staff Resources, Infrastructure & Strategy US Army Medical Command & Office of The Surgeon General 25 September 2014 UNCLASSIFIED Pre-Decisional – FOUO – Pre-Decisional

  2. AGENDA • Fiscal Law • Contract Law • The Anti-Deficiency Act • The Joint Ethics Regulation • How important Lawyers are • How important Comptrollers are Not What I Want To Talk About

  3. Instead Let’s Talk About . . . • Constants • Changed and Changing • How We Transform • Focus on Superior Patient Care • Understand the Environment in Which We Live • Deliver Ready Soldiers & Ready Medical Forces • Value the Patient Experience • Align Incentives: Integrated Resourcing & Incentive System (IRIS)

  4. Constants Mission, Vision, and Priorities • Mission: Army Medicine provides responsive and reliable health services and influences Health to improve readiness, save lives, and advance wellness in support of the Force, Military Families, and all those entrusted to our care • Vision • Strengthening the health of our Nation by improving the health of our Army • Priorities • Combat Casualty Care • Ready and Deployable Medical Force • Readiness of the Force • Health of the Soldier and Beneficiaries LTG Patricia D. Horoho Army Surgeon General and Commanding General, US Army Medical Command 10 March 2014

  5. Constants: TSG: “3 Years From Now …” (Dec 2012) • We will be an Operating Company • Our patients will benefit from a standardized patient experience • Capabilities and capacities of our facilities will be determined by the US Army Medical Command Headquarters. • Clinical Quality is standardized and variance is significantly reduced. • We will see improved accountability and better utilization of our resources. • We will focus on Health Outcomes • - Mental, Physical, Spiritual, and Emotional • We will promote Sleep, Activity, and Nutrition • - Soldiers, Family Members, and Retirees • We will reduce Body Mass Index (BMI) 15%-30% • - This will help reduce high blood pressure, hyper-lipidemia, diabetes, and other disease processes. • We will partner with civilian organizations • - Army Medicine is at the forefront of Healthcare payment and incentive reforms for the nation.

  6. Changed & Changing • Smaller DoD • MHS Governance & the Defense Health Agency • Smaller Army • Smaller MEDCOM • Civilian & Military Staff Reductions • Inpatient Closures & Other Service Adjustments • TF Futures: Fewer RMCs and MSCs • Retooled MEDCOM Headquarters • Larger Medical Centers • Health Benefit • Consolidated Health Plan (Single TRICARE) requested in the 2015 President’s Budget • Recommendations from the Military Compensation & Retirement Modernization Commissions due in Feb 15 • Expectations of Access, Safety, and Quality • Level of Scrutiny & Patience

  7. So, How Will We Proceed? • Understand the Environment in Which We Live • Focus on Superior Patient Care • Deliver Ready Soldiers • Deliver Ready Medical Forces • Value the Patient Experience • Align Incentives: Integrated Resourcing & Incentive System (IRIS) • Manage Our Labor: Hiring Data, Hiring Ceiling, Hiring Caps, Compensation

  8. Superior Patient Care • Quality • Access • Safety • HEDIS? • Satisfaction • No Harm Objectives Objectives Performance Performance • MHS Review? • Publicly available data? • Joint Commission data?

  9. Military Healthcare IS NOT Private Sector Medicine Readiness of the Force Health of Families & Retirees • An interdependent and overlapping mission set • An effective integrated system of comprehensive care • Providing many services not found in private sector healthcare • Driven by service, not profit Readiness of the Medical Force Casualty Care

  10. The Environment We Live In MHS Review: Access, Quality, Safety $4.1B DHP Savings Target MILCON Review MCRMC Enhanced Multi-Markets DoD Guidance 20% HQsReductions 4 Star & Above 2/5/10% DHP POM Reductions DHP POM 15-19 Funding Guidance -20% DHP HQ Reductions • Reduce Budgets • Reduce Staff • Centralize • Control/ Restrict Authority MHS Modernization Study I & II DHA Shared Services Restrictions on Travel, Conferences, Contracts, Printing 20-25% HQsReductions 2 Star & Above MEDCOM Military ES - 842 to -1,918(?) Work Force Shaping Civilian Ceilings ARMY Guidance Army Review of Access, Quality, Safety MILPER Reductions Operating & Generating MEDCOM Civilian ES Reduction AMEDD 2020 Integrated Resource & Incentive Model Performance Planning Workforce 2020 MEDCOM Guidance TF Futures MTF Downsizing

  11. Dealing With Cost

  12. Cost of Medicine in America vs Military Medicine • DoD spends 22% less on healthcare than other large employers while providing a more robust benefit and producing military readiness. • Total annual DoD Estimate of current Benefit for a typical family of four covered by TRICARE Prime is $17,196 ($4,299 per member per year) • Total annual cost of healthcare for a typical family of four covered by an employer-sponsored preferred provider plan (PPO) is $22,030 What Large US Employers & Their Employees Pay for Healthcare What DoD & Their Beneficiaries Pay for Healthcare $17,196 • Total annual US Family Health Plan for a typical family of four covered is (range): $20,000 - $23,500 Max Employee Out of Pocket <$600 $17,196 DoD Contribution • A Robust Military Direct Care System is the most cost effective way to deliver the benefit and ensure Readiness Source: Milliman Medical Index 2013, http://www.milliman.com/mmi/

  13. MTF COST OF CAREInpatient & Outpatient Cost Per Weighted Work UnitBubble size relative to volume of care delivered Cost Savings Potential = $668M Effect of moving high cost outliers to BAMC: DHA NCR: $251M Air Force: $187M Navy: $159M Army: $72M Source: MEPRS rolling 12 months ending April 2014

  14. Enrollment Trends FY2009-CurrentAn Army MEDCEN MCSC MTF Source: M2 DEERS, 20140721 MCSC Prime based on MTF PRISM/Catchment

  15. Labor Trends FY2001-CurrentAn Army MEDCEN Example Labor Trend By Skill Type ADMIN PARA-PROF RN PROFESSIONAL CLINICIAN Source: EASIV, 20140721 BMM / Volunteer excluded

  16. Labor Trends FY2001-CurrentAn Army MEDCEN Example Labor Trend Providers Enl, Off, Civ, Contract Labor Trend By Type Enl, Off, Civ, Contract Contracts Civilians MILITARY Contracts Civilians Labor Trend Spt Staff Off, Civ, Contract Officer Enlisted Civilians Source: EASIV, 20140721 BMM / Volunteer excluded

  17. Summary of MEDCOM Options to Meet the 1,918 Military Manpower Target

  18. Warrior Transition Units (WTU) • WTU population is projected to decrease from 5,550* to 4,500 at end of FY17 • Recommendation: • Apply 250 military authorization reductions previously categorized as acceptable risk by HQDA G-37/FM • Continue to assess WTU structure requirements as part of the HQDA G-37/FM steered Working Group to further identify additional authorizations for reduction * WTU population as of 28 July 2014 RISK: MODERATE • RISK ANALYSIS DISCUSSION • WTU structure requirements are anticipated to decrease over next several years • Additional savings may be generated with further mission consolidation • Political sensitivities due to the perception of eroded WT support may continue to persist • RISK ANALYSIS MITIGATION • Continued careful Army-steered assessment of WTU structure requirements

  19. Deliver a Ready Medical Force The Cost vs. Effectiveness Dilemma Cost and efficiency are necessary conditions, but not sufficient conditions The sufficient condition for the MRAP was Force Protection Force Protection = Health and Readiness of the Force

  20. The Cost vs. Effectiveness Dilemma Cost and Efficiency matter: However, if sufficient, high quality, civilian healthcare is unavailable in select local markets, Army Medicine has a statutory obligation to provide a base capability to care for Soldiers and Families to ensure Health and Readiness of the Force Places of concern include: Ft Irwin, Ft Wainwright, Ft Polk, Ft Riley, Ft Stewart, Ft Campbell, Ft Leonard Wood, etc. Cost and efficiency are necessary conditions, but not sufficient conditions Army Medicine = Health and Readiness of the Force

  21. Readiness – Case Mix Index =>1.5MHS Top 36 Data Source:FY2013 M2 SIDR

  22. Readiness - ICU Bed DaysMHS Top 35 Data Source:FY2013 M2 SIDR

  23. Readiness – Emergency Room Admitted DispositionsMHS Top 35 Data Source:FY2013 M2 SIDR

  24. Cost and Performance - RevenueMHS Top 35 Source of Workload Data: FY 2013M2 SIDR, CAPR and PDTS PPS Rates used for calculating RVU, APC, RWP and MH Bed Days Revenues. Rx Cost used for Rx Revenue RVU Rate$34.04 APC Rate $71.42 RWP Rate $8,967.00 BH Bed Days Rate $860.00

  25. Per Member Per Month Costs • West Point • Highest PMPM MEDCOM for 1st QTR FY14 - $515 • PMPM increased by 40% since 1ST QTR FY2011 • NRMC 20%; MEDCOM 1% • Greater than 10% Decrease 1st QTR FY13 – 1ST QTR FY14 • FT Leonard Wood (-17.2%) • FT Bliss (-14.1%) • LRMC (-11.0%) • BAMC (-10.6%) • FT Riley (-10.4%) -3.9% -1.8% -1.7% -8.2% -3.9% -2.0% % Change 1st Qtr FY13 – 1stQtr FY14

  26. Overview – Patient Experience IRIS Dollars: Approximately $70 Million per year for patient experience Inpatient: TRISS Outpatient: APLSS Why Army Provider Level Satisfaction Survey (APLSS)? Encounter based survey, providing “near real time” (the Civilian Standard) results down to the Provider Level Frequency: Survey is fielded daily and surveys are received within 48-72 hours of a visit Annual Sample Size: Approximately 150-160K per month Mode: E-mail for Active Duty and Dependents under 18; mail for other beneficiaries Response Rate: ~25% (~ 40K per month) • Why TRICARE Inpatient Satisfaction Survey (TRISS)? • The only survey to measure inpatient experiences and compare both purchased care and direct care with national benchmarks (HCAHPS) • Frequency: Survey is fielded bi-monthly for Direct Care and monthly for Purchased Care • Annual Sample Size: ~168,000 (~14k/month) • Mode: Mail within 42 days of discharge, with phone follow-up for those who don’t respond • Response Rate: Over 40% (~ 6,000 per month)

  27. Satisfaction and Clinical Efficacy • YES, We should engage in evidence based practice! • What does the evidence tell us? • What does OUR data tell us? • Satisfaction and Clinical Effectiveness • Satisfaction and Efficient Clinical Practice • Satisfaction and Prescribing Patterns

  28. Patient Experience and Quality are linked • Patient Experience is a very important marker of quality • Patient Experience is very important to Army Medicine. • Army Medicine has risen from worst to first among the three Services on ASD(HA) satisfaction surveys • And … • We put our money behind the desire to see this happen. • 30,000 surveys per month are returned. • 96% for Tier 4 = $450 for Q20 / $900 total = $324,000,000/Year • 94% for Tier 3 = $225 for Q20 / $450 total = $162,000,000/Year • 92% for Tier 2 = $ 75 for Q20 / $150 total = $ 54,000,000/Year • Below Tier 2 = lose money (up to $150 per survey) • Below Tier 1 = lose substantial money (up to $450 per survey)

  29. MEDCOM APLSS Jan 2007- Present April 2013: Methodology Shift to e-mail for Active Duty (and child dependents) Q-21 Sep 2009: Survey Work Group added common questions

  30. The Integrated Resourcing & Incentive System (IRIS) Aligning Incentives and Resources To Achieve Performance Gains UNCLASSIFIED

  31. FY15 Budget Framework • Statement of Operations • Primary Care Sub-capitation • Behavioral Health Model • Surgical Service Line • Telemedicine • Fee for Service • Primary Care in Transition • Special Program Carve Outs • Highlighted Incentives

  32. Significant Performance Improvements Staff Courtesy/Helpfulness Volume of Care Delivered in MTFs • APLSS Q20 • DoD PPS Compliance with National Evidence Based Medicine Standards Overall Healthcare Satisfaction Rating • TROSS Q32 • DoD inSight

  33. Transition to IRIS during FY14/15 • PBAM = Adjustment Model • Budget not directly connected to Performance Plan • No adjustments for exceeding / falling short on • Enrollment • Other workload • Many performance areas • Builds an increasing share of the budget (est $500 M) • Primary Care budget build directly connect to Perf Plan • Budget Build and PBAM Combined into IRIS • BH budget build based on BHSL Plan (Structure, FFS, Incentives) estimated $300 Million • PBAM replaced with a broader based incentive system

  34. Integrated Resource & Incentive System (IRIS)MEDCOM’s Application of Performance Based Budgeting • MEDCOM began using Performance Based Budgeting in 2006 • Known as the Performance Based Adjustment Model (PBAM) • Aligned funding & provided financial incentives to enhance performance and achieve objectives • Adjusted MTF budgets for volume and quality of care • Resulted in near continuous performance improvements in areas incentivized under PBAM • In FY14 MEDCOM transitioned to IRIS • Funding for Primary Care became capitated and based on planned enrollment instead of fee-for-service based on workload. • Behavioral Health funding linked to performance • Incentives expanded to 48 performance factors, some of which are: • Quality • HEDIS • Patient Satisfaction • ORYX • IPSR • AHRQ Preventable Admissions • Tobacco Use • Healthy Weight • P4P Readmissions • NCQA Medical Home Enrollment • Medical Readiness • Low Back Pain/Diabetes CPG • Wartime Clinical Skills Sustain • Joint Commission • Administrative • MEPRS Penalty • Coding Accuracy • Coding Timeliness • Bed Days Per 1000 Enrollees • PMPM Change • TOL Booked Appointments • PCM Continuity • Network: Non-Emergent ER Care • Secure Messaging • OR Utilization • Inpatient Occupancy • Inpatient Nurse Staffing • Admin Cost Efficiency • ROFR Take Rate • MEB Completed • Organizational Performance • Army VPP Star Status • Operating Company (Performance Objectives) • Leader Development • Civilian Development • Training • Capacity • Capitation • Fee For Service • Network PC Adjustment • MILPAY Adjustment • Coding Error Correction • Surgical Service Line • Telemed/Telehealth BOLD added in FY15

  35. Discussion

  36. MEDCOM Civilian End Strength ProfileUSDH Pay Accounts; All appropriations ao: 28 Aug 14 FY15 FY13 FY14 43,648 Desired ramp to 2014 Target 41,547 Actual Unnecessary Staff Loss - 3,174 (-8%) -3,398 (-8%) Jan to Sep 13 4,608 ~3,500 Open Actions are required to maintain steady ES • As of 28 Aug 2014 • In the 19 months since Jan 2013, the MEDCOM has experienced an unplanned civilian workforce loss of -12% or 5.165 employees. • Contributing to the loss are the cumulative effects of the Army civilian hiring freeze, Army imposition of civilian ES caps, financial uncertainty to include sequestration and shut down, reaction to programmed manpower losses in FY17 and beyond, and operational uncertainty created by the numerous studies and reviews being done on the future of military medicine. • This workforce loss represents a significant mission riskrequiring action to stabilize and restore our workforce to planned levels. • As of EOM August, we are 3,174 employees or 8% below our funded civilian ES plan and 3,064 (7%) below our FY14-end target. • MEDCOM continues to loss ESbut the rate of loss is near 0. • MEDCOM has 4,608 open recruit actions of which 941 are near completion* and should on board in September. • MEDCOM’s civilian ES should increase slightly September since we had more than 3,500 open actions in April and May. • Expect ES to remain below projection and >4% (1,600) below target through end of FY14. * Near Completion = Committed, Effective, EOD established, DHA Candidate Id, LQA determinations, Offered or Salary Determination

  37. Incentives Evolution: Strategic & Incremental Changes Over Time $572 M Leveraging Financial Incentives… Capacity--Payment Rates: PPS Adjusted Rates to Incentivize Core Product Lines PC, BH, Ortho, OB, & ER Removed BH Capacity Patient Satisfaction Overall (Q21) Added Access to Care (Q9, Q11, Q13) Modified thresholds & rates Added IP Pat Sat Quality (Satisfaction) 2007 2011 2004 2005 2006 2009 2010 2012 2008 EBP: 7 Metrics (HEDIS List) - Asthma Meds - Cancer Screening Breast Cervical Colorectal - Diabetes A1C Test A1C Control LDL Control Adopted Action List Added 2 Metrics: - Pneumovax - Chlamydia Screening Added ORYX Added BMI Added: - HEDIS Well Child Quality (EBP) $209 M Admin: 7 Metrics -Coding Accuracy (3) -MEPRS timeliness -SIDR and CAPER Completion (3) Added: -Network Primary Care -PCM Continuity Efficiency …To Achieve Performance Growth in Army Medicine

  38. IRIS Targets Adjusted targets (Q9,13,20,21) - Targets based on adjustments for percent of AD/ADFM survey response rate - Why? Historically, Ret/RetFM consistently score us about 5% higher – regardless of location. Therefore, the higher the percentage of Ret/RetFM response rate (often big Medical Centers), the higher the MTF’s Targets will be. Said another way, the greater percentage of AD/ADFM responses (generally associated with FORSCOM posts), the lower the Targets will be for the MTF. Tiers and Payments:

  39. Recruitment/Relocation/Retention Incentives • MCHR, 7 Jul 2014, subject: Re-Delegation of Civilian Human Resources Authorities and MEDCOM Matrix Version 30 Jun 2014 • Approval authority delegated from MEDCOM CoS to MSC/RMC Commanders • Recruitment and Relocation Incentives • Clinical positions • MSC/RMC Commanders may further delegate authority to COL 0-6 level Commanders • Non-clinical positions • Retained at MSC/RMC Commander level. No further delegation • Retention Incentives • Three Tier System based on occupational series • Occupational series not included in Tiers 1-3 require MEDCOM CoS decision

  40. Retention Incentive Approval Level • MSC/RMC Commanders • up to 25% for Tier 1 positions • up to 20% for Tier 2 positions • up to 15% for Tier 3 positions • may approve up to 10% retention incentives for employees covered under PDPP • MEDCOM CoS retains authority to approve retention incentives greater than 10% • may delegate approval authority to COL 0-6 Commanders • up to 20% for Tier 1 positions • up to 15% for Tier 2 positions • up to 10 for Tier 3 positions

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