Military Health System: The Defense Health Agency in 2016 VADM (Dr) Raquel Bono Director, Defense Health Agency December 1, 2015

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1 Military Health System: The Defense Health Agency in 2016 VADM (Dr) Raquel Bono Director, Defense Health Agency December 1, 2015

2 The Defense Health Agency Fully Operational / Continuity of Mission 1

3 The Defense Health Agency Fully Operational / Continuity of Mission The imperative of successful MHS Governance reform requires a sustained commitment by all components to adapt an enterprise focus, including the renewed priority of quality, patient safety and access throughout the entire MHS and the challenge of transitioning to a new, state-of-the-art electronic health record. Jointness, cost effectiveness and healthcare integration remain the guiding vision. -DepSecDef Work September

4 Why We Are Here It s on every slide Medically Ready Force Ready Medical Force 3

5 Our 2016 Priorities Support to the Services Support to Combatant Commanders Optimizing the DHA for the Future 4

6 Defense Health Agency Leadership Team Mr. Guy Kiyokawa Deputy Director Vice Admiral Raquel Bono Director CMSgt Vottero Acting Sr. Enlisted Advisor MG Richard Thomas Director Healthcare Operations RADM Bruce Doll Director Research & Development Mr. David Bowen Director Health IT Brig Gen Robert Miller Director Education & Training Mr. Darrell Landreaux Acting Director Business Support MG Jeffrey Clark Acting Director NCR-Medical Directorate 5

7 6 6

8 Defense Health Agency Global Operations / Global Support TRO West DHA - Aurora TRO South METC Health IT MMSO Great Lakes Armed Forces Med Examiner Defense Health Agency TRO North TRICARE Europe: Armed Forces Hlth Surveillance Center Natl Museum of Hlth and Medicine Walter Reed Natl Mil Med Center Ft Belvoir Cmty Hospital TRICARE Pacific 7

9 DHA as a Combat Support Agency 8

10 DHA Shared Services 1 Pharmacy Programs 6 Budget & Resource Management 2 TRICARE Health Plan FOC 29 Sep 15 7 Procurement/Contracting 3 Health Information Technology 8 Research, Development & Acq 4 Facilities FOC 3 March 15 9 Public Health 5 Medical Logistics FOC 3 March Medical Education & Training * Pending 90-Day Review 9

11 Pharmacy 1 Pharmacy Programs 6 Budget & Resource Management 2 TRICARE Health Plan FOC 29 Sep 15 7 Procurement/Contracting 3 Health Information Technology 8 Research, Development & Acq 4 Facilities FOC 3 March 15 9 Public Health 5 Medical Logistics FOC 3 March Medical Education & Training * Pending 90-Day Review 10

12 Compound Drugs Cost Trend and Impact from Screening $600,000,000 $500,000,000 DHP MERHCF Total Spend $400,000,000 $300,000,000 $200,000,000 $100,000,000 $0 10/1/ /1/ /1/2012 1/1/2013 2/1/2013 3/1/2013 4/1/2013 5/1/2013 6/1/2013 7/1/2013 8/1/2013 9/1/ /1/ /1/ /1/2013 1/1/2014 2/1/2014 3/1/2014 4/1/2014 5/1/2014 6/1/2014 7/1/2014 8/1/2014 9/1/ /1/ /1/ /1/2014 1/1/2015 2/1/2015 3/1/2015 4/1/2015 5/1/2015 6/1/2015 7/1/2015 Note: DHP Compound Pharmacy Expense represented by under age 65 beneficiaries 11

13 Compound Drugs Cost Trend and Impact from Screening $600,000,000 $500,000,000 DHP MERHCF Total Spend $400,000,000 $300,000,000 $200,000,000 $100,000,000 $0 10/1/ /1/ /1/2012 1/1/2013 2/1/2013 3/1/2013 4/1/2013 5/1/2013 6/1/2013 7/1/2013 8/1/2013 9/1/ /1/ /1/ /1/2013 1/1/2014 2/1/2014 3/1/2014 4/1/2014 5/1/2014 6/1/2014 7/1/2014 8/1/2014 9/1/ /1/ /1/ /1/2014 1/1/2015 2/1/2015 3/1/2015 4/1/2015 5/1/2015 6/1/2015 7/1/2015 Note: DHP Compound Pharmacy Expense represented by under age 65 beneficiaries 12

14 Compound Drugs Cost Trend and Impact from Screening $600,000, Monthly Compound Expense $550,000,000 $500,000,000 1 $450,000,000 Spend peaked in April $545M Last week in April alone over $200M $400,000, $350,000,000 $300,000, $250,000,000 $200,000, $150,000,000 $100,000, $50,000,000 May 1-May 11 (Initial Screen): $75M May 12-May 31 (Enhanced Screen) : $5M June $10.4 M July estimated $10.5 at current spend $0 0 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Sep-12 Nov-12 Jan-13 Mar-13 May-13 Jul-13 Nov-13 Nov-11 Sep-13 Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15 Sep-15 Note: DHP Compound Pharmacy Expense represented by under age 65 beneficiaries 13

15 Addressed Fraud; Assisted Criminal Activity Justice Dept will prosecute fraud 14

16 Shared Service: Pharmacy Programs Implementing Home Delivery Enterprise effort to move patients to the right source for prescription medications at the lowest cost to the patient and the government TRICARE For Life seamless migration to Home Delivery for chronic medications in February 2014 All TRICARE beneficiaries began migration on October 1 of this year Introduced ability for civilian providers to electronically request prescription drugs from nearby MTF Continued to adjust Rx co-pays to incentivize quality, costeffective options 15

17 TRICARE 1 Pharmacy Programs 6 Budget & Resource Management 2 TRICARE Health Plan FOC 29 Sep 15 7 Procurement/Contracting 3 Health Information Technology 8 Research, Development & Acq 4 Facilities FOC 3 March 15 9 Public Health 5 Medical Logistics FOC 3 March Medical Education & Training * Pending 90-Day Review 16

18 TRICARE 2017 Comprehensive reassessment of how we deliver / coordinate care -- more than just the benefit How we organize and administer TRICARE to include TRICARE contracts Patient-centered: Modernization and simplification of contracts and service Expand contemporary means to access health services beyond the physical office visit 17

19 DHA: Listening to Our Customers Acute Care Campaign April

20 DHA: Listening to Our Customers Based on our [NMFA] findings, we ask that the Defense Health Agency and Congress consider the following steps to improve access to acute care for military families: Develop and implement metrics that accurately assess acute appointment demand Expand clinic hours and the number of acute appointments Monitor progress on access initiatives Standardize the network urgent care referral process and monitor compliance at the MTF level Waive the network urgent care preauthorization requirement for a limited number of urgent care visits Limit the policy of directing beneficiaries to MTF emergency rooms Re-examine the referral policy 19

21 Access 3 rd Available Appt - 24hr LOWER IS BETTER Target MHS NCRMD 20

22 TRICARE Reform Transparency - Internal & External The Secretary of Defense demanded it; the MHS committed to it; the law (NDAA 2016) now describes exactly what is expected CMS / Hospital Compare requires it Tied to Medicare reimbursement VA participates in it, and shares it on its website Leading high reliability organizations embody it, even when it is below benchmarks, and can rapidly drive improvement The media has access to the data, without needing to ask us (and if they ask, we are obligated to share it) Patients expect it 21

23 MHS Transparency It s Coming! For Official Use Only

24 Health IT 1 Pharmacy Programs 6 Budget & Resource Management 2 TRICARE Health Plan FOC 29 Sep 15 7 Procurement/Contracting 3 Health Information Technology 8 Research, Development & Acq 4 Facilities FOC 3 March 15 9 Public Health 5 Medical Logistics FOC 3 March Medical Education & Training * Pending 90-Day Review 23

25 Shared Service: Health IT DoD Electronic Health Record July: Announcement of next generation Electronic Health Record (Leidos / Cerner / Accenture) Strategic enabler for the military medical mission Innovation built in to acquisition. Commercial off-the-shelf (COTS) product with 10 years of upgrades at no additional cost. Interoperability with federal and private sector health systems where over 60% of our health care is delivered. Research support tool. EHR expands opportunity for DoD to engage in large-scale / big data research 24

26 Shared Service: Health IT DoD Electronic Health Record DHA will serve critical role in ensuring infrastructure, security, and clinical needs. RADM (Ret) Dr Bill Roberts is Functional Champion -- Important all perspectives are represented in deployment: clinicians, business leaders, support staff, and patients. My focus ensuring that the EHR supports the clinical practice of medicine and enhances access, quality and safety! 25

27 Facilities 1 Pharmacy Programs 6 Budget & Resource Management 2 TRICARE Health Plan FOC 29 Sep 15 7 Procurement/Contracting 3 Health Information Technology 8 Research, Development & Acq 4 Facilities FOC 3 March 15 9 Public Health 5 Medical Logistics FOC 3 March Medical Education & Training * Pending 90-Day Review 26

28 Shared Service: Health Facilities Standardized demand signal and prioritization process for Medical Construction requirements Standardized the Sustainment, Restoration, and Modernization programming models Providing facilities support to e- MSMs for future capital requirements BUILDER implementation (Enterprise-wide Facility Condition Assessment) DHA onsite project management of Rhine Ordinance Barracks replacement project (Above right) Medically Ready Force...Ready Medical Force 27

29 MedLog 1 Pharmacy Programs 6 Budget & Resource Management 2 TRICARE Health Plan FOC 29 Sep 15 7 Procurement/Contracting 3 Health Information Technology 8 Research, Development & Acq 4 Facilities FOC 3 March 15 9 Public Health 5 Medical Logistics FOC 3 March Medical Education & Training * Pending 90-Day Review 28

30 Shared Service: Medical Logistics Expanding Defense Medical Materiel Standardization Program from supply/consumables to include equipment/medical devices. Increasing coordination with Uniformed Services and DLA focused on improved efficiency and lower delivered material costs Coordinating with DHMSM Deputy PMO on medical device/equipment interface and standardization policy. Reducing purchase card usage, materiel costs, and risk by increasing product lines to DLA s Electronic Catalog (ECAT). Good MEDLOG practices support Services and COCOMS! Medically Ready Force...Ready Medical Force 29

31 Budget & Resource Management 1 Pharmacy Programs 6 Budget & Resource Management 2 TRICARE Health Plan FOC 29 Sep 15 7 Procurement/Contracting 3 Health Information Technology 8 Research, Development & Acq 4 Facilities FOC 3 March 15 9 Public Health 5 Medical Logistics FOC 3 March Medical Education & Training * Pending 90-Day Review 30

32 Shared Service Budget & Resource Management Implementing ABACUS Third Party Collections (TPC) for outpatient and Medical Affirmative Claims (MAC) Initial implementation of guidance for a new common cost accounting structure (CCAS) to support consistent & transparent accounting transactions Standardize medical record coding policies/procedures for all three Military Services & continue development of a HIPAA-compliant remote medical record coding capability Medically Ready Force...Ready Medical Force 31

33 Procurement/Contracting 1 Pharmacy Programs 6 Budget & Resource Management 2 TRICARE Health Plan FOC 29 Sep 15 7 Procurement/Contracting 3 Health Information Technology 8 Research, Development & Acq 4 Facilities FOC 3 March 15 9 Public Health 5 Medical Logistics FOC 3 March Medical Education & Training * Pending 90-Day Review 32

34 Shared Service Procurement/Contracting Integrated contract service to support the full range of products and services needed throughout the organization Key Enablers Simplified processes for customers Accelerated timelines for everyone Increased transparency for vendors Enhanced professional acquisition workforce Medically Ready Force...Ready Medical Force 33

35 Research, Development and Acquisition (RDA) 1 Pharmacy Programs 6 Budget & Resource Management 2 TRICARE Health Plan FOC 29 Sep 15 7 Procurement/Contracting 3 Health Information Technology 8 Research, Development & Acq 4 Facilities FOC 3 March 15 9 Public Health 5 Medical Logistics FOC 3 March Medical Education & Training * Pending 90-Day Review 34

36 Shared Service Research Development & Acquisition Integrated Joint Program Committees for oversight of $2.2B medical research enterprise Established Clinical Investigation Research Office for multiservice clinical studies Integrated Armed Forces Medical Examiner System (AFMES) and Natl Museum of Health and Medicine Medically Ready Force...Ready Medical Force 35

37 Public Health 1 Pharmacy Programs 6 Budget & Resource Management 2 TRICARE Health Plan FOC 29 Sep 15 7 Procurement/Contracting 3 Health Information Technology 8 Research, Development & Acq 4 Facilities FOC 3 March 15 9 Public Health 5 Medical Logistics FOC 3 March Medical Education & Training * Pending 90-Day Review 36

38 Shared Service Public Health Standardized Periodic Health Assessment ~$210M annual cost avoidance New Joint Staff Surgeon Quarterly Health Surveillance Report Evolution of DHA/PHD Combat Support Agency role Collaborated w/ DLA to redistribute ~ 48.4K Doses of expiring Japanese Encephalitis Vaccine to MTFs with immediate need averted $3M loss Armed Forces Health Surveillance Center (AFHSC) became part of DHA in August

39 Education and Training 1 Pharmacy Programs 6 Budget & Resource Management 2 TRICARE Health Plan FOC 29 Sep 15 7 Procurement/Contracting 3 Health Information Technology 8 Research, Development & Acq 4 Facilities FOC 3 March 15 9 Public Health 5 Medical Logistics FOC 3 March Medical Education & Training * Pending 90-Day Review 38

40 Education and Training Shared Service Highlights One Stop Learning Management System Joint Knowledge Online (JKO) new home for on-line tools Joint Executive Skills Institute complete METC Strategic Partnerships Bridge programs with 43 schools in 23 states that recognize military training for credit (WH Initiative) Military Combat Medic to RN in 13 months a reality Medically Ready Force...Ready Medical Force 39

41 Multi-Service Markets: 2 or more Services, large beneficiary population, 45% direct care dollars, large GME & readiness platforms Puget Sound, Washington (Army) National Capital Region (DHA) Colorado Springs, Colorado (rotate Air Force/Army) Tidewater (Navy) San Diego (Navy) Ft. Bragg (Army) Oahu, Hawaii (Army) San Antonio, Texas (rotate Air Force/Army) = emsm = Single Service The Eight Largest Markets (and Service/Department Leads) 40

42 DHA Support to Markets Analytic support for decision-making Dashboard Performance Tools and resources to advance Access Quality Safety Important center of gravity for TRICARE Reform 41

43 MHS Performance Dashboard STRATEGIC ALIGNMENT THRESHOLDS COMPONENT PERFORMANCE DEV. PERFORMANCE MEASURE MHS PERFORMANCE AIM OBJECTIVE STATUS RED GREEN BLUE A N AF NCR MD PSC AS OF Medically Ready Force (PLS1) eadiness Ready Medical Force (PLS2) etter ealth Healthy People (PLS3) Improve Healthy Behaviors (IP5) Improve Clinical Outcomes and Consistent Patient Experience (PLS4) Report as of 10 SEPT 2015 Individual Medical Readiness (IMR) I 87% <75% 85% 90% 84% 90% 89% N/A N/A Jun 15 Sept 15 TBD TBD HEDIS Cancer Screening Index I 63% 50% 70% 90% 88% 94% 73% 79% 36% May 15 Sept 15 Risk Adjusted Mortality (All Cause) E.82 TBD TBD TBD Mar 15 Sept 15 Inpatient: Recommend Hospital (Satisfaction) I 75% <71% 73% 75% 71% 75% 80% 85% 73% Mar 15 Sept 15 Overall Satisfaction w/healthcare (Outpatient) I 94% Service Specific Service Specific Service Specific 92% 95% 96% 93% 92% Mar 15 Sept 15 **HAI (CLABSI) I 14 N/A N/A N/A Jun 15 Sept 15 DATA ENTRY etter are ower Cost Improve Safety (IP9) Improve Condition- Based Quality Care (IP7) Improve Comprehensive Primary Care (IP8) Optimize & Standardize Access & Other Care Support Processes (IP10) Improve Stewardship (PLS5) **PSI 5 - Retained Surgical Item or Unretrieved Device Fragment Count (Per Year) National Surgical Quality Improvement Program (NSQIP) (30 Day) All Case Morbidity Index I 11 N/A N/A N/A Dec 14 Jun 15 I 82% of MTFs green 10th percentile 11th - 89th percentile 90th percentile Multiple scores per service N/A Dec 14 Sept 15 CAUTI 14 TBD TBD TBD N/A Jun 15 Sept 15 Wrong Site Surgery 11 TBD TBD TBD N/A Jun 15 Sept 15 **HEDIS Diabetes Index I 54% 50% 70% 90% 68% 80% 76% 80% 20% May 15 Sept 15 **HEDIS Appropriate Care Index (Low Back Pain, Pharyngitis, URI) I 47% 50% 70% 90% 41% 67% 63% 61% 31% May 15 Sept15 NPIC Post-Partum Hemorrhage* E 3.9% NPIC Vaginal Deliveries w/coded Shoulder Dystocia Linked to a Newborn 2500 grams w/birth Trauma* I 10.9.% HEDIS (30-Day) Mental Health Follow-Up I 79% HEDIS All Cause Readmission E σ above NPIC avg.(3.3%) 2σ above NPIC avg.(12.5%) 50th percentile (74%) 50th percentile (0.79) within 2σ of NPIC avg. (3.3%) within 2σ of NPIC avg. (12.5%) 75th percentile (81%) 75th percentile (0.73) 2σ below NPIC avg.(3.3%) 2σ below NPIC avg.(12.5%) 90th percentile (85%) 90th percentile (0.68) 3.8% 3.6% 4.3% 5.6% N/A Dec 14 Sept % 7.1% 16.7% 0% N/A Dec 14 Sept 15 87% 86% 78% 85% 61% May 15 Sept N/A Nov 14 Jun 15 ORYX Transition of Care Index (Asthma, VTE, Inpt Psy(2)) I 50% 60% 75% 100% 44% 56% 50% 63% N/A Sept 14 Jun 15 AHRQ Prevention Quality Indicator (PQI) Index I 94% 70% 80% 90% 94% 94% 94% 94% N/A Dec 14 Sept 15 PCM Continuity I 61% 55% 65% 81% 61% 63% 61% 54% N/A Apr 15 Jun 15 PCM Empanelment E <1,100:1 1,100:1 >TBD Primary Care Leakage I 25.3% >24% 24% to > 20% 20% 22.8% 26.6% 27.5% 26.3% N/A May 15 Sept 15 **Avg. No. of Days to Third Next Available Future Appointment (Primary Care) I 7.6d >7d 7.0d 2.2d 6.4d 6.8d 8.8d 11.0d N/A Aug 15 Sept 15 **Avg. No. of Days to Third Next Available 24 Hour Appointment (Primary Care) I 1.7d >1d 1.0d 0.8d 1.9d 0.9d 2.0d 2.5d N/A Aug 15 Sept 15 **Percent of Direct Care Enrollees in Secure Messaging I 37% <50% 50% 60% 29% 45% 42% 40% N/A July 15 Sept 15 **Satisfaction with Getting Care When Needed (Service Surveys) PMPM Total Purchased Care Cost Private Sector Care Cost per Prime Enrollee OR Utilization **Total Enrollment I 86% Service Specific Service Specific Service Specific 83% 90% 91% 83% 90% Mar 15 Sept 15 I E I E I $ % $-47.7M -2.5% $ % 3.58M -0.1% >2.8% yearly growth 2.8% to > 0% yearly growth 0% yearly growth 13.2% 5.4% 9.4% -3.9% 11.6% Mar 15 Sept 15 Service Specific Service Specific Service Specific -7.0% -0.8% 0.3% -3.6% N/A Dec 14 Mar 15 >2.8% yearly growth <0% yrly growth 2.8% to > 0% yearly growth 0% to < 5% yrly growth 0% yearly growth 33.0% 22.2% 17.3% 2.8% 13.2% Mar 15 Sept 15 5% yrly growth -0.9% 3.1% -2.0% 1.4% N/A Aug 15 Sept 15 Pharmacy Percent Retail Spend I 54.7% >40% 40% to > 35% 35% 57.1% 57.4% 51.3% 41.0% N/A Apr 15 Sept 15 Productivity Targets I 93% Service Specific Service Specific Service Specific 94% 93% 93% 80% N/A Jun 15 Sept 15 Lower is better **Indicates Process Improvement Priority Indicates measure under development Developmental Status: A = Accountability; I = Improvement; E = Exploratory *NPIC calculates + provides the MHS w/ MHS, Service + MTF status relative to the NPIC database average

44 The DHA in 2016 Driving Value to Services and COCOMS Demonstrable service and support to the mission I Need Your Feedback and Input 43

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