The MHS Health Benefit Concept of Operations Our roadmap for transformation to achieve breakthrough performance Mike Dinneen, MD, PhD Director, Office of Strategy Management OASD(HA) and DHA michael.p.dinneen.civ@mail.mil
National Defense Strategy Continuously Solving a High Complexity Problem
Strategic Construct Linking the National Security Strategy to Joint Health Services Operational Medicine CONOPS* Capstone Concept for Joint Operations National Military Strategy Joint Concept for Health Services Health delivery that supports operational medicine TRICARE Benefit Problem Statement (JCHS): How can the Joint Force provide comprehensive health services to deployed forces in an operating environment characterized by highly distributed operations and minimal, if any, preestablished health service infrastructure? Solution: Integrated Joint Requirements Tailored Medical Forces and Operations Global Synchronization, Networking, and Interoperability Interoperable Service Capabilities *Refers to a Family of JROC Approved Documents - 3 - MHS Health Benefit Delivery CONOPS
Strategic Construct --- MHS Health Benefit Delivery CONOPS Capstone Concept for Joint Operations Operational Medicine CONOPS* National Military Strategy Joint Concept for Health Services Health delivery and services that support operational medicine TRICARE Benefit HBD CONOPS: How can Joint Force health readiness be maximized leveraging the delivery of effective and efficient health services for all MHS beneficiaries? *Refers to a Family of JROC Approved CONOPS Source: MHS Health Benefit Delivery CONOPS, Draft v3.0, 18 December 2015.
UNCLASSIFIED Desired End State The Big Picture Figure 4 from MHS HBD CONOPS 5 UNCLASSIFIED
UNCLASSIFIED More Capable Medical Force 6 UNCLASSIFIED
Outcomes that Matter - The Numerator in the Value Equation Survival Rates on Battlefield Against Expected Outcomes 100% 95% % Survived (30 Day Outcome) 90% 85% 80% 75% 70% 2007 2008 2009 2010 2011 Observed Survival Expected Survival 7
UNCLASSIFIED Desired End State More Capable Medical Force Build and Sustain Services Medical Capabilities Health Readiness Strengthen Our Integrated Learning Health System Focused on Readiness Fully Support Medical Deployment Cycle While Optimizing Healthcare Delivery Expand Services and DHA Leadership Development Enhance Emerging Medical Capabilities for a Joint Environment While Increasing Interoperability Ready Medical Force & Medically Ready Force Enhance Strategic Partnerships UNCLASSIFIED
UNCLASSIFIED Better Health 9 UNCLASSIFIED
Exhibit 1. Health Care Spending as a Percentage of GDP, 1980 2013 Percent * 2012. Notes: GDP refers to gross domestic product. Dutch and Swiss data are for current spending only, and exclude spending on capital formation of health care providers. Source: OECD Health Data 2015.
Exhibit 8. Health and Social Care Spending as a Percentage of GDP Percent Notes: GDP refers to gross domestic product. Source: E. H. Bradley and L. A. Taylor, The American Health Care Paradox: Why Spending More Is Getting Us Less, Public Affairs, 2013.
Exhibit 9. Select Population Health Outcomes and Risk Factors Life exp. at birth, 2013 a Infant mortality, per 1,000 live births, 2013 a Percent of pop. age 65+ with two or more chronic conditions, 2014 b Obesity rate (BMI>30), 2013 a,c Percent of pop. (age 15+) who are daily smokers, 2013 a Percent of pop. age 65+ Australia 82.2 3.6 54 28.3 e 12.8 14.4 Canada 81.5 e 4.8 e 56 25.8 14.9 15.2 Denmark 80.4 3.5 14.2 17.0 17.8 France 82.3 3.6 43 14.5 d 24.1 d 17.7 Germany 80.9 3.3 49 23.6 20.9 21.1 Japan 83.4 2.1 3.7 19.3 25.1 Netherlands 81.4 3.8 46 11.8 18.5 16.8 New Zealand 81.4 5.2 e 37 30.6 15.5 14.2 Norway 81.8 2.4 43 10.0 d 15.0 15.6 Sweden 82.0 2.7 42 11.7 10.7 19.0 Switzerland 82.9 3.9 44 10.3 d 20.4 d 17.3 United Kingdom 81.1 3.8 33 24.9 20.0 d 17.1 United States 78.8 6.1 e 68 35.3 d 13.7 14.1 OECD median 81.2 3.5 28.3 18.9 17.0 a Source: OECD Health Data 2015. b Includes: hypertension or high blood pressure, heart disease, diabetes, lung problems, mental health problems, cancer, and joint pain/arthritis. Source: Commonwealth Fund International Health Policy Survey of Older Adults, 2014. c DEN, FR, NETH, NOR, SWE, and SWIZ based on self-reported data; all other countries based on measured data. d 2012. e 2011.
Outcomes that Matter: The Health Related Quality of Life Measure (HRQOL) HRQOL Defined: The measure consists of four simple validated questions about overall health, including mental and physical status, reflecting the multiple social determinants of heath. It is sometimes referred to as the Healthy Days survey. HRQOL Questions: 1. Would you say that in general your health is excellent, very good, good, fair, or poor? 2. Now thinking about your physical health, which includes physical illness and injury, how many days during the past 30 days was your physical health not good? 3. Now thinking about your mental health, which includes stress, depression, and problems with emotions, how many days during the past 30 days was your mental health not good? 4. During the past 30 days, approximately how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?
Healthcare to Health Are we fielding a complete team?
What does it mean to win at health? What does it mean to lose? Win = Thrive Lose = Suffer
A Football Team has Three Squads Offense Defense Special Teams What squad are we fielding now?
Defense Healthcare Offense Defensive Line: Primary Care Dental Urgent Care Emergency Rooms Pharmacies Offensive Line: Acute illness, Minor injuries Unhealthy lifestyle Linebackers: Specialty Care Inpatient Care Running Backs: Chronic illness, Major Trauma Defensive Ends and Safeties: Sub-Specialty Care Intensive Care Case Management Skilled Nursing Care What side are patients on? Receivers: Complex Illness Multiple Chronic Illnesses
Diabetes gets past Health Defenses Touchdown!! Amputation, dialysis, chronic pain, loss of sight, 24 hour nursing Heart Failure Kidney Failure High Blood Pressure High Blood Sugar - Diabetes Pre Diabetic Weight Gain
Where is the Defensive Coordinator? Is this role even defined in health today? When the training is in functional silos, teamwork occurs only by accident and
Ineffective care transitions Lack of specialist coordination Lost lab results Repeated studies
Let s think about the offensive unit Who would we have on the team? How would we know we are winning? Who plays at the different positions?
Defense Defensive Line: Poor Diet Lack of Exercise Smoking Using Alcohol or Drugs Linebackers: Accidents /Falls Crime / Violence Toxic exposure Defensive Ends and Safeties: Epidemics Natural Disasters War Health What side are patients on? Offense Offensive Line: Parents, Teachers Health Coaches Primary Care Quarterback: Person/Patient Running Backs: Epidemiologists Employers Public Health Workers Architects Receivers: Policy Makers City Planners Disaster planning
Implications for Training?
UNCLASSIFIED Desired End State Better Health Strengthen Our Integrated Learning Health System Focused on Readiness Deliver Evidence-Based, Patient- Centered Care Provide Healthcare Anywhere Support Healthy and Safe Environments Support TRICARE Reform Improve Resilience, Health and Human Performance Maximize the Health of Wounded, Ill, and Injured Support Healthy Behaviors Health Readiness Ready Medical Force & Medically Ready Force Enhance Culture of Safety 24 UNCLASSIFIED
For Official Use Only BETTER CARE 25-25 -
Creating Value in Healthcare Jessie s Story 18 yo college freshman with first episode rectal bleeding, anemia Diagnosis: Evaluated by PA at Bethesda, referred immediately for colonoscopy at Walter Reed. Dx: Possible Crohn s vs. Ulcerative Colitis Medications initiated No education provided --- Patient is terrified. Initiation of Care: Enrolled at NNMC but, since in college, you should change your enrollment site 20 phone calls by patient and patient s mother, unable to transfer enrollment site Patient s mother flies to Chicago to change enrollment and find PCM Initial visit with PCM to get GI referral PCM states - Why don t you just quit college, you need a GI guy Initial Specialty Visit Excellent but rushed; Treatment focused on medications and diet No educational provided 8-26
Creating Value in Healthcare Jessie s Story Hospitalization one - flu symptoms GI specialist defers to PCM; PCM not available; ER Visit Hospitalized for Crohn s Flare Hospitalization two bleeding, (Hct 28), abdominal pain for 3 days, PCM not available, ER visit - repeated all labs and two more CTs After 3 days, released to dorm, falling behind in school Hospitalization three abdominal pain, vomiting and HA, (PCM /GI not available) ER Visit Lumbar Puncture and Admitted after two days, HA worse, when I stand up but discharged anyway -- I lost the chance to take my finals Patient initiates talk with PCM about availability and self care, obtains e mail, direct phone number no more hospitalizations for 18 months. 8-27
Creating Value in Healthcare Jessie s Story July 2009 Happy Birthday You are no longer eligible for TRICARE and have been dropped from PRIME Several hours to reestablish PRIME but, needed new referral for gastroenterologist. Had to be there in person. Waited 2 hours in PCM office, seen for 3 minutes, to get referral, no exam. Referral lost by TRICARE or PCM? Pain returns, PCM not available, referral not done so could not see gastroenterologist. ER, Hospitalized, returned home but, no F/U, ER again one week later. 8-28
Cost of Care Actual Billed Charges Hospitalization 10/22-10/24 Med-Surg $1,109 Pharm $556 IV $11 Supplies $109 Lab $58 Lab/Immun $378 Lab/Hem $301 Lab/Micro $75 Lab/Uro $143 CT Scan Body $4,263 ER $1,668 Pulmonary Fxn $224 Drugs $360 Other Rx $1,249 Total $11,677 ER Visit 11/01 Med Sur $112 Lab/Chem $587 Lab/Hem $91 Lab/Bact $295 Lab/Uro $60 Ultrasound $893 ER $1,134 Pul Fxn $112 Drugs $305 Per Vasc $1,531 Other Rx $1,104 Total $6,224 8-29
Findings Our current incentive design hindered the care experience and outcomes for Jessie. TRICARE (private sector care) did not work for Jessie. Support processes failed for Jessie. There were safety issues in the care of Jessie. Jessie did not have a good experience in primary care. No one was managing the pathway of care for Jessie. 8-30
UNCLASSIFIED Desired End State Better Care Strengthen Our Integrated Learning Health System Focused on Readiness Deliver Evidence-Based, Patient- Centered Care Provide Healthcare Anywhere Support Healthy and Safe Environments Support TRICARE Reform Enhance Culture of Safety Improve Healthcare Outcomes and Experience Maximize the Health of Wounded, Ill, and Injured Support Healthy Behaviors Improve Access and Other Care Support Processes 31 Health Readiness Ready Medical Force & Medically Ready Force UNCLASSIFIED
UNCLASSIFIED REDUCED RATE OF PER CAPITA COST GROWTH 32 UNCLASSIFIED
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PMPM Fiscal Quarter Year over Year Growth Trend 3.5% 2.8% 2.0% Note: MHS Target is based on the external benchmark of the Kaiser Family Foundation and the Health Research & Educational Trust annual Employer Health Benefits Survey Family Premium increase less 1% point per agreement with USD(P&R) and is based on YTD performance as opposed to quarterly as shown on graph. This metric/target is part of the Department's Annual Performance Plan (APP) and Annual Performance Report (APR). - 34 -
UNCLASSIFIED Desired End State Reduced Rate of Per Capita Cost Growth Improve Stewardship Health Readiness Strengthen Our Integrated Learning Health System Focused on Readiness Support Healthy Behaviors Deliver Evidence-Based, Patient- Centered Care Improve Access and Other Care Support Processes Support TRICARE Reform Ready Medical Force & Medically Ready Force Enhance Culture of Safety 35 UNCLASSIFIED
How will we Organize for Success? We will become an integrated learning health system! 36
UNCLASSIFIED Our Foundation: An Integrated Learning Health System Improve Reliability of Processes Align Incentives to Achieve Outcomes Health Readiness Strengthen Our Integrated Learning Health System Focused on Readiness Improve Information and Analytics Infrastructure Optimize Support Functions for Integrated System Enhance Strategic Partnerships Services and DHA Align Facilities, Personnel, and Capabilities to Optimize Readiness Services, Recruit, Train, Educate and Sustain the Total Force to Meet Future Challenges Align Resources Against Strategic Priorities and Ensure Fiscal Accountability Ready Medical Force & Medically Ready Force 38 UNCLASSIFIED
UNCLASSIFIED Operational Approach 41 Figure 6 from MHS HBD CONOPS UNCLASSIFIED