Military Health System Review & Analysis. Process Improvement Priorities Analysis of one year effort. 29 June 2017

Transcription

1 Military Health System Review & Analysis Process Improvement Priorities Analysis of one year effort. 29 June 2017

2 Overall measures Green or Blue: PIP Performance Overview Comparison of Performance as of June 2016 and June 2017: As of June 16 As of June 17 MHS 2 4 Air Force 5 4 Army 1 3 Navy 6 7 DHA-NCR 2 5 MEASURE Data As Of MHS Air Force Army Navy DHA-NCRMD 16-Jun 17-Jun 16-Jun 17-Jun 16-Jun 17-Jun 16-Jun 17-Jun 16-Jun 17-Jun 16-Jun 17-Jun CLABSI 1 15-Dec 16-Dec URFO 16-Mar 17-Mar HEDIS Diabetes Composite 2 16-Feb 17-Feb 75% 80% 80% 83% 66% 73% 81% 86% 77% 67% HEDIS Acute Conditions Composite 2 16-Feb 17-Feb 68% 80% 83% 87% 41% 65% 91% 99% 69% 95% Avg No. of Days to Third Next Available Future Appt 16-Apr 17-Apr Avg No. of Days to Third Next Available 24 Hour Appt 16-Apr 17-Apr Percent of Direct Care Enrollees in Secure Messaging 16-Apr 17-Apr 42.14% 46.72% 45.19% 49.46% 34.46% 39.19% 49.77% 53.83% 47.70% 54.58% Satisfaction with Getting Care When Needed 3 N/A 17-Mar N/A 83% N/A 82% N/A 84% N/A 83% N/A 85% Total Empanelment 16-Mar 17-Mar -0.4% -0.4% -0.5% -0.6% -0.8% -0.8% 0.1% 0.2% 0.5% 0.01% 1. CLABSI June 2016 score reflects new calculation pulled from Carepoint. Previous score reported incident number, so this has been edited to reflect current methodology 2. MHS Performance for HEDIS Diabetes and Acute measures reflects Direct Care only (removed MCSC from performance); measure reported using treatment DMIS 3. MHS transitioned to JOES Dec 2106; threshold to be established and performance reported at the start of FY18. 2

3 Guide for Individual Measure Review Slides Interpretation Data Visualizations Stacked Bar Plot: Shows the percentage of MTFs that are Blue, Green, Yellow, and Red in the two timeframes of interest Summary of MTF performance improvement is reported as the total change in the percentage of Blue and Green MTFs [# MTFs as of # MTFs as of 2016] / # MTFs as of 2016 Performance Trend: Shows performance at component and MHS level over time Performance improvement is reported as the percentage difference between the first and last reporting period [Performance as of 2017 Performance as of 2016] / Performance as of 2016 Stacked Bar Plot (Example) Performance Trend Chart (Example) *All data used in this analysis is pulled directly from CarePoint as of 6 JUN

4 URFO Review MHS MTF Level Improvement MHS Trend Over Time Summary: Overall, performance has improved (less URFOs) by 33% 8% more MTFs became green / blue Air Force Army Navy DHA-NCR Mar-16 Jun-16 Sep-16 Dec-16 Mar-17 Mar-16 Jun-16 Sep-16 Dec-16 Mar-17 Mar-16 Jun-16 Sep-16 Dec-16 Mar-17 Mar-16 Jun-16 Sep-16 Dec-16 Mar Mar-16 Jun-16 Sep-16 Dec-16 Mar-17 0% MTF performance and trend change as all at 0 URFO * Stacked bar graphs reflect reported performance at Child DMIS 0% MTF performance change 25% trend increase 18% MTF improvement 67% trend improvement 33% MTF improvement and 100% trend improvement to achieve 0 URFO 5

5 HEDIS Acute Conditions Review MHS MTF Level Improvement MHS Trend Over Time Summary: 100% 90% 80% 70% Overall, performance increased by 18%, and has remained green 60% 50% 40% 10% more MTFs became green / blue Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 * MHS Direct Care only (excludes MCSC) Air Force Army Navy DHA-NCR 100% 80% 60% 40% 100% 80% 60% 40% 100% 80% 60% 40% 100% 80% 60% 40% Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 1% MTF improvement 4% trend improvement 20% MTF improvement 24% trend improvement 5% MTF improvement 8% trend improvement * Stacked bar graphs reflect reported performance at Child DMIS; Performance computed using Treatment DMIS methodology 20% MTF improvement 26% trend improvement 7

6 Third Next 24 Hour Appointments Review MHS MTF Level Improvement MHS Trend Over Time Summary: Overall, performance improved by 13% (lower is better) % more MTFs became green / blue Air Force Army Navy DHA-NCR Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 16% MTF improvement 8% trend improvement * Stacked bar graphs reflect reported performance at Child DMIS 32% MTF improvement 31% trend improvement 1% MTF improvement 2% trend improvement 0% MTF performance change 84% trend decline 9

7 Secure Messaging Enrollment Review MHS MTF Level Improvement MHS Trend Over Time Summary: 60% 55% 50% 45% Overall, performance steadily increased by 5% 40% 35% 30% 15% more MTFs became green / blue Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Air Force Army Navy DHA-NCR 50% 50% 50% 50% 30% 30% 30% 30% Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 11% MTF improvement 4% trend improvement * Stacked bar graphs reflect reported performance at Parent DMIS 19% MTF improvement 5% trend improvement 23% MTF improvement 4% trend improvement 0% MTF improvement 7% trend improvement 10

8 Getting Care When Needed Review 86.0% 85.0% 84.0% 83.0% 82.0% 81.0% 80.0% FY17Q1 FY17Q2 MHS 81.4% 83.3% Air Force 81.5% 82.1% Army 81.2% 83.6% Navy 81.3% 83.1% DHA-NCRMD 83.3% 85.2% Summary: All components transitioned to JOES in Dec 2016; thresholds for this new measure will be established and available for FY18; measure will be evaluated for improvement in FY18 With just 2 periods of performance reported, improvement by each of the components has happened 11

9 FY18 PIP Measure Recommendations Improvement Category Measures Rationale Measures and Thresholds to remain the Same Measure to be expanded to include reporting of all wards July 2017; Zero Patient Harm CLABSI currently just report at ICU level. Zero Patient Harm URFO Goal of Zero Harm; MHS remains red on this measure. Improve Condition Based Quality Care Improve Condition Based Quality Care Keep Remove Add HEDIS Diabetes HEDIS Acute Conditions *Note: Provider Efficiency measure methodology issues identified; the BAC will address concerns as part of the FY18 measures normal review process. The FY18 Core measure updates will be presented for approval at the Sept R&A There is still opportunity for improvement in the screening measure most components are red/yellow even though overall measure for direct care reached green threshold; continue to show MCSC data remove from inclusion of MHS overall calculation report DC only There is still opportunity to improve performance in LBP and URI (red/yellow) even though 3 of 4 components overall green. continue to show MCSC data remove from inclusion of MHS overall calculation Improve Access Third Next 24HR Appts MHS has not achieved green threshold for this measure; currently red Improve Access Improve Access Zero Patient Harm Improve Access Improve Access Increase Effectiveness and Efficiency of Direct Care Platform Improve Access Increase Direct Care PC Capacity Process around secure messaging will switch to automatic enrollment; Secure Messaging continue to monitor during automation change over. No FY17 thresholds established - Dec 2016 was the first report all Getting Care When Needed using JOES; believe there is an opportunity for improvement once thresholds established for FY18. Category and Measures to be Added Determined to be an opportunity for improvement based on MHS WSS current performance being red. Spec Care: Avg Days from Consult to Fills gap addressing specialty care; thresholds to be established FY18. Booking Spec Care: Avg Days from Booking to Fills gap addressing specialty care; thresholds to be established FY18. Appt Actionable measure tied to cost category; focuses on specialty care Provider Efficiency* providers. Category and Measures to be Removed as a PIP MHS below the green threshold at 5.6 days and has had sustained Third Next FTR Appts improvement on this measure over a 7 month period; maintain measure on core dashboard. Improvement category and measure not aligned; once new Total Empanelment empanelment measure developed and tested consider for FY19. Measure to remain on core dashboard. Requested Decision: Approval of FY18 Process Improvement Priority recommendations

10 Institute of Medicine (IOM) Vital Signs Framework

11 Measure Set Examples

12 A Model for Describing Healthcare Outcomes Tier 1 Survival Degree of health or recovery Tier 2 Time to recovery and time to return to normal activities Disutility of care or treatment process (e.g. diagnostic errors, inefficient care, treatment related discomfort, complications, adverse effects) Tier 3 Sustainability of health or recovery and nature of recurrences Long-term consequences of therapy Ref: Porter, NEJM, 363:26;p

13 A Model of Healthcare Outcomes Tier 1 Survival Degree of health or recovery Tier 1 Life Expectancy? HRQOL, Level of Function Tier 2 Time to recovery and time to return to normal activities Disutility of care or treatment process (e.g. diagnostic errors, inefficient care, treatment related discomfort, complications, adverse effects) Tier 2 Do we know how long people will be impaired, how long treatment will last? Do we know type and likelihood of adverse outcomes or complications of treatment Tier 3 Sustainability of health or recovery and nature of recurrences Long-term consequences of therapy Tier 3 Do we know likelihood of relapse and length of time before relapse Does treatment actually cause any long term conditions? 17

14 For Official Use Only Overview: Porter s Strategy for Value Transformation In his article The Strategy That Will Fix Health Care, Michael Porter explains six interdependent strategies that make up the value agenda to transform the U.S. health care system. The six strategies of the value agenda are shown to the right: 1. Organize into integrated practice units 2. Measure outcomes and costs for every patient 3. Move to bundled payments for care cycles 4. Integrate care delivery across separate facilities 5. Expand excellent services across geography 6. Build an enabling information technology platform The following slides provide further detail on each strategy and link Porter and Lee s six strategic components to the strategic objectives of the Military Health System

15 MHS Executive Dashboard MEASURE Individual Medical Readiness (IMR) Forward Resuscitative Surgery Capacity Humanitarian Assistance/ Disaster Relief Capacity Risk Adjusted Mortality (Standardized Mortality Ratio) DATA AS OF THRESHOLDS RED YELLOW GREEN BLUE MHS ARMY NAVY PERFORMANCE AIR FORCE DHA- NCRMD MARINE CG MCSC 3/2017 <75% 75% 85% >90% N/A 84% 90% 88% N/A 91% 89% N/A 5/2017 <65% 65% >75% >85% N/A 83% 77% 80% N/A N/A N/A N/A 5/2017 <65% 65% >75% >85% N/A 92% 83% 92% N/A N/A N/A N/A 9/2016 See Below ** N/A See Below ** See Below ** N/A N/A N/A Inpatient: Recommend Hospital 12/2016 <72% 72% 73% 75% 77% 77% 74% 80% 81% N/A N/A - CLABSI 12/2016 < >3.5 > N/A N/A N/A URFO* 3/2017 Current quarter > 3 quarter average Current quarter < 3 quarter average 0 events in current quarter 0 events for 3 quarters N/A N/A N/A Quality (Outpatient) Composite 3/2017 <50% 50% >70% >90% 73% 80% 93% 87% 87% N/A N/A 27% <7.5 PTS >7.5 PTS >10.5 PTS >13.5 PTS N/A N/A 4.2 Access Composite Specialty Care: Avg Days from Consult to MTF Booking Specialty Care: Avg Days from Booking to Appointment Varying Component Specific 56% 75% 63% 38% 44% N/A N/A N/A <8PTS 8 PTS 12 PTS 16 PTS N/A N/A N/A 11/2016 PENDING (Days) N/A N/A N/A 11/2016 PENDING (Days) N/A N/A N/A PMPM 12/2016 >3.2% yearly growth N/A 3.2%-0% yearly growth 0% yearly growth 1.60% 2.68% -2.65% 2.75% 3.92% N/A N/A -0.33% Total Empanelment 4/2017 <0% growth N/A 0% growth 5% growth -0.5% -0.8% 0.1% -0.7% 0.1% N/A N/A -2.5% Pharmacy Percent Retail Spend 3/2017 >30% N/A 30% 25% 25% 23% 26% 26% 19% N/A N/A N/A Provider Efficiency 12/2016 <61% N/A >61% >79% 39% 41% 37% 38% 44% N/A N/A N/A *URFOs displayed as a total count of Non-Dental and Dental events. ** Thresholds for Risk Adjusted Mortality: Blue: Standardized Mortality Ratio (SMR) less than 1 with the upper CI limit of the ratios 95% CI being less than 1 Green: The CI of the ratio s 95% upper and lower CI include 1 Contents confidential and privileged. Only to be disclosed internally IAW 10 U.S.C Component, Command, MTF & Market detailed information available on Red: SMR greater than 1 and the lower limit of the ratio s 95% confidence interval (CI) is greater than As of 1 June 2017

16 Executive Dashboard Performance: How are we faring on measures that are not a PIP? The MHS set a by when date for the PIP measures. These PIP measures are a subset of measures on the Executive Dashboard. The MHS has demonstrated improvement in 7 of the 9 PIP measures. The Executive Dashboard measures which are not PIP measures are listed below: 2 measures have improved, 1 measure with no change, 4 measures with declining performance and 1 measure not calculated at the MHS level. Can we equate having a by when date as having influence on performance? Is there utility in assigning a by when date for these measures? MEASURE DATA AS OF MHS Jun 17 Jun 16 Change in MHS Performance PERFORMANCE ARMY NAVY AIR FORCE DHA-NCRMD MCSC Jun 17 Jun 16 Jun 17 Jun 16 Jun 17 Jun 16 Jun 17 Jun 16 Jun 17 Jun 16 Individual Medical Readiness (IMR) Mar 17 Dec 15 N/A N/A N/A 84% 83% 90% 80% 88% 80% N/A N/A N/A N/A Risk Adjusted Mortality (Standardized Mortality Ratio) Sep 16 Sep N/A N/A Inpatient: Recommend Hospital Dec 16 Mar 16 77% 78% 77% 74% 74% 77% 80% 80% 81% 85% N/A N/A 7 Day Mental Health Mar 17 Mar 16 69% 68% 80% 78% 77% 77% 69% 67% 75% 77% 43% PCM Continuity Apr 17 Apr 16 58% 59% 58% 60% 59% 61% 57% 56% 57% 55% N/A N/A Leakage Apr 17 Apr 16 28% 25% 24% 23% 30% 26% 32% 27% 30% 26% N/A N/A PMPM** Dec 16 Dec % 0.3% 2.7% 5.6% -2.6% 1.2% 2.8% 0.7% 3.9% -2.2% -0.3% -3.3% Total Empanelment Apr 17 Apr % -0.5% -0.8% -0.9% 0.1% 0.1% -0.7% -0.6% 0.1% 0.5% -2.5% -3.9% Pharmacy Percent Retail Spend Mar 17 Mar 16 25% 27% 23% 25.% 26% 29% 26% 28% 19% 22% N/A N/A * Based on existing measure methodology ** PMPM measure for both years is based on the revised health risk equivalent lives methodology which reflect changes due to ICD-10 diagnosis codes and pharmacy changes. Forward Resuscitative Surgery Capacity and Humanitarian Assistance/Disaster Relief Capacity are measures on the Executive Dashboard however, not included in this analysis since there is not a standard methodology for comparison Contents confidential and privileged. Only to be disclosed internally IAW 10 U.S.C Component, Command, MTF & Market detailed information available on As of 1 June 2017

17 MHS Core Dashboard Aim Measure Data Date Red Yellow Green Blue MHS ARMY NAVY AIR DHA- FORCE NCRMD MCSC IMR 3/2017 <75% 75% 85% >90% N/A 84% 90% 88% N/A N/A Readiness F.R. Surgery Capacity 5/2017 <65% 65% >75% >85% N/A 83% 77% 80% N/A N/A Humanitarian Assistance 5/2017 <65% 65% >75% >85% N/A 92% 83% 92% N/A N/A Better Health HRQOL Pending Pending Data Pending Risk Adjusted Mortality (Standardized Mortality Ratio) 9/2016 See Below* N/A See Below* See Below* N/A Inpatient: Recommend Hospital 12/2016 <72% 72% 73% 75% 77% 77% 74% 80% 81% N/A CAUTI 12/2016 <2.5 >2.5 >3.5 > N/A CLABSI 12/2016 < >3.5 > N/A Better Care Lower Cost Current quarter > 3 WSS 3/2017 quarter average Current quarter > 3 URFO 3/2017 quarter average Current quarter < 3 quarter average Current quarter < 3 quarter average 0 events in current quarter 0 events in current quarter 0 events for 3 quarters N/A 0 events for 3 quarters N/A HEDIS Diabetes 3/2017 <50% >50 % >70 % >90 % 56% 71% 82% 83% 68% 20% Acute Conditions Composite 3/2017 <50% >50 % >70 % >90 % 63% 68% 100% 89% 95% 27% Cancer Screening 3/2017 <50% >50 % >70 % >90 % 66% 91% 89% 78% 91% 36% 7-Day Mental Health Follow-up 3/2017 <51.74% 51.74% 62.20% 69.22% 69.37% 79.69% 77.39% 69.31% 75.09% 43% All Cause Readmissions 12/2016 >0.81 <0.81 <0.73 < N/A Primary Cesarean Section (AHRQ IQI 33) Pending Pending Data Pending Unexpected Newborn Complications Pending Pending Data Pending Post-Partum Hemorrhage Pending Pending Data Pending Well Child Visits 3/2017 <80.50% >80.50 % >86.52 % >89.52 % 86.93% 88.95% 85.61% 87.65% 88.86% 83.56% PCM Continuity 4/2017 <55% >55 % >65 % >75 % 57.58% 57.55% 58.70% 56.93% 56.51% N/A Primary Care Leakage 4/2017 >28.0% <28.0 % <24.0 % <20.0 % 28.0% 23.5% 30.0% 32.0% 29.6% N/A Third Next Future Appointments 4/2017 >8 Days <8 Days <7 Days <2 Days N/A Third Next 24 Hour Appointments 4/2017 >1.5 Days <1.50 Days <1 Days <0.80 Days N/A Spec Care: Avg Days from Consult to Booking 11/2016 Pending N/A Spec Care: Avg Days from Booking to Appt 11/2016 Pending N/A Secure Messaging 4/2017 <37% >37% >50% >75% 46.70% 39.20% 49.50% 53.80% 54.60% N/A Secure Messaging Utilization 4/2017 <4% >4% >5% >8% 5.58% 6.46% 4.86% 4.79% 9.32% N/A Outpt Prov Communications Composite 12/2016 Pending 85% 87% 87% 83% 85% N/A Getting Care When Needed 12/2016 Pending 81% 81% 81% 81% 83% N/A PMPM 12/2016 >3.20% N/A <3.20% <0 % 1.60% 2.68% -2.65% 2.75% 3.92% -0.33% Total Purchased Care Cost 1/2017 >FY Target N/A <FY Target <Next FY Target 6.5% 3.6% 7.7% 7.2% 24.5% N/A Private Sector Care Cost 12/2016 >3.21% <3.21 % <3.40 % <0 % -1.13% -1.01% -1.07% 1.28% 10.22% -1.48% Total Empanelment 4/2017 <0.0% N/A >0.0 % >5.0 % -0.5% -0.8% 0.1% -0.7% 0.1% -2.5% Pharmacy Percent Retail 3/2017 >30% N/A <30 % <25 % 24.5% 22.5% 25.9% 25.9% 19.1% N/A Provider Efficiency 12/2016 <61% N/A >61% >79% 39% 41% 37% 38% 44% N/A OR Utilization Pending Pending Under Development PCM Empanelment Pending Pending Under Development *Thresholds for Risk Adjusted Mortality: Blue: Standardized Mortality Ratio (SMR) less than 1 with the upper CI limit of the ratios 95% CI being less than 1 Green: The CI of the ratio s 95% upper and lower CI include 1 Red: SMR greater than 1 and the lower limit of the ratio s 95% confidence interval (CI) is greater than 1 Contents confidential and privileged. Only to be disclosed internally IAW 10 U.S.C Component, Command, MTF & Market detailed information available on As of 1 June 2017

18 Individual Medical Readiness Total Force Medically Ready (TFMR) exceeds the 85% HA Goal. New, standardized PHA improves identification of required IMR items. Reserve Component (RC) MR improvement constrained by multiple factors. Why is it important? Individual Medical Readiness (IMR) is the current indicator of the medical readiness status of the Force and requires Medical and Line collaboration. What are we measuring? IMR consists of 6 elements and 4 categories. IMR Working Group is pursuing standardization of element components, category definitions, and reporting criteria in DoDI update. Total Force Medically Ready (TFMR) is the sum of FMR and PMR. ELEMENTS: Periodic Health Assessment (PHA) Deployment-Limiting Conditions (DLC) Dental Assessment Immunization Status Medical Readiness Labs Medical Equipment Total Force Medically Ready (TFMR) CATEGORIES: Fully Medically Ready (FMR) Current PHA, labs, immunizations, med equip; Dental Readiness Class (DRC) 1 or 2; no DLCs Partially Medically Ready (PMR) lack one or more immunizations, labs, or med equip Not Medically Ready has DLC or is in DRC 3 Indeterminate overdue PHA or DRC 4 What is our current and desired performance? TFMR consistently exceeds the 85% HA goal, but not all Service components (Guard/Reserve) meet the goal. What are the causes of the gaps in performance / What are the causes of success? Dental deficiencies [below the 95% DRC 1&2 goal (see table)] negatively impact the ability to reach MR goal. Need command emphasis to reduce number of overdue PHAs and dental exams. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Continue to optimally resource RC medical readiness programs. Improve command emphasis on IMR. Support IT solutions for 1) new, standardized PHA, which facilitates completion of IMR requirements and 2) interoperable Service medical readiness systems Working Group: IMR WG Measure Advocate Name: COL Heidi Warrington Phone number: DSN Monitoring: Quarterly PERCENT DENTAL READINESS CLASS 1 & 2 (Goal = 95% or higher) CY14Q3 CY15Q3 CY16Q3 CY16Q4 ARMY AD ARMY RES ARMY GUARD NAVY AD NAVY RES AF AD AF RES AF GUARD USMC AD USMC RES COAST GUARD AD COAST GUARD RES Data source: Service medical readiness systems TFMR Thresholds: Blue: > 90% Green: > 85% Red: < 75% Data as of 1 Jan 17

19 Risk Adjusted Mortality (All Cause) (Standardized Mortality Ratio, SMR) Air Force, Army, Navy and MHS overall rates are 2 standard deviations better than the expected rate (lower is better). NCR-MD deep dive on data revealed the need to review methodology to identify hospice and palliative care patients as expected deaths. What are we measuring? All Cause Risk Adjusted Standard Mortality Ratio (SMR) allows MTFs to measure the adult inpatient mortality rate to determine if performance is better than, worse than or consistent with the expected rate for specific diagnoses and procedures given the risk factors of the patient population. Excludes maternal and perinatal patients. Why is it important? Mortality is a key outcome for hospitalized patients. For almost all patients the treatment strategy is directed toward helping patients survive the acute illness. Lapses in quality commonly increase the risk of mortality. Mortality can be reliably measured using appropriate methodologies. What is our current and desired performance? The Army, Navy, Air Force and overall MHS risk adjusted mortality rates are statistically better than the expected rate. NCR-MD is statistically worse than expected. The desired performance is for the SMR to be at or below the expected rate of 1. What are the causes of the gaps in performance / What are the causes of success? A portion of the gaps in performance have been identified through the deep dive of the data. An opportunity to improve the methodology was identified relating to identification and documentation of hospice and palliative care patients. Additionally, tools to better identify the severity of illness are being researched. Both of these directly affect the ratio. Army has educated Commanders as to the current state of this metric. Navy and Air Force MTFs conduct mortality reviews for each death. NCR-MD established a Mortality Committee to review deaths Year MHS Navy Army Air Force NCRMD 2013-Q Q Q Q Q Q Q Q Q Q Q Q Working Group: CMWG Measure Advocate: Dr. Kugler Phone number: Monitoring: IMACS / CMWG Date Source: P4I MHS PHP Note: Lower is better Thresholds: Blue: Standardized Mortality Ratio (SMR) less than 1 with the upper CI limit of the ratios 95% CI less than 1 Green: The CI of the ratio s 95% upper and lower CI include 1 Red: SMR greater than 1 and the lower limit of the ratio s 95% confidence interval (CI) is greater than 1 What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Methodology modifications under consideration. Conducting mortality reviews provides facilities with information to validate quality of care and documentation as well as identify opportunities to improve care and the methodology. Documentation of all comorbid conditions to better improves quality of data. Data as of 17 May 2017

20 100% 90% Recommend Hospital (TRICARE Inpatient Satisfaction Survey) FY2017Q1 results for the standardized TRISS survey. All Services and NCR are reporting weighted ratings starting FY16Q3-Q4. All Services exceed the 73% Green target, which is greater than the HCAHPS 50 th percentile (72%). Data prior to FY16Q3 are unweighted Metric Fiscal Year TRISS Targets TRISS DC Overall Satisfaction with Inpatient Care Recommend Hospital Higher is Better Weighted Weighted/Unweighted - P4I TRISS PC SVC and HCAHPS HCAHPS 50 th 75 th NCR Avg TRISS Army TRISS Navy TRISS Air Force TRISS NCR FY12 70% 72% 70% 78% 70% 65% 70% 77% 80% Percent Satisfied 80% 70% 60% FY2012Q1 FY2012Q2 FY2012Q3 FY2012Q4 FY2013Q1 FY2013Q2 FY2013Q3 FY2013Q4 FY2014Q1 FY2014Q2 FY2014Q3 FY2014Q4 FY2015Q1 FY2015Q2 FY2015Q3 FY2015Q4 FY2016Q1 FY2016Q2 FY2016Q3 FY2016Q4 FY2017Q1 Army TRISS Navy TRISS Air Force TRISS NCRMD TRISS TRISS Direct Care TRISS Purchased Care FY14 Actual (Red) FY15 Target (Green) FY15 Target (Blue) Note: All data in this graph are unweighted and match the P4I website. There are no data available for FY14Q4. Ratings for FY2015Q1 includes data from November to December FY16Q3-FY17Q1 include weighted TRISS ratings Why is it important? (1) to produce data about patients perspectives of care that allow meaningful comparisons between military hospitals and across civilian hospitals locally, regionally or nationally; (2) to enhance accountability in health care by increasing the transparency of the quality of hospital care. What are we measuring? Willingness to Recommend: Would you recommend this hospital to your friends and family? (4-point scale, from definitely no to definitely yes ; percent satisfied is definitely yes ). What is our current and desired performance? FY14 Services and NCRMD average is 72% and FY2015 goal will be 73% across the Services and NCR. What are the causes of the gaps in performance / What are the causes of success? (1) Improved ratings of OB care will raise the overall average; (2) Medical/Surgical are comparable to HCAHPS 50 th percentile. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? (1) Generalized evidence from MHS surveys indicates typical drivers of willingness to recommend tend to be improved communication between patients and doctors/nurses FY13 71% 73% 71% 77% 73% 69% 73% 77% 82% FY14** 72% 71% 73% 71% 76% 73% 69% 73% 79% 83% FY15 Target- 73% Green FY15 Target- Blue 75% FY % 72.9% 71% 78% 74.4% (72%*) (+1.4%) 71.2% (68%*) (+2.2%) 74.0% (72%*) (+1.0%) 79.2% (78%*) (+0.2%) 84.6% (83%*) (+1.6%) FY16Q2 74.3% 73.3% FY16Q3*** 75.4% 75.2% FY16Q4*** 74.1% 75.9% 72% 78% FY17Q1*** 76.8% 74.9% 77.5% (74%*) (+4.5%) (75.4%) (+2.4%) (74.1%) (+1.1%) (76.8%) (+3.8%) 74.1% (72%*) (+5.1%) (73.8%) (+4.8%) (72.6%) (+3.6%) (76.5%) (+7.5%) 76.5% (74%*) (+3.5%) (74.2%) (+1.2%) (73.5%) (+0.5%) (74.1%) (+1.1%) 80.0% (78%*) (+1.0%) (79.8%) (+0.8%) (77.0%) (-2.0%) (80.1%) (+1.1%) 85.1% (84%*) (+2.1%) Note: Data on the left side of the table (white cells) are weighted and match TRISS reporting, but may not match the shaded, weighted and unweighted P4I data on the right. The HCAHPS percentiles are from the Public Report published on FY17Q1 HCAHPS percentiles were obtained from the HCAHPS April 2017 Public Report. *Ratings in parentheses are weighted. ** Ratings for FY2014 include data from FY14Q1-Q3. FY14Q4 and October 2014 TRISS data are not available. *** FY16Q3-FY17Q1 include weighted TRISS ratings Working Group: MHS Survey Work Group Measure Advocates: Name: Dr. Rich Bannick/Dr. Kim Aiyelawo, Dr. Melissa Gliner, Dr. Sharon Beamer, Dr. Dan Muraida, Ms. Janice Ellison Phone number: Monitoring Data Source: DHA TRISS, May 2017 (80.9%) (-2.1%) (79.7%) (-3.3%) (80.8%) (-2.2%) Thresholds: FY 2017 Approved Targets. Blue: >= 2% above Green target (75%) Green: >=2% above FY 2014 Direct Care (DC) average (73%) Red: < FY 2014 Direct Care (DC) average (71%) Data as of 19 May17

21 Provider Communication Composite (TRICARE Outpatient Satisfaction Survey/Joint Outpatient Experience Survey CAHPS) Tagline: FY2017Q1 results for the JOES-C are weighted. Because this is different from the TROSS survey, historical data are not comparable to the FY2016Q4 JOES-C data. 100% JOES-C Survey Data Metric Overall Satisfaction with Outpatient Care Provider Communication Higher is Better Weighted 90% 80% Fiscal Year TROSS/ CAHPS TROSS TROSS JOES-C C&G Targets PC DC 50 th Adjuste d DC CAHPS Adjuste d PC CAHPS FY14** 79% 78% 86% 82% 83% Army (TROSS/ JOES-C) Navy (TROSS/ JOES-C) Air Force (TROSS/ JOES-C) NCR (TROSS/ JOES-C) FY15 80% 82% 85%** 82%** 83%** 81% 79% 79% 84% FY16Q2 80% 82% 81.0% 79.9% 79.1% 81.2% 70% TROSS Survey change in May % FY2014Q3 FY2014Q4 FY2015Q1 FY2015Q2 FY2015Q3 FY2015Q4 FY2016Q1 FY2016Q2 FY2016Q3 FY2016Q4 FY2017Q1 ARMY NAVY AIR FORCE NCR TROSS/JOES-C DC TROSS PC CAHPS 50th Percentile Note: All data in this graph are weighted. FY16Q4 data uses weighted JOES-C Provider Communication data benchmark data will be reported when CAHPS C&G database data becomes available. Why is it important? (1) to produce data about patients perspectives of care that allow meaningful comparisons between military hospitals and across civilian hospitals locally, regionally or nationally; (2) to enhance accountability in health care by increasing the transparency of the quality of care. What are we measuring? Provider Communication Composite: There are four measures that make up the composite; Provider explained things clearly, Provider Listened, Provider showed respect, and Provider spent enough time. (4-point scale, from never to always ; percent satisfied is always ). What is our current and desired performance? FY15 Services and NCRMD average is 80%. What are the causes of the gaps in performance / What are the causes of success? What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? (1) Generalized evidence from MHS surveys indicates typical drivers of willingness to recommend tend to be improved communication between patients and doctors/nurses. NOTE: The Joint Outpatient Experience Survey (JOES) has created a consistent, standardized survey and methodology for assessing MTF care FY16Q3 79% 83% 82.6% 75.6% 77.3% 83.1% FY16Q4 * FY17Q1 * Target- Green Target- Blue Working Group: MHS Survey Work Group Measure Advocates: Name: Dr. Rich Bannick/Dr. Kim Aiyelawo, Dr. Mel Gliner, Dr. Sharon Beamer, Dr. Dan Muraida, Ms. Janice Ellison Phone number: % 87.0% 87.0% 83.0% 85.0% 82% 83.3% 81.0% 82.0% 81.2% Beginning in FY16Q4 JOES-C data is reported rather than TROSS. JOES-C is based on the latest version of CAHPS Clinican & Group (v 3.0) which references patient experience from the past 6 months rather than 12 months. The revised JOES-C Provider Communication Composite excludes the Knew Medical History and Provider Understandable questions. *FY16Q4 data uses JOES-C Provider Communication **CAHPS C&G 50 th and Adjusted benchmarks for FY15 onward are based on FY2015 CAHPS data. The FY2016 benchmark data will be reported when the CAHPS C&G 3.0 database is updated. Monitoring Data Source: DHA JOES-C, May 2017 Thresholds: Blue: Green: Red: Data as of 19 May17

22 Number of Infections per 1,000 Device Days Inf # Central Line Associated Bloodstream Infection (CLABSI) ICU only Since the last report in March, MHS CLABSI performance has remained green Army Air Force Navy NCRMD MHS Device Days CLABSI Infections per 1,000 Device Days (CY2014Q1 - CY2016Q4) Army Air Force Navy NCRMD MHS Rate Inf # Device Days Rate Inf # Device Days Rate Inf # Device Days Rate Inf # Working Group: PSIC Measure Advocate Name: Dr. Ashok Ramalingam Phone number: (703) Monitoring: PSAC Date Source: NHSN Thresholds: Blue: Average Index Points < 10 th Percentile Green: Average Index Points > 10 th and < 50 th Percentile Yellow: Average Index Points > 50 th and < 90 th Percentile Red: > 90 th Percentile Why is it important? CLABSIs are associated with increased morbidity, mortality, and health care costs. It is now recognized that these infections are largely preventable when evidence-based guidelines are followed. What are we measuring? The number of infections per 1,000 device days by quarter. 2014Q1 4 3, , , , What is our current and desired performance? 2014Q2 2 2, , MHS had 33 CLABSI infections in the past year (2016Q1-2016Q4). MHS performance is relatively 2014Q3 6 3, , , , stable over the past three years. Desired 2014Q4 2 2, , , performance is zero CLABSI. 2015Q1 3 3, , What are the causes of the gaps in 2015Q2 6 2, , performance / What are the causes of success? 2015Q3 7 2, , , MHS has seen improvement since CY Q4 10 3, , , associated temporally with PfP and the use of IHI 2016Q1 4 3, , bundles. However, currently MHS does not have a 2016Q2 6 2, , good method to measure Central Line Insertion Practice (CLIP) adherence and compliance with the 2016Q3 3 2, , best practices. Success is associated with infection 2016Q4 6 3, , prevention continuously on every patient with a Note: As of 03/29/2017. ICUs included are Medical, Medical/Surgical, Surgical, Medical/Surgical Pediatric, and Trauma. central line placed. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Continue to monitor infection data and provide customer centric data on a quarterly basis. Market the availability of CLABSI Driver Diagram to guide improvement efforts and/or as a military treatment facility (MTF) level CLABSI prevention tool/resource. Market the availability of evidence-based practice improvement guide for preventing CLABSI events. Support the Infection Prevention Community of Practice (CoP) held quarterly and offer opportunities for obtaining Continuing Education Credits (CEUs). Continue Infection Prevention and Control Working Group (IPCWG) meetings every other month. Maintain awareness of process of hiring Service Headquarters level Infection Preventionist (IPs) to guide improvement efforts. Device Days Rate Contents confidential and privileged IAW 10 USC Do not disclose.

23 CLABSI Standardized Infection Ratio (SIR)-ICU Only CLABSI performance is as expected for 3/3 ICU types 2 SIR by ICU Type (CY2014 H1 - CY2016 H2*) Year Half Medical Medical / Surgical Trauma SIR H H H * H= Half year Why is it important? The SIR is a summary measure used to track HAIs at a national or local level over time. The CLABSI SIR allows you to summarize your data by more than a single location, adjusting for differences in the incidence of infection among the location types. What are we measuring? 2014H1 2014H2 2015H1 2015H2 2016H1 2016H2 Medical Medical / Surgical Trauma National Benchmark 2015H H H Note: As of 03/29/2017. ICUs included are Medical, Medical/Surgical, and Trauma (all adult). Working Group: PSIC What is our current and desired performance? Performance is not statistically different than predicted. Measure Advocate Desired performance is significantly lower than predicted number of infections. Name: Dr. Ashok Ramalingam What are the causes of the gaps in performance / What are the causes of success? MHS has had significant improvement since CY2012 associated temporally with PfP and the use of IHI bundles, with Phone number: (703) multiple instances of exemplary performance for the SIR across the three ICU locations listed. Diligent Monitoring: PSAC attention to best practice details for prevention of CLABSI by nursing, physician, and infection prevention personnel has led to improved performance. Currently MHS does not have a good method to measure Date Source: NHSN compliance with the best practices. Thresholds: What could we do to close the gap / If there is no gap, what could we do to continue to succeed or Blue: Significantly better (below) the expected improve even more? Continue to monitor infection data and provide customer centric data on a quarterly SIR performance of 1 basis. Market the availability of CLABSI Driver Diagram to guide improvement efforts and/or as a military treatment facility (MTF) level CLABSI prevention tool/resource. Market the availability of evidence-based Green: Same the expected SIR performance of 1 practice improvement guide for preventing CLABSI events. Support the Infection Prevention Community of Red: Significantly worse (above) the expected Practice (CoP) held quarterly and offer opportunities for obtaining Continuing Education Credits (CEUs). SIR performance of 1 Continue Infection Prevention and Control Working Group (IPCWG) meetings every other month. Maintain awareness of process of hiring Service Headquarters level Infection Preventionist (IPs) to guide improvement efforts Contents confidential and privileged IAW 10 USC Do not disclose.

24 Unintended Retained Foreign Object (URFO) MHS had two fewer URFO events in 2017Q1 compared to 2016Q4, but performance remained red Number of Sentienel Events URFO Sentinel Events (CY2014Q2 CY2017Q1) Army Air Force Navy NCRMD MHS Why is it important? Unintended Retained Foreign Object (URFO) events are potentially preventable adverse events which often increase patient suffering and cost of care. What are we measuring? The number of URFO events that result in no harm (but reached a patient), harm, or death. A retained foreign object is defined as any foreign object that is unintentionally left in the patient during a procedure. What is our current and desired performance? Between 04/1/2014 and 3/31/2017 (three years), 67 URFO sentinel events were reported. The desired performance is zero URFO events. What are the causes of the gaps in performance / What are the causes of success? Based on RCAs submitted, management systems (human performance), training, and communication are the leading root causes for URFOs. Increased leadership focus has driven down URFO occurrence in some Services What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Continue to centrally monitor and report URFO sentinel event (SE) data on a quarterly basis. Ensure URFO Driver Diagram is available as desired for improvement efforts and/or as an MTF level URFO prevention tool/resource. Encourage any new developments following the analysis of monitoring questions aimed at identifying current MHS URFO prevention efforts. Leverage successful collaboration with Services SMEs/Patient Safety Leads, that resulted in the development evidence-based practice improvement guide for preventing URFO events, which was made available to the field (June, 2016). Leverage lessons learned through MTF's participating in the Institute for Healthcare Improvement (IHI) Surgical Collaborative Year Air Army Quarter Force Navy NCRMD MHS 2014Q Q Q Q Q Q Q Q Q Q Q Q Note: As of 04/01/2017. Numbers are based on reported date, only include TJC events, and include both dental and non-dental URFO events. Working Group: PSIC Measure Advocate Name: Dr. Ashok Ramalingam Phone number: (703) Monitoring: PSAC Date Source: Sentinel Event Database Thresholds: Blue: At least three consecutive quarters with zero events Green: Zero events in current quarter Yellow: Current quarter is lower than the average of the previous three quarters Red: Current quarter is the same or greater than the average of the previous three quarters Contents confidential and privileged IAW 10 USC Do not disclose.

25 Non-Dental Unintended Retained Foreign Object (URFO) MHS had three fewer Non-Dental URFO events in 2017Q1 compared to 2016Q4, and performance moved to yellow Number of Sentinel Events Non-Dental URFO Sentinel Events (CY2014Q2 CY2017Q1) Army Air Force Navy NCRMD MHS Year Quarter Army Air Force Navy NCRMD MHS 2014Q Q Q Q Q Q Q Q Q Q Q Q Why is it important? Unintended Retained Foreign Object (URFO) events are potentially preventable adverse events which often increase patient suffering and cost of care. What are we measuring? The number of URFO events that result in no harm (but reached a patient), harm, or death. A retained foreign object is defined as any foreign object that is unintentionally left in the patient during a procedure. What is our current and desired performance? Between 04/1/2014 and 3/31/2017 (three years), 67 URFO sentinel events were reported. The desired performance is zero URFO events. What are the causes of the gaps in performance / What are the causes of success? Based on RCAs submitted, management systems (human performance), training, and communication are the leading root causes for URFOs. Increased leadership focus has driven down URFO occurrence in some Services What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Continue to centrally monitor and report URFO sentinel event (SE) data on a quarterly basis. Ensure URFO Driver Diagram is available as desired for improvement efforts and/or as an MTF level URFO prevention tool/resource. Encourage any new developments following the analysis of monitoring questions aimed at identifying current MHS URFO prevention efforts. Leverage successful collaboration with Services SMEs/Patient Safety Leads, that resulted in the development evidence-based practice improvement guide for preventing URFO events, which was made available to the field (June, 2016). Leverage lessons learned through MTF's participating in the Institute for Healthcare Improvement (IHI) Surgical Collaborative Note: As of 04/01/2017. Numbers are based on reported date, only include TJC events, and include non-dental URFO events. Working Group: PSIC Measure Advocate Name: Dr. Ashok Ramalingam Phone number: (703) Monitoring: PSAC Date Source: Sentinel Event Database Thresholds: Blue: At least three consecutive quarters with zero events Green: Zero events in current quarter Yellow: Current quarter is lower than the average of the previous three quarters Red: Current quarter is the same or greater than the average of the previous three quarters Contents confidential and privileged IAW 10 USC Do not disclose.

26 Dental Unintended Retained Foreign Object (URFO) MHS had one Dental URFO event in 2017Q1, up from 0 in 2016Q4 Number of Sentinel Events Dental URFO Sentinel Events (CY2014Q2 CY2017Q1) Army Air Force Navy NCRMD MHS Year Quarter Army Air Force Navy NCRMD MHS 2014Q Q Q Q Q Q Q Q Q Q Q Q Why is it important? Unintended Retained Foreign Object (URFO) events are potentially preventable adverse events which often increase patient suffering and cost of care. What are we measuring? The number of URFO events that result in no harm (but reached a patient), harm, or death. A retained foreign object is defined as any foreign object that is unintentionally left in the patient during a procedure. What is our current and desired performance? Between 04/1/2014 and 3/31/2017 (three years), 67 URFO sentinel events were reported. The desired performance is zero URFO events. What are the causes of the gaps in performance / What are the causes of success? Based on RCAs submitted, management systems (human performance), training, and communication are the leading root causes for URFOs. Increased leadership focus has driven down URFO occurrence in some Services What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Continue to centrally monitor and report URFO sentinel event (SE) data on a quarterly basis. Ensure URFO Driver Diagram is available as desired for improvement efforts and/or as an MTF level URFO prevention tool/resource. Encourage any new developments following the analysis of monitoring questions aimed at identifying current MHS URFO prevention efforts. Leverage successful collaboration with Services SMEs/Patient Safety Leads, that resulted in the development evidence-based practice improvement guide for preventing URFO events, which was made available to the field (June, 2016). Leverage lessons learned through MTF's participating in the Institute for Healthcare Improvement (IHI) Surgical Collaborative Note: As of 04/01/2017. Numbers are based on reported date, only include TJC events, and include dental URFO events. Working Group: PSIC Measure Advocate Name: Dr. Ashok Ramalingam Phone number: (703) Monitoring: PSAC Date Source: Sentinel Event Database Thresholds: Blue: At least three consecutive quarters with zero events Green: Zero events in current quarter Yellow: Current quarter is lower than the average of the previous three quarters Red: Current quarter is the same or greater than the average of the previous three quarters Contents confidential and privileged IAW 10 USC Do not disclose.

27 MHS Quality (Outpatient) Composite The Navy achieved the maximum threshold of 90%. Air Force, Army and NCRMD reached the target threshold of 70%. Improvement opportunities focused on reducing variation among the MTFs. Aug 14 Mar 16 MHS Navy Army Air Force NCRMD MCSC/ Overseas Jun Oct Feb Aug Mar Jun Oct Feb Aug Mar Jun Oct Feb Aug Mar Jun Oct Feb Aug Mar Jun Oct Feb Aug Mar Jun Oct Acute Conditions 52% 50% 51% 53% 56% 65% 75% 97% 100% 99% 41% 38% 49% 52% 65% 64% 59% 88% 89% 87% 61% 59% 72% 74% 95% 30% 36% 27% ND 27% Low Back Pain ND 1 Pharyngitis ND 1 URI % ND 2 HEDIS Diabetes 51% 54% 55% 56% 57% 77% 80% 84% 85% 86% 63% 67% 70% 71% 73% 70% 80% 80% 83% 83% 76% 71% 73% 74% 67% 20%* 20%* 20%* 20% 20%* A1C Screening A1C Good Control N/A N/A N/A N/A N/A Mental Health F/up** Quality Composite 62% 69% 67% 62% 67% 84% 92% 93% 93% 93% 72% 75% 73% 80% 80% 72% 82% 80% 80% 87% 78% 83% 87% 87% 87% 36% 39% 27% 27% 27% % Change from Aug 14 5% 9% 8% 15% 9% -9% *Only 1 of 2 components of for diabetes index available NCQA HEDIS benchmarks updates applies annually in January ** 7 day Mental Health Follow-up replaces 30-day Mental Health Follow-up in 2016 What are we measuring? This composite includes the equally weighted sub-measures: 1) Acute Conditions Composite 2) Diabetes Composite, and 3) Mental Health Follow-up. The rate of compliance with the measures is converted to index points based on the National Committee for Quality Assurance (NCQA) HEDIS national benchmarks. Data are displayed as percent of possible index points obtained for the measures. Why is it important? A quality composite is important to summarize detailed information across the multiple quality measures into a consolidated indicator of performance. The selected measures provide the MHS with an overview of performance for key outpatient populations. What is our current and desired performance? The Navy has achieved the maximum performance thresholds while Air Force, Army and NCR-MD have reached the target threshold. Desired performance is for all MTF to ultimately obtain 90% of the possible index points. This would align MHS performance with the top 10%-25% of health plans submitting data to NCQA. Our ability to impact network providers is limited Working Group: PCMH Measure Advocate: Dr. Kugler Phone number: Monitoring: IMACS/CMWG Date Source: P4I MHS PHP Thresholds: Blue: 90 % of Possible Index Points Green: 70% of Possible Index Points Yellow: 50% of Possible Index Points Red: < 50% of Possible Index Points What are the causes of the gaps in performance / What are the causes of success? Performance gaps: Communication of care provided outside of enrollment site, Coding and documentation of point of care tests. Successes Clinics establishing and consistently using well defined processes, protocols and TSWF forms. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? With all direct care components meeting the target, the focus for improvement is reduction of MTF level variation for the individual measures. Dissemination and spread of successful practice provides the MHS with the opportunity to move from pocket of excellence to a system of excellence. Data as of 17 May 2017 Feb 17

28 HEDIS Diabetes Composite Navy and Air Force exceeded target of 70% for the past 12 months. Army has exceeded target for past 9 months. Healthcare Effectiveness Data and Information Set (HEDIS) Diabetes Care - MHS Note: Higher is better. Number of measures included in the index decreased from four to two in What are we measuring? The index includes 2 diabetes care measures for direct care: a process measure (annual A1C testing) and an outcome measure (A1C test results in good control (<8.0)). Only one measure ( annual A1C testing) is available in the purchase care claims data. The rate of compliance with the measures is converted to index points based on the HEDIS national benchmarks. Data is displayed as percent of possible index points obtained for the measures. Why is it important? The MHS has approximately 137,000 enrolled diabetics. Diabetes is the seventh leading cause of death in the United States. Many complications from diabetes, such as amputation, blindness and kidney failure, can be prevented if detected and managed in the early stages. What is our current and desired performance? The desired performance is to ultimately obtain 90% of the possible index points. Generally, this would align MHS performance with the top 25% of health plans submitting data to National Committee for Quality Assurance (NCQA). The Navy, Air Force and Army have reached the 70% target. NCR-MD rate has decreased over the past 6 months. What are the causes of the gaps in performance / What are the causes of success? Performance gaps - Labs drawn outside MTF without capture of data; Variability of processes and execution; Purchased Care data based only on claims data and thus only one measure. Successes- Organized, proactive team based approach; Clinical Practice Guidelines in TSWF; inclusion of Chief Medical Officer in performance improvement efforts; Inclusion of MTFs in emsm in monthly market board Month-Year Navy Army Air Force NCRMD *MCSC/Overseas - Data for only 1 of the 2 index measures are available and included in the performance calculation ** NCQA HEDIS benchmarks updates applies annually in January Working Group: PCMH Measure Advocate: Dr. Kugler Phone number: Monitoring: IMACS/CMWG Date Source: P4I MHS PHP MCSC/ Overseas Jul-14 76% 64% 69% 76% 20% Jul-15 79% 69% 79% 83% 20% Mar-16 80% 67% 80% 71% 20% Apr-16 81% 65% 80% 70% 20% May-16 82% 67% 80% 73% 20% Jun-16 84% 70% 80% 73% 20% Jul-16 84% 72% 79% 72% 20% Aug-16 85% 72% 80% 76% 20% Sep-16 84% 71% 82% 78% 20% Oct-16 85% 71% 83% 74% 20% Nov-16 84% 72% 84% 73% 20% Dec-16 85% 72% 84% 70% 20% Jan-17 88% 74% 83% 69% 20% Feb-17 86% 73% 83% 67% 20% Thresholds: Blue: 90 % of Possible Index Points Green: 70% of Possible Index Points Yellow: 50% of Possible Index Points Red: < 50% of Possible Index Points What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Action lists identifying patients needing diabetes A1C testing are available to clinic staff. Data internally transparent in CarePoint to support MTFs with collaborative learning from others. Emphasis on screening and reduction in performance variation needed. Navy- BUMED provides HEDIS analysis to regional and specialty leaders monthly; Coordination at command level, PCMH and TSWF; sharing of best practices; Attendance at AF HEDIS webinars. Data now available in CarePoint at clinic and provider level. Data as of 15 May 2017

29 MHS Acute Conditions Composite Navy has obtained 100% of possible index points for past 4 months. Air Force and NCR-MD exceed the 70% target for the MHS Acute Conditions Composite and continue to maintain or improve performance. Healthcare Effectiveness Data and Information Set (HEDIS) Acute Condition Composite - MHS Note: Higher is better. What are we measuring? The composite includes HEDIS measures for appropriate use of imaging studies for low back pain, use of antibiotics for upper respiratory infection (URI) and treatment of pharyngitis with antibiotics and strep test. The rate of compliance for each measure is converted to index points based on the HEDIS national benchmarks. Data is displayed as percent of possible index points obtained for the three measures combined. Why is it important? Over use of antibiotics has been directly linked to the prevalence of antibiotic resistance. Overuse of imaging studies unnecessarily exposed patients to radiation. Overuse of antibiotics and imaging studies wastes resources. What is our current and desired performance? The desired performance is to ultimately obtain 90% of the possible index points. This would generally align MHS performance with the top 25% of health plans submitting data to National Committee for Quality Assurance (NCQA). A performance rate of 70% of index points is provided as a target. The Navy has consistently surpassed the 90% target and has obtained 100% for the past 4 month. This equates with performance of the top 10% of health plans submitting data to NCQA. What are the causes of the gaps in performance / What are the causes of success? Performance gaps include lack of documentation of point of care test for pharyngitis and coding discrepancies with the URI protocol. Our ability to impact network providers is limited in current contracts. Successes include clinics using well defined LBP protocols and TSWF forms do better on LBP measure. Education and workflow modifications to include coding and documenting point of care tests for pharyngitis Month- MCSC/ Navy Army Air Force NCRMD Year Overseas Jul-14 67% 40% 64% 63% 37% Jul-15 68% 40% 62% 53% 31% Jan-16* 89% 40% 81% 63% 29% Feb-16 91% 41% 83% 69% 29% Mar-16 93% 41% 85% 63% 28% Apr-16 95% 48% 85% 72% 28% May-16 96% 49% 86% 72% 27% Jun-16 97% 49% 88% 72% 27% Jul-16 98% 50% 89% 73% 27% Aug % 51% 89% 77% ND Sep % 51% 89% 81% ND Oct % 52% 89% 84% ND Nov % 52% 89% 87% ND Dec % 53% 89% 93% ND Jan-17 99% 63% 87% 95% ND Feb-17 99% 65% 87% 95% ND NCQA HEDIS benchmarks updates applies annually in January Data changes from enrollment to treatment site in 2016 Working Group: PCMH Measure Advocate: Dr. Kugler Phone number: Monitoring : IMACS / CMWG Date Source: MHS PHP P4I Thresholds: Blue: 90 % of Possible Index Points Green: 70% of Possible Index Points Yellow: 50% of Possible Index Points Red: < 50% of Possible Index Points What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Disseminated protocols and information found to be successful in controlling LBP imaging referrals. Educate providers on URI evaluation and treatment as well as pharyngitis coding, and documenting rapid strep tests. Utilize TSWF forms. Optimize use of advancement of the electronic capabilities and incorporate into workflows. Maximizing MTF access to facilitate providing care at enrollment site and protocol utilization. Data as of 17 May 2017

30 7 Day Mental Health Direct and purchased care performance fairly consistent with slight decrease in overall variability across MHS Healthcare Effectiveness Data and Information Set (HEDIS) 7 Day Follow-up Note: Higher is better. Why is it important? Follow-up after hospitalization ensures gains made during hospitalization are not lost resulting in the need for readmission. The follow-up helps health care providers assess the patient s transition to the home or work environment as well as detect early posthospitalization reactions or medication problems. What are we measuring? The measure looks at continuity of care for mental illness by assessing the percentage of patients 6 years of age and older who were hospitalized for selected mental disorders and who were seen on an outpatient basis by a mental health provider within 30 days after their discharge. What is our current and desired performance? The desired performance is for MTFs to obtain 4 or 5 index points thus reaching the top 2 levels of performance (HEDIS 90 th and 75 th Percentile) for the index measures. The Army, Navy and NCR-MD are at the maximum level while the Air Force and MCSC are below the threshold. Month- Year Jul-14 Jul-15 Navy Army Working Group: TSSCAB Measure Advocate: Dr. Kugler Phone number: Monitoring IMCCS / CMWG Data Source: P4I MHS PHP Air Force NCRMD MCSC Feb-16 77% 78% 66% 76% 43% Mar-16 77% 78% 67% 77% 43% Apr-16 78% 78% 67% 75% 44% May-16 78% 78% 67% 75% 44% Jun-16 78% 78% 68% 75% 43% Jul-16 78% 79% 68% 76% 43% Aug-16 78% 78% 68% 76% 44% Sep-16 79% 79% 68% 76% 44% Oct-16 79% 79% 68% 74% 43% Nov-16 79% 79% 70% 75% 44% Dec-16 79% 79% 70% 75% 44% Jan-17 78% 79% 70% 74% 43% Feb-17 78% 79% 70% 74% 43% NCQA HEDIS benchmarks updates applies annually in January th percentile = 72.97% 75 th percentile = 63.26% 50 th percentile = 53.19% th percentile = 69.22% 75 th percentile = 62.20% 50 th percentile = 51.74% Thresholds: Blue: HEDIS 90 th percentile Green: HEDIS 75 th percentile Red: HEDIS 50 th Percentile and below What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Engage with TRICARE contractors to assist with this measure, engage local inpatient MH facilities to facilitate booking of follow-up appointments at discharge, and use limited case management resources to assist these patients. Reinforce provider education on follow-up after discharge. TRO s identified a coding issue that was corrected in Aug What are the causes of the gaps in performance / What are the causes of success? AFMS analysis shows that we perform similarly to the other services for each BenCat, but that we have a significantly higher % of retired enrollees the group with the lowest performance on this measure across all services. Army BH community continues to make this a priority and is working to ensure all AD are captured. Other beneficiary categories are seen off post and so are more difficult to ensure f/u. Lack of f/u continuity after d/c Data as of 15 May 2017

31 Access Composite MHS View Overall Composite is higher than Oct 16 but the same as Jan 17. Direct Care Army Navy Air Force NCRMD All Access Composite HR Future Leakage 23.5% 30.1% 32.2% 29.6% 27.9% PCM Continuity 57.6% 57.6% 58.7% 56.5% 57.6% JOES GCWN 85% 84% 84% 86% 85% JOES Response Rates* 8% 8% 10% 22% 9% * Does not include Getting Care When Needed (GCWN); targets are pending. In the interim, the composite consists of four measures at a maximum of four points each. Why is it important? To improve satisfaction with access/seeing a provider when needed, MTFs must ensure appointment supply meets patient demand, reduce unnecessary utilization through demand management/team based care and offer convenient options such as secure messaging and phone visits, What are we measuring? Each of the five access measures (Third Next 24-hour, Third Next Future, % enrollment in secure messaging, PCM continuity, leakage and satisfaction) are scored according to performance range (1 pt red; 2 pts yellow; 3 pts green; 4 pts blue; the total points represents the access composite with a maximum of 20 points.) What is our current and desired performance? Current average performance is 10 points total or in the yellow range; desired performance is the green range in each measure. What are the causes of the gaps in performance / What are the causes of success? Access and continuity must be balanced to optimize convenience and patient experience. Reasons for gaps include staffing shortfalls, training deficits and a misalignment of supply and demand for care on the days/at the times patients want to be seen. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Establish standard processes and procedures, match supply and demand, offer convenient care options to reduce leakage (extended hours, virtual visits, MTF UC fast tracks, practice demand management, reduce unnecessary utilization, reinforce reliable Patient/Team relationship Working Group: Tri-Service PCMH Advisory Board Measure Advocate Name: Regina Julian Phone number: Monitoring: Monthly Data Source: TOC and MHS Dashboard Thresholds:* Blue: 16 points Green: > 12 points Yellow > 8 points Red: < 4 points Composite data as of April 2017

32 Access Composite Details for Back-Up Slides 24HR FTR Values Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Air Force Army Navy NCR MD Direct Care HR FTR Points Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Air Force Army Navy NCR MD Direct Care PCM Continuity Leakage Values Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Air Force 56.1% 57.8% 57.6% 58.8% 57.9% 57.7% 57.6% 27.1% 29.4% 29.4% 29.5% 31.7% 30.6% 32.2% Army 54.9% 57.4% 58.1% 58.7% 58.1% 57.7% 57.6% 21.9% 23.1% 23.2% 22.6% 24.2% 22.8% 23.5% Navy 57.6% 58.5% 58.8% 60.5% 59.0% 59.5% 58.7% 25.5% 27.5% 27.7% 28.5% 30.0% 29.2% 30.1% NCR MD 53.0% 54.0% 53.2% 46.7% 57.7% 57.4% 56.5% 26.3% 27.4% 26.6% 27.6% 29.3% 29.7% 29.6% Direct Care 56.1% 57.8% 57.6% 58.8% 57.9% 57.7% 57.6% 24.4% 26.1% 26.2% 26.2% 27.9% 26.9% 27.9% PCM Continuity Leakage Points Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Air Force Army Navy NCR MD Direct Care

33 Average Number of Days to Third Next 24-Hour Appointments Mean Jan-17 Apr-17 Change Air Force % Army % Navy % NCRMD % Direct Care % Median Jan-17 Apr-17 Change Air Force % Army % Navy % NCRMD % Direct Care % Data as of 30 Apr 17

34 Average Number of Days to Third Next Future Appointments Mean Jan-17 Apr-17 Change Air Force % Army % Navy % NCRMD % Grand Total % Median Jan 17 FTR Apr 17 FTR Change Air Force % Army % Navy % NCRMD % Direct Care % Data as of 30 Apr 17

35 Primary Care Leakage MHS Not Meeting Target at 27%. Why is it important? This measure is intended to assess whether patients are able to receive timely access to primary care within the direct care system. What are we measuring? Primary care workload that is delivered in non-primary care settings of the MTF (non-pcmh, ED, or UC) or in the network. What is our current and desired performance? Total MHS performance at 27% relative to goal range of 24%-20%. Army meeting target; DHA-NCR, Air Force and Navy above target. What are the causes of the gaps in performance / What are the causes of success? Complexity per episode increasing in PSC. Urgent Care Pilot driving care out. Successes: Access initiatives, Use of Secure Messaging and Nurse Advice Line. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Improve patient access and appointment availability (i.e. Avg days to 3 rd Next Available); growth and utilization of patient communication tools (i.e. Secure Messaging, Simplified Appointing, and Nurse Advice Line). Working Group: PCMH WG Measure Advocate Name: Dr. Kugler/Gina Julian Phone number : (703) Date Source: M2 TEDNI and CAPER Data as of 30 Apr 17

36 PCM Continuity Service Jan 17 Apr 17 Change Apr 17 Median Air Force 58.1% 56.7% -1.4% 59.4% Army 58.7% 57.6% -1.1% 58.0% Navy 60.5% 60.2% -0.3% 62.1% NCR MD 56.7% 56.5% -0.2% 59.8% All 58.8% 57.6% -1.2% 59.8% Data as of 30 Apr 17

37 Satisfaction with Getting Care When Needed (Service/JOES Surveys) This measure indicates an average assessment of access to outpatient care experience from the beneficiary s perspective. JOES was phased in for Navy and NCR mid-fy16q3, Army end of FY16Q3, and Air Force end of FY16Q4. FY2017Q1 JOES results are the first quarter with all Services & MTFS relying on the same standardized survey and methodology. Anticipate proposed new FY2018 targets based on FY2017 Q1-Q3 results. Percent Satisfied 100% 95% 90% 85% 80% 75% 70% 65% TROSS Survey change in May 2014 JOES begins for Navy and NCR JOES begins for Army JOES begins for AF FY12Q1 FY12Q2 FY12Q3 FY12Q4 FY13Q1 FY13Q2 FY13Q3 FY13Q4 FY14Q1 FY14Q2 FY14Q3 FY14Q4 FY15Q1 FY15Q2 FY15Q3 FY15Q4 FY16Q1 FY16Q2 FY16Q3 FY16Q4 FY17Q1 FY17Q2 Army Navy Air Force NCR Direct Care Purchased Care Services/NCRMD Red Green Target Blue Target Note: A new TROSS instrument, with a new response scale (change from 6pt to 4pt scale ), began fielding during FY14Q3 (May 2014). The large increase in TROSS results From FY14Q2 to FY14Q3 are likely due to the instrument change; reaching a new normal when the ratings stabilize in FY15 TROSS DC and PC. AF data for FY16Q1 has 2 months of data because of a gap in service. JOES was phased in for Navy and NCR mid- FY16Q3, Army end of FY16Q3, and Air Force end of FY16Q4. FY17Q1 data are weighted JOES ratings for each of the Services. Metric Direction Fiscal Year Services and NCRMD Average Satisfaction with Getting Care When Needed Higher is Better Army (APLSS/ JOES) Navy (PSS/JOES) Air Force (SDA/JOES) NCRMD (APLSS+TROSS/ JOES) TROSS/ JOES-C DC TROSS/ JOES-C PC FY12 85% 83% 86% 87% 77% 71% (70%*) 81% (85%*) FY13 85% 82% 90% 88% 79% 71% (70%*) 80% (85%*) FY14 84% 82% 91% 89% 79% 76% 86% FY15 Target- Green 84% 93% 91% 81% FY15 Target- Blue 86% 95% 93% 83% FY % (+2.3%) FY16Q3 86.6% (+2.6%) 82.7% (+0.7%) 84.4% (+2.4%) 90.0% (-1.0%) 86.5%** FY16Q4 82.4% (-1.6%) 81.5%** 83.3%** 90.4% (+1.4%) 89.3% (+0.3%) 89.4% (+0.4%) 82.1% (+3.1%) 84.7%** 83.1% (+7.0%) 84.1% (+8.1%) 90.0% (+4%) 91.9% (+5.9%) 84.0%** 76.3% % 1 FY17Q1 81.4%*** 81.2%*** 81.3%*** 81.5%*** 83.3%*** 79.0% % 1 FY17Q2 83.3%*** 83.6%*** 83.1%*** 82.1%*** 85.2%*** Note: *All data are unweighted except TROSS DC and PC data in parentheses for FY12-13 and any reported JOES data, which are weighted. ** Navy and NCR are reporting JOES data starting FY16Q3. Army is reporting JOES data starting FY16Q4. Air Force is reporting JOES data starting at the end of FY16Q4. ***FY17Q1-FY17Q2 data are weighted JOES ratings for each of the Services and DC 1 JOES-C: Weighted GCWN Ratings Why is it important? Access to comprehensive, quality health care services is important to achieve the best health outcomes and healthy life for all MHS beneficiaries. What are we measuring? Get Care When Needed : In general, I am able to see my provider when needed. (5-point scale, from strongly agree to strongly disagree ; percent satisfied is agree and strongly agree ). What is our current and desired performance? FY14 Services and NCRMD average is 84% and FY2015 goal will be a 2% increase in each Service s FY 2014 average. What are the causes of the gaps in performance/what are the causes of success? (1) High volume of patients who require care for limited resources to support the request; (2) More work needed to improve patient appointment templates/provider availability. (1) Modeling is underway to examine the impact of the implementation of the MHS First Call Resolution and Do Not Call Back Policy. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? (1) Book appointments in accordance with access to care and referral management protocols; (2) Share best practices among facilities with the highest access to care; (3) Generalized evidence from national surveys indicates typical drivers of satisfaction tend to be access-specific: getting/timeliness of appointments. NOTE: The Joint Outpatient Experience Survey (JOES) has created a consistent, standardized survey and methodology for assessing MTF care Working Group: MHS Survey Work Group Measure Advocates: Name: Dr. Rich Bannick/Dr. Kim Aiyelawo, Dr. Melissa Gliner, Dr. Sharon Beamer, Dr. Dan Muraida, Ms. Janice Ellison Phone number: Monitoring Data Source: DHA JOES, April 2017 Targets for FY 18 will be proposed in July Previous Service-based survey targets were: Green: 2% above each Service FY 2014 average; Blue: 2% above each green target. Data as of 19 May 17

38 Average Number of Days from Consult to Booking Exploratory measure monitors compliance with the Specialty Care Referral DHA-IPM , signed on 18 January 2017, which states MTF commanders and/or Senior Market Manager will, to the greatest extent possible, establish processes that enable initial specialty care referrals to be appointed to the direct care system before the patient leaves the MTF. RMS Data Ordered to Booked (A - B)* Service Sep-16 Oct-16 Nov-16 Army Air Force Navy NCR MHS *RMS Report SEP-NOV2016_REPORT_BY_DMIS Note: Data source is the Referral Management Suite (RMS. Updated data are not available until June due to contract issues. We are working to replicate the data with a pull from MDR to ensure monthly updates. Why is it important? Improves the patient experience and access to care What are we measuring? To monitor compliance with the Specialty Care Referral DHA-IPM What is our current and desired performance? Current: MHS 3.01; Army: 3.22; Air Force: 2.93; Navy: 2.66; NCR: 3.20 Desired: 1 day or less What are the causes of the gaps in performance / What are the causes of success? Gaps exist in the referral process across the direct care system. A lack of a streamlined referral process and centralized specialty booking increase variance in the time from consult to booking. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Comply with the Specialty Care Referral DHA-IPM and adopt proposed processes outlined in 2017 NDAA Section 709 on appointing processes and procedures Working Group: MHS Referral Management Working Group Measure Advocate Name: Ms. Regina Julian Phone number: Monitoring: TSPCCIB Date Source: Referral Management Suite (RMS) Thresholds: Blue: N/A Green: N/A Red: N/A

39 Average Number of Days from Booking to Appointment Exploratory measure to measure the number of days from booking in CHCS/MHS Genesis to appointment in specialty care RMS Data Booked to Actual Appointment Date (B - C)* Service Sep-16 Oct-16 Nov-16 Army Air Force Navy NCR MHS *RMS Report SEP-NOV2016_REPORT_BY_DMIS Note: Data source is the Referral Management Suite (RMS. Updated data are not available until June due to contract issues. We are working to replicate the data with a pull from MDR to ensure monthly updates. Why is it important? Improves the patient experience and access to care What are we measuring? To monitor compliance with the Specialty Care Referral DHA-IPM and the Access to Care Policy What is our current and desired performance? Current: MHS 14.33; Army: 14.18; Air Force: 15.55; Navy: 12.67; NCR: Desired: Entire process should meet the ATC standard of 28 days What are the causes of the gaps in performance / What are the causes of success? Product lines are not standardized across direct care n terms of expected number of encounters, provider availability and appointment types/mix. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Optimize specialty product lines and standardize appointing processes, procedures and appointment types as identified in draft DHA IPM to support 2017 NDAA Section Working Group: MHS Referral Management Working Group Measure Advocate Name: Ms. Regina Julian Phone number: Monitoring: TSPCCIB Date Source: Referral Management Suite (RMS) Thresholds: Blue: N/A Green: N/A Red: N/A

40 Percent MTF Enrollees Registered in Secure Messaging Service Feb-17 Mar-17 Apr-17 Air Force 48.3% 48.8% 49.5% Army 38.9% 39.0% 39.2% Navy 53.4% 53.6% 53.8% NCR MD 54.6% 55.4% 54.6% Direct Care 46.1% 46.4% 45.7% Data as of 30 Apr 17

41 Secure Messaging Utilization Service Apr-17 Air Force 4.8% Army 6.5% Navy 4.9% NCR MD 9.3% Direct Care 5.6% Data as of 30 Apr 17

42 Per Member Per Month MHS Meeting Target for Per Member Per Month. Why is it important? Measures the total health care cost for TRICARE Prime enrollees. Directly links costs to patients, providing a means to target and reduce costs. What are we measuring? Measure focuses on the TRICARE Prime population where the MHS has the most control and visibility into the full continuum of care received. What is our current and desired performance? Current performance is a small increase of 1.6% which is well below the target of 3.4%. What are the causes of the gaps in performance / What are the causes of success? Migration of maintenance medications from the retail pharmacy to either the TRICARE Mail Order or Military Treatment Facilities (MTFs) resulted in significant improvements. Additionally, through the Pharmacy & Therapeutics Committee explicit formulary management and actionable Prime enrollee leakage reports for nonmaintenance medication further reductions overall costs were achieved. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? With pharmacy now under control, focus needs to shift to Outpatient Care where utilization is increasing at higher rate than experienced in the past couple of years Working Group: BAC Measure Advocate Name: Mr. Greg Atkinson Phone number: Monitoring: Mr. Greg Atkinson Data Source: M2 TED-I / TEDNI / Enrollment / SIDR / CAPER / Radiology / Laboratory / Pharmacy / MEPRS Thresholds: Blue: 0% annual growth Green: 0.0% - 3.4% annual growth Red: >3.4% annual growth Data as of May 2017

43 Total Empanelment Total MHS Empanelment Below Target. Why is it important? This measure looks at how many patients the Direct Care portion of the MHS serves. Increasing enrollment and access should ultimately decrease purchased care costs and improve readiness. What are we measuring? The number of Prime, Reliant (only those enrolled to Op Forces), and TRICARE Plus beneficiaries for each MTF based on Alternate Care Value (ACV) group and Service enrollment site in the M2 TRICARE Relationship Summary. What is our current and desired performance? MHS performance closed at 0.4% below target. This reflects empanelment increases for Navy and DHA-NCR that were offset by Army and Air Force decreases. What are the causes of the gaps in performance / What are the causes of success? For Air Force, bulk of the decline is from ADFMs despite increase in AD end-strength. Army declining trend will continue due to reduction in end-strength. Navy MTFs near maximum enrollment. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? AF has initiatives underway to address provider availability, especially during summer underlaps; this includes a policy letter outlining beneficiary disengagement/recapture Working Group: BAC P4I Measure Advocate Name: Dr. Kugler/Mr.Todd Gibson Phone number: (703) Data Source:M2 TRICARE Relationships (DEERS) Summary Thresholds: Blue: > 5% Yearly Growth Green: 0-5% Yearly Growth Red: <0% Yearly Growth

44 Pharmacy Percent Retail Spend MHS and Components Exceeding FY17 Target of 30% Pharmacy Retail Spend. Why is it important? This measure encourages MTFs to most effectively channel or recapture pharmacy workload to the MTF or mail order pharmacy and drive down retail pharmacy usage. What are we measuring? Retail Pharmacy Spend divided by Total Pharmacy Spend. Total costs are full costs (net cost to the Government) at each point of service. What is our current and desired performance? Component and total enterprise performance is exceeding target as of FY17 FM5. Since FY15 FM8, all Components have experienced decreases. FY17 target is 30%. What are the causes of the gaps in performance / What are the causes of success? Migration of maintenance medications from the retail pharmacy to either the TRICARE Mail Order or Military Treatment Facilities (MTFs) resulted in significant improvements. Additionally, through the Pharmacy & Therapeutics Committee explicit formulary management and actionable Prime enrollee leakage reports for non-maintenance medication further reductions overall costs were achieved. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more?. With retail pharmacy now under control, focus needs to shift to Outpatient Care where utilization is increasing at higher rate than experienced in the past couple of years Working Group: Pharmacy WG Measure Advocate Name: CAPT Ed Norton Phone number: (703) Monitoring: Mr. Bill Davies Data Source: M2 Pharmacy (PDTS)