Institute of Medicine Moving to a More Integrated Health System

Transcription

1 Pre-Decisional deliberative matter For official use only within DoD The Military Health System Institute of Medicine Moving to a More Integrated Health System Dr. Jonathan Woodson Assistant Secretary of Defense for Health Affairs March 20, 2013 Governance Implementation Planning Team

2 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 The MHS is measured against each of the roles for which it is responsible warfighter support, employer, provider, insurer, educator, and researcher 3

3 The Quadruple Aim 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 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. Better Care Providing a care experience that is patient and family centered, compassionate, convenient, equitable, safe and always of the highest quality. 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. 4

4 % Survived (30 Day Outcome) A Ready Medical Force Survival Rates on Battlefield Against Expected Outcomes 100% 95% 90% 85% 80% 75% 70% Observed Survival Expected Survival 5

5 $B % od DoD Topline An Employer s Perspective Health Budget as Percent of Defense Budget $ % $60 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% 10.0% $50 8.1% 8.1% 7.5% 8.0% $40 5.9% 6.0% $30 4.0% $20 $10 2.0% $- 0.0% 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 Unified Medical Budget % of DoD Topline Projections 6

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

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

8 Better Health OPERATION LIVE WELL/ Healthy Base Initiative National Prevention Strategy Health and Safe Community Environments Clinical and Community Preventive Services Empowered People Elimination of Health Disparities Operation Live Well Objectives Active Living Healthy Eating Tobacco Free Living Mental & Emotional Well Being Quadruple Aim Readiness Population Health Experience of Care Per Capita Cost 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 9

9 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

10 Overhead and Governance Headquarters Only Part of the Story Private Sector $16,377M Direct Care $8,149M Consolidated Health $2,194M Base Operations $1,743M Info Mgt $1,423 Edu. and Train. $705M Management Activity $312M 11

11 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

12 Near Term MHS Transformation Efforts 13

13 The Goal: Deliver Value Value = Outcomes Cost Value = Readiness Experience of Care + + Cost (Over a Span of Time) Population Health Creating a high value Military Health System is predicated on defining and measuring value. 14

14 Simultaneous Transformation of Care and Payment Can Help Reduce Costs while Improving Care/Health Delivery System Fully Integrated Delivery System Ideal Level 2/3 Medical Homes Transition Volume-driven Fragmented Care The Past Fee-for-service Simple process and structure measures (small % of total payment) Primary Care Sub- Capitation; FFS for Specialty/IP Care coordination and intermediate outcome measures (moderate % of total payment) Bundled/Episode Payment, Full Prepayment Outcome measures large % of total payment Payment Bundling P4P Design Adapted from From Volume to Value: Better Ways to Pay for Health Care, Health Affairs, Sep/Oct

15 Achieving better system integration from the ground up. Healthy and Resilient Individuals, Families and Communities Ready Medical Force Operational Medicine Medically Ready Force Occupational Medicine Primary Execution Structure Tricare Network of Providers Major Multi-Service Market MTFs (NCA, SA, SD, Tidewater, Madigan, Tripler, CO) Operational Medicine Community Hospitals and Clinics Shared and Support Services The Defense Health Agency Health Plan Management Resource Perspective Shared Services (IM/IT, Contracting, Logistics, HR Mgmt, Facilities, Fin Mgmt, etc) Education and Training (METC, GME, USUHS) Research and Development 16

16 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 Reference: Ten strategies to lower costs, improve quality, and engage patients, Health Affairs, Feb 2013, 32:2. 17

17 Learning & Growth Per Capita Cost Experience of Care Population Health Readiness Strategic Imperative Improve Individual and Family Medical Readiness Enhance Psychological Health & Resiliency Exec Sponsor MHS Strategic Imperatives Scorecard Performance Measure Development Status Previous Performance Current Performance FHPC Medically Ready to Deploy 82% 84% +2% 82% 85% 85% TBD Measure of Family Readiness (i.e., PHA for families) - Change FY2012 Target FY2014 Target FY2016 Target MHS Strategic Initiatives Implement Policies, Procedures & Partnerships to Meet Individual Medical Readiness Goals Optimize Healthcare Markets to Support GME and Readiness 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 FHPC Depression Screening, Referral (R) and Treatment (T) 71%/75% 67%/76% -4%/+1% 50%/75% 50%/75% 50%/75% Enhance Value CPSC MHS Cigarette Use Rate (Active Duty 18-24) 21% 20% -1% 18% 16% TBD CPSC Adults with Diagnosis of Overweight or Obese 7%/28% 8%/30% +1%/+2% 50%/90% 100%/100% 100%/100% Engage Patients in Healthy Behaviors 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% Improve Measurement and Management of Population Health to Accelerate the Shift from Healthcare to Health CPSC HEDIS Index: Preventive Cancer Screens & Well Child Visits (DC/PC) 8/6 10/5 +2/-1 12/10 15/12 15/16 CPSC HEDIS Index: Cardiovascular, Diabetic & Mental Health Care (DC/PC) 28/5 24/4-4/-1 36/12 50/16 50/21 Deliver Evidence- Based Care CPSC Direct Care Readmission Rate (Medical/Surgical) CPSC Wrong Site Surgery and Procedures (Direct Care) Implement Evidence Based Practices Across the MHS to Improve Quality and Safety CPSC Antibiotic Received Within 1 Hour Prior to Surgical Incision 96% 97% +1% 98% 98% 98% Excel in Wounded, Ill and Injured Care CPSC CPSC Medical Evaluation Board Stage Timeliness Integrated Disability Evaluation System (IDES) Percent of Service Members Rating Medical Evaluation Board Experience as Favorable % 47% -6% 70% 75% TBD Optimize Pharmacy Practices to Improve Quality and Reduce Cost JHOC Primary Care 3rd Available Appointment (Routine/Acute) 72%/51% 68%/49% -4%/-2% 78%/62% 86%/68% 94%/75% Optimize Access to Care Promote Patient- Centeredness 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 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 Implement Patient Centered Medical Home Model of Care to Increase Satisfaction, Improve Care and Reduce Per Capita Costs Manage Health Care Costs CFOIC Annual Percent Increase in Per Capita Costs 1.8% 4.3% +2.5% 9.5% - - CFOIC Emergency Room Visits Per 100 Enrollees Per Year Implement Alternative Payment Mechanisms to Pay for Value Enable Better Decisions Foster Innovation Develop Our People CPSC EHR Usability Deliver information for better decisions (Clinical Enterprise Intelligence) CFOIC Effectiveness in Going from Product to Practice (Translational Research) CFOIC Human Capital Readiness / Build Skills & Currency - CFOIC Primary Care Staff Satisfaction 58% 58% - 62% 65% 71% - Implement Modernized iehr to Improve Outcomes and Enhance Interoperability Improve Governance to Achieve Better Quadruple Aim Performance Concept Only Measure Algorithm Developed Current Performance Known and Current Target Approved Out-Year Targets Approved Design Phase Approved Funded 18

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19 Health Care Management Model Logic Structure State 1: Free of Disease, Low risk State 2: Free of Disease, High risk State 3: Has Disease, Uncomplicated Increasing Resource Requirements State 4: Has Disease, Complicated

20 Health Care Management Model Conceptual Structure Scenario Data Clinical Data Population Data Allocation Policy Access Barriers Resource Capacities HMM Disease States Clinical Programs Resource Consumption Rates Disease State Transition Probabilities Disease Profile over time Workload over time

21 Health Care Management Model Projected Analytic Results

22 Aspirational Model Control your future or be a victim of the future

23 Futures-Based Agile Thinking Inspiration Phase ( ) Implemented Scenario-Based Methodology (Alternative Futuring) Identified 4 Transformational/Environmental Issues Ideation Phase ( ) 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 Implementation ( ) 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

24 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 AFMS Vector or String

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27 Federal Health Strategy Map Identify common priorities Identify common principles Outline common objectives

28 Federal Health Strategic Matrix Leadership Readiness Value Quality Optimize Healthiness Team Effectiveness Collaborative Partnership Knowledge Access Situational Awareness Research and Development Accountability Risk Taking Education and Training Agility Resiliency Strengthen Communications Focused Acquisition Transform Management Strengthen Systems Prioritize Investment Excellence in Execution Interagency Initiatives Choice/Options Knowledge, Data Management, and Analytics Humanitarian Response Increase Access Cost Efficiency Federal Collaboration Standardization Continuous Care Innovation, Science, Technology Recapture Care Manage Cost Facility Renewal Fiscal Stewardship Health as a Team Sport Leade rship Devel opme Wisd nt om Gene ratio Reso n urce Stewa rdshi p

29 Value Stream of the WIN Initiative Human Flourishing National Quality Strategy Wellness Initiative for the Nation National Prevention Strategy Grow Connect Live Survive Pyramid of Prosperity Productivity Preparedness Prosperity Growth Disparity Quality Cost Value Proposition Environment Beneficent Purpose Health Care Core Components National Debt National Medical Bill

30 Back Up 31

31 Proposed Incentive Measures Readiness: Health: **IMR Indeterminate Rate Currency - Further study. ** 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 ** = Measure to be included in initial set of incentive measures 32

32 Healthcare: Proposed Incentive Measures (Con t) 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 ** 3 rd 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) ** = Measure to be included in initial set of incentive measures 33

33 Cost: Proposed Incentive Measures (Con t) ** 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. People (All measures in development) Staff Engagement Staff Safety PC Staff Satisfaction ** = Measure to be included in initial set of incentive measures 34

34 2012 MHS Performance Report Card Readiness Target 1 Medically Ready to Deploy 82% 84% 2012 * Current 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) ($) 18% 20% 5 Adults with Diagnosis of Overweight or Obese 50%/90% 8%/30% / 6 Adolescents & Children with Diagnosis of Overweight or Obese 50%/75% 9%/31% / 7 Exclusive Breastfeeding During Newborn Hospitalization 70% 63% 8 HEDIS Index: Preventive Cancer Screens & Well Child Visits (DC/PC) 12/10 10/5 / Experience of Care 9 HEDIS Index: Cardiovascular, Diabetic & Mental Health Care (DC/PC) 36/12 24/4 / 10 Direct Care Readmission Rate (Medical/Surgical) Wrong Site Surgery and Procedures (Direct Care) 0 1 NC 12 Antibiotic Received Within 1 Hour Prior to Surgical Incision 98% 97% 13 Medical Evaluation Board Stage Timeliness Integrated Disability Evaluation System (IDES) ($) 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 ($) 24% 22% 18 Percent of Visits Where MTF Enrollees See Their PCM 60% 57% 19 Satisfaction with Health Care 62% 60% Per Capita Cost 20 Annual Percent Increase in Per Capita Costs ($) % 21 Emergency Room Visits Per 100 Enrollees Per Year ($) Primary Care Staff Satisfaction 62% 58% NC Improving ($) Denotes lower is better Yes No * Data lag 3-6months 35