National Capital Region Medical Directorate Enhanced Multi Service Market Journey John D. O Boyle, MD, CAPT, MC, USN Chief Medical Officer NCR MD

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1 National Capital Region Medical Directorate Enhanced Multi Service Market Journey John D. O Boyle, MD, CAPT, MC, USN Chief Medical Officer NCR MD March 2017

2 Disclosures Presenter has no financial interest to disclose. 2

MHS Governance Reform Journey DoD Task Force on MHS Governance DepSecDef Planning Memo DepSecDef Nine Commandments Memo 1949 2006 September 2011 March 2012 March 2013 17 studies over 57

model for MHS governance Recommended an Enhanced MSM (emsm) model providing budgetary and short term personnel management authority for MSM Directed I Planning for MHS Governance Reform

3 MHS Governance Reform Journey DoD Task Force on MHS Governance DepSecDef Planning Memo DepSecDef Nine Commandments Memo September 2011 March 2012 March studies over 57 years 8 recs for unified service/unified joint command 6 recs for added central authority 3 recs keep separate Service lines 18th study over 62 years 7th rec added central authority DHA model for MHS governance Recommended an Enhanced MSM (emsm) model providing budgetary and short term personnel management authority for MSM Directed I Planning for MHS Governance Reform OASD(HA) DHA Shared Services JTF CapMed transition emsms Directed implementation of MHS Governance Reform OASD(HA) & TMA transition DHA (as CSA) Shared Services NCR Directorate emsms 3

Colorado Springs, Colorado (rotate Air Force/Army) 3. Tidewater, Virginia (Navy) 2 1 3 4.

4 Where are the enhanced Multi Service Markets (emsms)? emsm Markets and Service/Department Leads 1. National Capital Region (Defense Health Agency) 5 2. Colorado Springs, Colorado (rotate Air Force/Army) 3. Tidewater, Virginia (Navy) San Antonio, Texas (rotate Air Force/Army) 4 5. Puget Sound, Washington (Army) 6. Oahu, Hawaii (Army) 6 emsms provide over 40% of all MHS Healthcare Delivery 4

5 OUR HISTORY National Capital Region (NCR) Future BASE REALIGNMENT AND CLOSURE JTF CAPMED ESTABLISHED WRNMMC AND FBCH OPEN DEFENSE HEALTH AGENCY (DHA) ESTABLISHED NATIONAL CAPITAL REGION ADVANCES NDAA 2017 The Base Realignment and Closure Act (BRAC) of 2005 directed the closure of both National Naval Medical Center (NNMC) and Walter Reed Army Medical Center (WRAMC) JTF CapMed was created in 2007 to guide the congressionally mandated consolidation of military medical facilities in the greater Washington D.C. area Walter Reed National Military Medical Center, Bethesda opened on Sep. 15 and on Aug. 31, Fort Belvoir Community Hospital began serving patients with a patient transferred from DeWitt Army Community Hospital A joint, integrated Combat Support Agency that enables the Army, Navy, and Air Force medical services to provide a medically ready force and ready medical force to Combatant Commands in both peacetime and wartime The NCR has 11 military medical treatment facilities with over 246,000 enrolled beneficiaries focused on sustaining a ready medical force, delivering better care and an improved patient experience at a lower cost Title VII, Section 702 of the National Defense Authorization Act directs reform of the administration of the Defense Health Agency and military medical treatment facilities 5

6 emsm CONOPS Functional Organizational Structure emsm Functional Organizational Structure Senior Market Manager Director Admin/IT Support Directorate of Clinical Operations Directorate of Market Analysis & Evaluation Directorate of Business Operations Appointing and Referral Management Quality Management Market Performance Planning & Reporting Logistics MCSC Operations/ Recapture Management Direct Care Optimization/ Capability Risk Management Data Analysis & Program Evaluation Strategic Planning MOUs/MOAs/ Contracting & Venture Capital Population Health Patient Safety Case & Disease Management Research Business Process Reengineering Manpower & Budget Management IM/IT Telehealth Readiness Clinical Standardization Emergency Response Planning Federal Partnerships/ Community Relations Health Education & Training Ancillary Services ** Central CLR Processing Market Business Workload Reporting/ Enrollment ** Expanded Functions ** Central Appointing Strategic Communications/ Patient Satisfaction 6

MTFs MTFs MTFs WRNMMC FBCH JPC NHC Annapolis NHC Quantico WNY Clinic Rader AHC Kimbrough AHC McNair AHC Bolling

7 Organizational Structure Secretary of Defense SEC Navy SEC Army SEC Air Force CJCS USD(P&R) ASD(HA) CNO CSA CSAF Defense Health Agency Navy SG BUMED Army SG MEDCOM MAJCOMS AF SG NCR emsm NCR Medical Directorate NME ARHC A MDW MTFs MTFs MTFs WRNMMC FBCH JPC NHC Annapolis NHC Quantico WNY Clinic Rader AHC Kimbrough AHC McNair AHC Bolling Clinic Malcolm Grow Medical Clinic Pentagon Flight Clinic Pentagon (DiLorenzo) Tri Service Dental Clinic Dumfries Fairfax 7

8 National Capital Region Academic Health and Readiness System 8

9 Common emsm Challenges Leadership: perspective, maturity, development Strategy: emsm Strategy vs Service priorities High Reliability Organization principles The Service led emsm Performance: Performance Management System Data overload: MTFs, emsm, regional HQ, TRO, Services, DHA, etc. = Noisy Drivers: Enrollment.Access to Care Productivity.Containment/Recapture Patient Satisfaction Collision of Compliance, Accreditation, and Governance Distribution of Assets: Integrated manning documents Movement of personnel, equipment, monies Governance Structures and Workflow: Issue identification, Prioritization, and Decision Making 9

medical force to Combatant Commands in both peacetime and wartime.

Design and Prototype Health Readiness Solutions (W4) Ready Medical Force DHA supports Readiness solutions that meet joint mission needs.

10 DEFENSE HEALTH AGENCY STRATEGY MAP v2.2 1 March 2017 The Defense Health Agency (DHA) is a joint, integrated Combat Support Agency that enables the Army, Navy, and Air Force medical services to provide a medically ready force and ready medical force to Combatant Commands in both peacetime and wartime. ENDS WAYS Strengthen Our Role as a Combat Support Agency Deploy Solutions for 21st Century Battlespac e (W1) Respond to Immediate Mission Needs (W2) Support Integrated Training Requirements (W3) Design and Prototype Health Readiness Solutions (W4) Ready Medical Force DHA supports Readiness solutions that meet joint mission needs. (E1) Operational Medicine CONOPS Conduct Health-Related Research (W5) Joint Concept for Health Services Strengthen Our Partnership with the Services Deliver and Sustain Electronic Health Record (W8) Improve System of DHA Accountability (W9) I trust the DHA to deliver the support I need for mission success. (E2) Support Service Needs for Data, Reporting, and Analytics (W7) READINESS Leverage Strategic Partnerships (W10) Modernize TRICARE (W11) Optimize Existing ESAs (W12) Build Robust Improvement Capability (W13) Gather, Develop, and Prioritize Requirements in Support of DHA s Current and Future Mission (W6) Health Benefit Delivery CONOPS Medically Ready Force Optimize Defense Health Agency Operations DHA creates greater value through Operational Excellence. (E3) Improve Health Outcomes and Exp. in the NCR (W15) Maximize Value from Suppliers and Partners (W17) Optimize Portfolio of DHA Initiatives (W14) Implement DHA Performance Management System (W16) Optimize Critical Internal Management Processes (W18) Improve Health Outcomes and Experiences in the NCR W15 Create an integrated learning health system across the market that brings services to the patient, not vice versa, and delivers highly reliable quality health outcomes Fully utilize capability and capacity in both primary and specialty care within the market Sustain and improve currency of the total Medical Force (including Uniformed Military, Civilians, and Contractors) Create a culture of proactive prevention to engage patients anywhere, anytime, and reduce the need for healthcare Continuously improve care processes to be responsive and respectful of our beneficiaries needs and choices NCR Strategic Initiatives High Reliability Culture of Quality Seamless Patient & Team Experience Optimizing a Fully Engaged Direct Care System MEANS Strengthen Customer Focus (M1) Shape Workforce for Success (M2) Align Resources Against Strategic Priorities and Ensure Fiscal Accountability (M3) Advance a Culture of Continuous Learning (M4) Academic Health & Readiness System 10

11 OUR VISION National Capital Region (NCR) NATIONAL CAPITAL REGION ACADEMIC HEALTH & READINESS SYSTEM The National Capital Region (NCR) Academic Health & Readiness System (AHRS) is the preeminent integrated academic health system in America, connecting every federal hospital and clinic in our region to generate and sustain a ready medical force 11

12 OUR PRIORITIES National Capital Region (NCR) NATIONAL CAPITAL REGION ACADEMIC HEALTH & READINESS SYSTEM Build and sustain a high reliability culture of quality that permeates throughout our organization and has the paramount goal of zero harm to patients and staff Infuse input from our patients, caregivers, and staff into high velocity learning and rapid cycle innovation design methods in order to put the NCR AHS at the vanguard for improving caregiver wellbeing and experience, patient experience, quality and safety Enhance the professional operational readiness of our personnel and teams through the active holistic management of both the direct and purchased care sectors of the TRICARE marketplace across the NCR 12

13 OUR FUTURE National Capital Region (NCR) NATIONAL CAPITAL REGION ACADEMIC HEALTH & READINESS SYSTEM The NCR AHRS is the healthcare system of choice for beneficiaries in the National Capital Region, and the employer of choice for our total workforce, active duty, civil service and contractors The NCR AHRS leads the Military Health System in delivering the quadruple aim the best experience of care at the best value resulting in the best health and maximized readiness

14 NCR MD Critical Focus Areas Access to Care Product Line Integrations and Optimization Referral Management Secure Messaging / Nurse Advice Line Urgent and Emergency Care Academic Health & Readiness System 14

Patient Satisfaction Inpatient and Outpatient

averages and exceed Inpatient Targets 92%

questionnaire changes implemented 76% Inpatient

No data reported for FY 2014 Q4 Data Source: TROSS

15 Patient Satisfaction Inpatient and Outpatient Satisfaction in the NCR remain higher than MHS averages and exceed Inpatient Targets 92% Outpatient Satisfaction with Care Received TROSS questionnaire changes implemented 76% Inpatient Satisfaction: How would you rate this hospital? No data reported for FY 2014 Q4 Data Source: TROSS (Question 32) as of 20 January 2016, TRISS (Question 21) as of 04 January

16 PRODUCTIVITY GROWTH LEADERBOARDS Top 25 Growth Facilities FY13 16 PROVIDER AGG trvu LEADERBOARD RANKED BY GROWTH FROM FY13 TO FY16 Rank Parent Name Growth Growth Rate 1 FT BELVOIR COMMUNITY HOSP FBCH 526,630 25% 2 WALTER REED NATL MIL MED CNTR 602,015 21% 3 NH CAMP LEJEUNE 242,379 16% 4 AF C 59th MDW WHASC LACKLAND 232,822 14% 5 AMC BAMC FSH 269,281 7% 6 AHC MONCRIEF JACKSON 21,140 2% 7 AF MC 88th MED GRP WRIGHT PAT 19,182 2% 8 ACH MARTIN BENNING 25,258 1% 9 NH JACKSONVILLE (11,517) 1% 10 ACH WINN STEWART (26,046) 2% 11 AMC TRIPLER SHAFTER (71,155) 2% 12 AMC MADIGAN LEWIS (116,669) 3% 13 AMC WILLIAM BEAUMONT BLISS (76,093) 3% 14 AMC WOMACK BRAGG (161,735) 6% 15 NH CAMP PENDLETON (105,101) 6% 16 AF MC 60th MED GRP TRAVIS (61,509) 6% 17 AMC DARNALL HOOD (183,630) 7% 18 AF MC 99th MED GRP NELLIS (73,760) 8% 19 KIMBROUGH AMB CAR CEN MEADE (84,549) 8% 20 ACH LEONARD WOOD (96,653) 8% 21 NMC SAN DIEGO (371,661) 8% 22 JAMES A LOVELL FHCC (94,760) 9% 23 AHC REYNOLDS SILL (101,826) 9% 24 ACH BLANCHFIELD CAMPBELL (181,347) 9% 25 NMC PORTSMOUTH (458,508) 11% MS-DRG RWP LEADERBOARD RANKED BY GROWTH FROM FY13 TO FY16 Rank Parent Name Growth Growth Rate 1 NH GUANTANAMO BAY 30 35% 2 ACH MARTIN BENNING % 3 AF MC 88th MED GRP WRIGHT PAT % 4 ACH LEONARD WOOD % 5 FT BELVOIR COMMUNITY HOSP FBCH % 6 NH CAMP LEJEUNE % 7 AF H 31st MED GRP AVIANO 22 11% 8 NH JACKSONVILLE % 9 AMC WOMACK BRAGG % 10 NH CAMP PENDLETON 286 9% 11 NH NAPLES 17 8% 12 ACH KELLER WEST POINT 57 7% 13 AMC BAMC FSH 1,853 6% 14 NH SIGONELLA 8 6% 15 AMC MADIGAN LEWIS 824 6% 16 NH OKINAWA 84 4% 17 ACH EVANS CARSON 154 4% 18 NMC SAN DIEGO 622 3% 19 AF H 96th MED GRP EGLIN 71 2% 20 NH GUAM AGANA 25 2% 21 WALTER REED NATL MIL MED CNTR 164 1% 22 ACH BLANCHFIELD CAMPBELL (11) 0% 23 AMC WILLIAM BEAUMONT BLISS (52) 1% 24 AMC DARNALL HOOD (122) 2% 25 ACH IRWIN RILEY (51) 3% Source: MHS MART (M2), February

17 NATIONAL CAPITAL REGION emsm Embedded Physical Therapy $3,000,000 $2,500,000 Average quarterly PSC down $1.5M FY13 to FY16 and down $451K FY15 to FY16 35,000 30,000 Physical Therapy Product Line Market Integration The Problem PSC Amount Paid emsm Enrollees $2,000,000 $1,500,000 $1,000,000 $500,000 25,000 20,000 15,000 10,000 5,000 DC Encounter emsm Enrollees $8M in NCR enrollee PT network care expenses in FY14 and $6.3M in FY15 Enough referrals for more PTs Limited space for rehab, no new MILCON emsm referral acceptance rates 80 85% The Solution Added 11 Physical Therapy FTEs across the region to recapture care Embedded PTs in the PCMH to maximize space utilization Sent the PT to the patient, not the patient to the PT $ Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q3 Q4 0 Purchased Physical Therapy NCR Enrollee Physical Therapy Encounters Source: MHS MART (M2), 17

18 INCREASED ACCESS IN THE NCR Direct Care Optimization is adding appointments in stages over 15,000 additional appointments to date Annual additional promised / projected SPEC appointments per wave Apr Aug 2016 Jul Dec , ,048 + Oct Present 23,400 (est.) 38,580 (est.) SPECs annually Wave 1 Wave 2 Wave 3 Wave 4 Allergy Pediatric subspecialties Orthopedics ENT Pulmonary Dermatology Audiology Endocrine Rheumatology Speech therapy Cardiology Chiropractic GI General Surgery Hem/Onc Neurology OB GYN Ophthalmology Optometry Pain PM&R Physical Therapy Podiatry Sleep Urology Vascular surgery Plastic surgery Pediatric subspecialties Moved to direct booking without clinic optimization Completed optimization Reflects actual additional appointments Completed optimization Reflects actual additional appointments Optimization in process Assumes all providers meet agreed encounter targets Source: Current data CHCS SPEC encounter data via Dashboard, Sep 1 Dec 30, 2016 / Projection and Baseline data CHCS data, Nov 2,

19 COMPARATIVE EFFICIENCY Cost per Unit by Inpatient Facility FY2016 Qtr1 $35K Mt Home $30K Oak Harbor 29 Palms $25K Beaufort Cost per MS DRG RWP $20K $15K $10K $5K Wainwright Sill Pensacola Jackson Knox Polk Travis Bremerton BAMC Tripler Jacksonville Eustis Portsmouth FBCH Keesler Pendleton Lejeune Elmendorf Stewart Bragg San Diego Hood Eglin Leonard Wood Gordon Campbell Carson Lewis Wright Pat Bliss Benning Riley Nellis Irwin FBCH (FY13) WRNMMC West Point WRNMMC (FY13) $K $30 $40 $50 $60 $70 $80 $90 $100 $110 $120 $130 $140 $150 $160 Cost per RVU Data Source: Health Affairs PMPM FY16 Q1 Export file 19

20 TOTAL GROSS OBLIGATIONS Spending Less on Direct Care 5 Year Execution Trend for NCR MD (WRNMMC & FBCH) From FY12 FY16 Total Obligations reduced by 4.8% 20

21 Market Successes Embedded Physical Therapy Per Member Per Month (PMPM) FBCH / MGMC OB Care $2,500,000 $2,000,000 $1,500,000 $1,000,000 $500,000 $0 Average quarterly PSC$ down $852K FY14 to FY16 and down $453K FY15 to FY Q Q Q Q Q Q Q Q Q Q Q Q4 NCR MD Supporting Market Needs with 11 new PT Providers Improved Patient Satisfaction Improved PTAccess Improved OrthoAccess FY16 Expected $2.5M PSC Reduction from FY14 levels LOWER IS BETTER Growth Rate 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 5.0% 10.0% 15.0% MHS MCSC AF NCR MD FY2016 NCR MD FY2013 Army Navy $200 $250 $300 $350 $400 $450 $500 $550 $600 $650 PMPM $700K $600K $500K $400K $300K $200K $100K $0K Eliminated $2M PSC ERSA Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Southern Maryland Costs Southern Maryland Admissions Live Births at FBCH

22 Top Five Successes 1. Market Management & Empowered Market Leaders Market Initiative Champions 2. Quality of Care Institute for Healthcare Improvement Leadership Alliance Partnership for Patients (PfP) Ambulatory Settings 3. Academic Health & Readiness System Tri Federal Cancer Initiative, an alliance between the Walter Reed Murtha Cancer Center, Uniformed Service University of Health Sciences, and the National Cancer Institute to standardize Clinical Practice Guidelines for cancer treatment 4. Operational Support & Readiness Provided over 300 medical personnel to support Joint Forces Headquarters National Capital Region 46% of all Army GME programs and 28% of all Army trainees 34% of all Navy GME programs and 23% of all Navy GME trainees 5. Stewardship Reduced obligations by 6% from an FY12 base of $1.37 billion to an FY15 base of $1.29 billion. Decreased professional care purchased for our enrollees by a third in the NCR emsm, from $90M in FY13 to $64.5 M in FY15 22

23 What s Next Single market strategy o How to continue transformation to an HRO. o Distribution of Assets Synergy with MHS Review o Leadership, Safety, Performance Management o Quality, Access, Production, Containment/Recapture Refining our Governance Processes o NCR as the 4 th service. o Unified Department Chairs o Streamlined Product lines 23

24 National Defense Authorization Act (NDAA) 2017 Section 702 DHA leading the way A single Agency with oversight of an integrated system of health and readiness delivered through the direct management of each MTF and regional market, utilizing standardized processes and centralized budget accountability to promote transparency to the Department, beneficiaries, Services and Combatant Commands. 24

25 Questions 25 25

26 National Defense Authorization Act (NDAA) 2017 Readiness and Operational Support linked Readiness Health Benefit is means to an end, not the end itself Operational Support Health Benefit 26

27 Guiding Principles for Implementing the NDAA Readiness is primary Services are ultimately responsible for readiness supported by DHA DHA is responsible for the health benefit supported by the Services who will use this as a means to enable and sustain readiness The direct care services will be first choice to support readiness DHA creates healthcare direction, policies and procedures for the direct care system DHA is the single source budget authority for the direct care system All Active Duty Personnel are tied to an operational requirement 27

THE ASSISTANT SECRETARY OF DEFENSE 1200 DEFENSE PENTAGON WASHINGTON, DC MEMORANDUM FOR UNDER SECRETARY OF DEFENSE (COMPTROLLER)

THE ASSISTANT SECRETARY OF DEFENSE 1200 DEFENSE PENTAGON WASHINGTON, DC 20301-1200 NOV 16 2017 HEALTH AFFAIRS MEMORANDUM FOR UNDER SECRETARY OF DEFENSE (COMPTROLLER) SUBJECT: Fiscal Year 2018 Direct Care