SAMHS emsm Update 1 Nov 2015 Damon G. Baine Colonel, USA, MS Chief Operating Officer, SAMHS emsm

SAMHS emsm Update 1 Nov 2015 Damon G. Baine Colonel, USA, MS Chief Operating Officer, SAMHS emsm

Agenda Review of emsm CONOPS and Governance SAMHS Update Business Plan SAMHS Performance Examples emsm Victories Common emsm Challenges Key emsm Executive Skills

MHS Governance Reform Journey Historical MHS Governance Studies DoD Task Force on MHS Governance DepSecDef Planning Memo DepSecDef Nine Commandments Memo 1949-2006 17 studies over 57 years 8 recs for unified service/unified joint command 6 recs for added central authority 3 recs keep separate Service lines September 2011 18th study over 62 years 7th rec added central authority DHA model for MHS governance March 2012 Directed I-Planning for MHS Governance Reform OASD(HA) DHA Shared Services JTF-CapMed transition emsms March 2013 Directed implementation of MHS Governance Reform OASD(HA) & TMA transition DHA (as CSA) Shared Services NCR Directorate emsms 3

Evolution to the SAMHS emsm Joint Military Medical Command MSMO BRAC Law SAMHS and SAMHS emsms 1987-1991 Execution challenges Many victories: Integrated GME programs through SAUSHEC STRAC 2004 Multi-Service Market Offices established Support new TRICARE Managed Care Support Contracts 2005-2007 Mandated several changes Relocated inpatient medical functions from WHMC to BAMC Transitioned WHMC to WHASC 2011-2013 2011: SAMHS established by MOA signed by Army and Air Force Chiefs of Staff 2013: DepSecDef memo established emsms empowered with new authorities 4

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What are Multi-Service Markets? Multi-Service Markets (MSMs) are geographic areas where at least two different Service MTFs have overlapping catchment areas as defined by TRICARE (30/60 minute drive time for primary/specialty care). There are 11 locations in the U.S. that 8 10 11 7 9 6 5 4 2 3 1 are Multi-Service Markets: 1. Tidewater, VA 2. National Capital Region 3. Charleston, SC 4. Bragg/Pope, NC 5. Mississippi Gulf Region, MS 6. San Antonio, TX 7. Colorado Springs, CO 8. Puget Sound, WA 9. Oahu, HI 10. Fairbanks, AK 11. Anchorage, AK There 4 overseas locations also deemed Multi-Service Markets: 1. Okinawa, Japan 2. Kaiserslautern, Germany 3. Osan Community, South Korea 4. Guam 6

Where are the enhanced Multi-Service 1. National Capital Region (Defense Health Agency) 2. Colorado Springs, Colorado (rotate Air Force/Army) Markets (emsms)? emsm Markets and Service/Department Leads 5 3. Tidewater, Virginia (Navy) 4. San Antonio, Texas (rotate Air Force/Army) 2 1 3 5. Puget Sound, Washington (Army) 6. Oahu, Hawaii (Army) 6 4 emsms provide over 40% of all MHS Healthcare Delivery 7

What is Enhanced? Single Market Manager Within each emsm, an appointed market manager has the authority to: Manage the allocation of the budget for the market Direct common clinical and business functions for the market Direct the movement of workload and workforce among the medical treatment facilities Develop, execute and monitor the business performance plan Single Market Plan Within each emsm, 5-year Business Performance Plans will be: Fully-integrated across the entire market and will replace current MTF based business plans Based on a 5-year planning cycle, as opposed to the current 3-year plan Aligned with budget execution process to ensure continuity No easy task to evolve legacy processes 8

emsm Concept of Operations MDAG MDAG provides authority to emsm office to investigate, analyze, and initiate changes across the market. emsm office sets Business Performance Plan objectives and submission--seeks out opportunities to improve all facets of healthcare delivery while reducing costs. emsm Office MTFs provide feedback to emsm office on what works and what does not collaborative approach is critical to success. emsm Partners (Services) Market components work with emsm office to assist in Business Performance Plan execution. Disconnects resolved locally or at MDAG. MTFs Relationships are still evolving 9

Reference emsm CONOPS 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 10

As developed and inferred from: Deputy Secretary of Defense Memorandum, Implementation of Military Health System Governance Reform, 11 Mar 13 Enhanced Multi-Service Market Concept of Operations, 11 Mar 14 Includes emsms +2 of Naval Medical Center San Diego and Womack Army Medical Center ASD(HA) OPCON TACON DepSecDef Memo MDAG OPCON TACON ADCON Services emsm CONOPS MOG/MBOG/ MPOG/SAG emsm CONOPS DHA NMC San Diego emsm LG Womack AMC DepSecDef Memo San Antonio Puget Sound NCR Dir Tidewater emsm MTFs Hawai i OPCON TACON Colorado Springs emsms

emsm Governance Structure SAMHS Maj Gen Iddins MM BG Holcomb Vice MM BAMC Commander COL Renz Board of Directors Senior Leader Council 59 th MDW Commander Maj Gen Iddins Chief Operating Officer COL Baine Sr Enlisted Liaison SGM Adams Clinical Operations Col Lloyd Business Operations LTC DeVries Other Army Clinics SAMMC DCCS Col Pendergrass Chief Nurse Executive Col Foulk emsm Analytics WHASC CD COL Ekstrand Other Air Force Clinics Allied Health COL Fryar emsm Business Planning

MTF Footprint 13

SAMHS Processes & Staffing Flowchart Products: MOU s Action Memos Decision Briefs BCA s If product approved by SAMHS Division Chief, AT briefs SLC If product approved by SLC presented at BOD Board of Directors (BOD) Senior Leaders Council (SLC) SAMHS COO Provides strategic guidance and decision-making for SLC Requests the creation of Action Teams (AT), authorizes & provides staff to serve on AT, & decides what items to go to the BOD for decision Assigns SAMHS Leadership with Task Business Operations Division Clinical Operations Division Assigns SAMHS Project Officer with Task lead to organize and direct AT AT briefs Task Results to SAMHS Div Chief SAMHS Project Officer SAMHS Project Officer SAMHS Project Officer SAMHS Project Officer Action Team Action Team Action Team Action Team Action Team Action Team Action Team Action Team SAMHS evolution from collaborative/committee structure to Joint, action oriented, Action Team (AT) structure 14

SAMHS Action Teams & Lines of Effort Matrix SAMHS Action Teams SAMHS Lines of Effort Transform Access Safety & Quality Patient Experience Enrollment Growth Behavioral Health Pharmacy PT Recapture Reporting Schedule Access to Care Behavioral Health Data Quality Orthopedic Recapture Patient Experience Primary Care Pharmacy Quality & Safety Strategic Communication & Marketing Surgical Communities of Interest: Clinical Support: LAB/RAD Medical Education & Training Research 15

The emsm Business Plan

For Official Use Only The emsm Performance Review Process MARKETS DHA ANALYTICS LEADERS 1. Develop & send Performance Plan & data to DHA Analytics Cell 2. Collect data, develop emsm Report Card 3. Analyze issues, develop actionable recommendations 4. Leaders review & take action on recommendations - 17 -

FY15-19 Business Performance Plan Executive Summary Capability Overview # ORs: Physical: 144 Staffed: 136 # Total Beds: Physical: 1,791 Staffed: 1,508 # Skill Type 1 & 2: 4831.39 Total DHP Direct Care Funding*: $5.8B *(including MILPERS) Productivity Target Total 5-Yr Productivity Change (Work) 1.17 M 271,859 Targeted Annual Productivity (work RVUs) (K) FY15 FY16 FY17 FY18 FY19 Total 5-Yr Change 829 9,075 9,699 10,073 10,227 10,244 1,172 FY14 Population Eligible MTF-Enrolled MCSC-Enrolled 1,724,135 877,455 150,396 Total 5-Yr Prime Enrollment Change 109 K* 28 Total Market Initiatives Impact on Quadruple Aim Readiness Health Healthcare Cost 22 of 28 initiatives address 14 of 28 initiatives address 25 of 28 initiatives address 25 of 28 initiatives address Enrollment Targeted Annual Enrollment (K) Total 5-Yr Target FY15 FY16 FY17 FY18 FY19 Change 1,039 943 993 1,038 1,050 1,052 109 *Calculated as projected market enrollment in FY19-projected enrollment in FY15. Enrollment numbers include Prime and Plus. Total 5-Yr Net Estimated Savings $1.02 B Financial Impact (Savings) ($M) FY15 FY16 FY17 FY18 FY19 5-Yr Total Savings 137.3 205.7 249.2 267.3 269.3 1,129.0 Costs 15.4 22.3 25.1 25.3 25.4 113.6 Net 121.9 183.3 224.0 241.9 243.8 1,015.3 Total 5-Yr Recapture $1.08B** Mod Study Annual Recapture ($M) Target Recapture FY15 FY16 FY17 FY18 FY19 Total ($) 961.2 130.2 197.1 239.2 257.0 259.1 1,082.7 **Excludes all pharmacy-related dollars, as pharmacy is not included in the Mod Study target 18

Capability Overview FY14 Population Initiative Readi-ness APPROVED SAMHS FY15-19 Business Performance Plan Executive Summary # MTFs: 10 # ORs: Physical: 33 Staffed:_32 # Total Beds: Physical: _425_ Staffed:_366 # Skill Type 1 & 2: _888.96_ Total DHP Direct Care Funding*: $1.6B *(including MILPERS) Eligible MTF-Enrolled MCSC-Enrolled 247,969 123,326 15,736 Impact on Quadruple Aim Health Healthcare Net Cost Savings ($000) Implementation Costs ($000) Total Productivity Change Total Enrollment Change Total Recaptur e ($000) Inpatient Transfer X X X $32.3M $13.8M 2,839 RWPS N/A $46.1M Behavioral Health Recapture Cost X X X X $14.6M $6.3M Orthopedics Recapture X X X $8.6M $3.7M 18,615 MH Bed Days 128,000 parvus 60,600 parvus Enrollment Growth X X X - *TBD - 6,334 - Productivity Enhancement Plan (Less BH, Ortho and Inpt) X X X X $117.7M $50.4M Production Plan RWPS, pa RVUS, APCS and MH Bed Days N/A N/A $20.9M $12.3M - $168.2M Pharmacy Recapture** X $121.5M $36.5M N/A N/A $173.6M AGGREGATE TOTAL: $294.7M $110.7M - 6,334 $421.1M TOTAL LESS PHARMACY: $173.2M $74.2M - 6,334 $247.6M - Decimal rounding results in numbers total discrepancies - Enrollment Change is difference between FY15 Target and FY19 Target; present day growth is 11,147 (PRIME) - Skill Type I & II is A & B MEPRS Only; - Pharmacy included in initiatives for tracking; 4% decrease year over year prescribed for FY14-FY18 BPP - Implementation cost is the DHA Prescribed 30% planning factor - ** Pharmacy Recapture not to be counted in totals as will be accounted for through Shared Service - SAMHS Assessment on recapture is ~$247.6M of the $272.3M Modernization Target and 271K work RVUS of the 343K Target. Mod Study Target Recapture ($) Total 5-Yr Net Estimated Savings $173.3M Financial Impact (Savings) ($M) FY15 FY16 FY17 FY18 FY19 5-Yr Total Savings $34.2M $51.5M $53.9M $53.9M $53.9M $247.6M Costs $10.3M $15.4M $16.1M $16.1M $16.1M $74.2M Net $23.9M $36.0M $37.7M $37.7M $37.7M $173.3M Productivity Target Enrollment Target Total 5-Yr Productivity Change (Work) 271,859 Targeted Annual Productivity (work RVUs) (M) FY15 FY16 FY17 FY18 FY19 Total 5-Yr Prime Enrollment Change 6,334 Targeted Annual Enrollment (K) FY15 FY16 FY17 FY18 FY19 Annual Recapture ($M) FY15 FY16 FY17 FY18 FY19 Total 5- Yr Change 138K 133K 138K 140K 140K 140K 6K Total 5-Yr Recapture $247.6M Total 5-Yr Change 343,614 2.34M 2.47M 2.61M 2.61M 2.61M 271,859 Total $272.3M $34.2M $51.5M $53.9M $53.9M $53.9M $247.6M

SAMHS emsm Performance Examples

BPP Core Measures Total Purchased Care Total Purchased Care ($M) ( Less Pharmacy ) Lower is Better (Rolling 12) M2 (TED, TED-NI) FY13 Q4 Baseline FY14 Apr FY15 Apr Trend $224M $218M $192M Private Sector Care Cost per Prime Enrollee Private Sector Care Cost Per Prime Enrollee Lower is Better PMPM Pivot for CMS (042115) FY13 Q3 Baseline FY14 Q2 FY15 Q2 Trend $86 $69 $63 Operating Room Utilization OR Performance (12 Month Average) * Data from Army MTF's and Ft. Belvoir SMS (3163509) (Rolling 12) Target FY13 Q3 Baseline FY14 Aug FY15 Aug Trend >80% 60.80% 68.30% 73.00% OR Case Load (12 Month Average) * Data from Army MTF's and Ft. Belvoir SMS (3163508) (Rolling 12) Target FY13 Q3 Baseline FY14 Aug FY15 Aug Trend >85 40.3 44.7 48.2 21

Prime Enrollment Prime Enrollment Higher is Better M2 (TRICARE Detail) Target FY13 Q3 Baseline FY14 Sep FY15 Sep Trend 133,763 119,958 124,968 126,858 Non-Prime Primary Care Workload BPP Core Measures continued Non Enrollee Primary Care Workload (FFS) (RVUs + APCs, Excludes Coast Guard & VA) Higher is Better (Rolling 12) Target IRIS Database Pull FY13 Q3 Baseline FY14 Aug FY15 Jul Trend 686,373 648,252 597,462 Overall Satisfaction w/ Healthcare Inpatient Overall Satisfaction - Inpatient (Recommend Hospital) Higher is Better TRISS Target FY13 Q3 Baseline FY15 Q1 FY15 Q2 Trend 71.00% 85% 83.30% 82.70% Overall Satisfaction - Inpatient (Rate Hospital) Higher is Better TRISS Target FY13 Q3 Baseline FY15 Q1 FY15 Q2 Trend 71.00% 81.00% 80.00% 78.80% 22

Per Member Per Month BPP Core Measures continued Per Member Per Month (Dollar Amount) Lower is Better PMPM Pivot for CMS (042115) FY13 Q3 Baseline FY14 Q2 FY15 Q2 Trend $419 $438 $464 Per Member Per Month Growth Rate (Percent Change Quarter Over Quarter) Lower is Better PMPM Pivot for CMS (042115) Target FY13 Q3 Baseline FY14 Q2 FY15 Q2 Trend <=2.0% 5.60% -1.10% 5.60% Target By FY18 Percent Retail Pharmacy Spend FY13 Q3 Baseline Percent Retail Pharmacy Spend Lower is Better (1 Month) M2 (PDTS) FY14 Apr FY15 Apr Trend 25% 31.10% 30.00% 52.20% Primary Care Leakage Primary Care Leakage Lower is Better PCM Leakage data_16feb2015 Target FY13 Q3 Baseline FY14 Feb FY15 Feb Trend <24% 26.10% 29.00% 30.00% 23

Productivity Targets (Mil/Civ Skill Type 1&2) Productivity Targets Skill Type 1 Military Higher is Better (Rolling 12) Provider Production Report 15.06 /15.03 14-Dec 15-Apr FY13 Q3 Target % of # Met % of # met Trend Baseline ExpectedWorkl ExpectedWorkl oad / Total oad / Total 100% 90.00% 76.80% 203/436 76.50% 187/385 BPP Core Measures continued Productivity Targets Skill Type 1 Civilian Higher is Better (Rolling 12) Provider Production Report 15.06 /15.03 14-Dec 15-Apr FY13 Q3 Target % of # Met % of # met Trend Baseline ExpectedWorkl ExpectedWorkl oad / Total oad / Total 100% 80.50% 51/92 82.30% 40/74 Productivity Targets Skill Type 2 Military Higher is Bette (Rolling 12) Provider Production Report 15.06 /15.03 14-Dec 15-Apr FY13 Q3 Target % of # Met % of # met Trend Baseline ExpectedWorkl ExpectedWorkl oad / Total oad / Total 100% 75.80% 65/138 72.70% 33/72 Productivity Targets Skill Type 2 Civilian Higher is Better (Rolling 12) Provider Production Report 15.06 /15.03 14-Dec 15-Apr FY13 Q3 Target % of # Met % of # met Trend Baseline ExpectedWorkl ExpectedWorkl oad / Total oad / Total 100% 87.10% 113/161 86.80% 112/167 24

SAMHS Right of First Refusal TRO-South

SAMHS Right of First Refusal TRO-South Top 10 SAMHS emsm- TOP 10 SPECIALTIES BASED ON NUMBER OF REFERRALS (italicized rows include ties) ROFRs % ROFRs ROFRs ROFRs % ROFRs TOP SPECIALTIES BASED ON Actively Actively Referred to Accepted by Accepted by NUMBER OF REFERRALS (italicized Rejected by MTF 1 MTF 2 Rejected by MTF rows include ties) MTF 3 MTF ROFRs Passively Rejected by MTF 4 Physical Therapy, general 229 47 21% 182 79% 0 Dermatology, general 144 97 67% 47 33% 0 Gynecology (Non-Maternity) 99 94 95% 5 5% 0 Ophthalmology, general 95 92 97% 3 3% 0 Ear Nose & Throat, general 88 87 99% 1 1% 0 Cardiology, general 83 81 98% 2 2% 0 Orthopedics, knee & shoulder 64 43 67% 21 33% 0 Urology, general 53 52 98% 1 2% 0 Neurosurgery, general 45 41 91% 4 9% 0 General Surgery 41 40 98% 1 2% 0 Monthly Total Apr 15 545 356 65% 189 35% 0 May 15 488 254 52% 234 48% 0 Jun 15 580 296 51% 284 49% 0 Quarterly Total 1613 906 56% 707 44% 0 'ROFR data extracted from Humana Military Report Gallery for Apr- Jun 2015 'This table shows the number of non-urgent referrals by specialty that were sent to the MTF for this quarter and how many referrals were accepted or rejected. 1ROFRs Referred- number of referrals that were sent to the MTF for acceptance 2ROFRs Accepted number of referrals the MTF accepted 3ROFRs Rejected- Number of referrals rejected by the MTF (including the passive denials- MTF takes no action within one business day) 4ROFRs Passively Rejected: number of referrals the MTF passively denied (MTF takes no action within one business day)

Specialty Analysis Example

Specialty Analysis Example Continued 28

Specialty Analysis Example Continued Work RVUs (Actual includes Primary and Additional Provider) 12,000 10,000 8,000 6,000 4,000 2,000 - Individual Provider Productivity Ophthalmology SEP14 to AUG14 KIM,YU HYON HAYES,BARTLETT H TOWNLEY,JAMES RICHARD III SUHR,ABRAHAM WONDUK WELCH,MARK SMITH,BENJAMIN HEBER CALDWELL,MATTHEW C RUBINATE,LAURA STEIGLEMAN,WALTER A GRANT,AARON DANIEL EVANGELISTA,CHARISMA BAUTISTA BRAMBLETT,GREGORY THOMAS GEDWIL VALENTIN,FRANK E SHEROL VEGDIE THOMAS,SCOTT A MAUFFRAY,RANDY O DRAYPAU CROSJN FRIEDMAN,MIRIAM SMITH,ROBERT E BASKIN,DARRELL E CHACKO,BENJAMIN KOHDAV JOHNSON,ANTHONY JAMES ANDERSON,DANIEL M HARRJN ROBERTS,SANFORD E BOWES,HARRISON NESBIT JR DAVIES,BRETT W APSEYD VUVIN PANDAY,VASUDHA ARUNA MITTELB CROLEY,JANIS K HAAARO LEUJESS THEJAR LAUCYN CALDCHRI Individual Provider Data by Name Actual Work RVU Target Annual work RVU Target: AD, CIV: 4,731 CON: 5,144 GRAKEN ROHLUI HERRMARC GROVES,LUCAS LEE RODRIGUEZ,CHRISTOPHER J MOSES,ARIAN A ROE,JOSHUA R ODEA,TAMANNA MADSEN,MICHAEL HOWARD LUTMER,SEAN MICHAEL BENNION,JOHN L MICHEL,RYAN JOSEPH POWELL,MARION R CROSKREY,JASON A GILLIS,JOHN F GALLAGHER,COLIN FRANCIS [-----------Residents-------------- 29

Specialty Analysis Example Continued Provider Information Productivity (M2) Distribution of Time (DMHRSi) Provider Name Prov Type Actual Work RVU Months (>10 RVU) Target MGMA (Annual FY16) Paid FTE Clinical Time GME Time Admin Time Other Available Non Available KIM,YU HYON Active Duty 10,114 12 4,731 4,731 HAYES,BARTLETT H Active Duty 7,219 12 4,731 4,731 TOWNLEY,JAMES RICHARD III Active Duty 6,820 12 4,731 4,731 SUHR,ABRAHAM WONDUK Active Duty 6,610 12 4,731 4,731 WELCH,MARK Active Duty 6,477 12 4,731 4,731 SMITH,BENJAMIN HEBER Active Duty 5,966 12 4,731 4,731 CALDWELL,MATTHEW C Active Duty 5,196 12 4,731 4,731 RUBINATE,LAURA Active Duty 5,107 12 4,731 4,731 STEIGLEMAN,WALTER A Active Duty 4,249 12 4,731 4,731 GRANT,AARON DANIEL Active Duty 3,960 12 4,731 4,731 EVANGELISTA,CHARISMA BAUTISTA Active Duty 3,764 10 3,943 4,731 BRAMBLETT,GREGORY THOMAS Active Duty 3,532 12 4,731 4,731 GEDWIL Civilian 3,519 12 4,731 4,731 VALENTIN,FRANK E Active Duty 3,477 12 4,731 4,731 SHEROL Contractor 3,106 12 5,144 5,144 Individual Providers by Name VEGDIE Contractor 3,043 12 5,144 5,144 THOMAS,SCOTT A Contractor 3,000 12 5,144 5,144 MAUFFRAY,RANDY O Active Duty 2,798 12 4,731 4,731 DRAYPAU Active Duty 2,511 9 3,548 4,731 CROSJN Active Duty 2,395 9 3,548 4,731 FRIEDMAN,MIRIAM Contractor 2,364 12 5,144 5,144 SMITH,ROBERT E Contractor 2,340 12 5,144 5,144 BASKIN,DARRELL E Active Duty 2,168 8 3,154 4,731 CHACKO,BENJAMIN Contractor 1,545 12 5,144 5,144 KOHDAV Contractor 1,429 12 5,144 5,144 JOHNSON,ANTHONY JAMES Active Duty 1,214 7 2,760 4,731 ANDERSON,DANIEL M Active Duty 1,010 7 2,760 4,731 HARRJN Active Duty 960 12 4,731 4,731 ROBERTS,SANFORD E Contractor 714 12 5,144 5,144 BOWES,HARRISON NESBIT JR Contractor 679 11 4,715 5,144 DAVIES,BRETT W Active Duty 608 3 1,183 4,731 APSEYD Contractor 594 12 5,144 5,144 VUVIN Active Duty 514 7 2,760 4,731 PANDAY,VASUDHA ARUNA Contractor 490 5 2,143 5,144 MITTELB Active Duty 361 6 2,366 4,731 CROLEY,JANIS K Contractor 333 12 5,144 5,144 HAAARO Active Duty 202 5 1,971 4,731 LEUJESS Active Duty 188 3 1,183 4,731 THEJAR Active Duty 14 1 394 4,731 30

SAMHS emsm Victories Single, Unified Business Plan Standardized 2 Appointment Types Family Medicine, Pediatrics, Internal Medicine Integrated Dermatology, Cytology Single Consult Review Roll-up dashboards Distributed Care Collaboration Wilford Hall Academy One Call Resolution Inpatient Integration Initiative

Common emsm Challenges Leadership: perspective, maturity, development Strategy: emsm Strategy vs Service priorities High Reliability Organization(s)? Integrated vs Federated vs other? The Service-led emsm? Performance: Performance Management System (synergistic) Data overload: MTFs, emsm, regional HQ, TRO, Services, DHA, etc. = Noisy Incentive Systems: IRIS, etc. 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 System Support to emsms Intermediate Headquarters processes

The Way Forward Single market strategy How to continue transformation to an HRO? Distribution of Assets Key Market Engagement Federal Health Care Consortium CEO Forum BoD/Administrative Coordination Meeting Synergy with MHS Review Leadership, Safety, Performance Management Quality, Access, Production, Containment/Recapture Refining our Integrative Governance Processes Single Department Chairs? Single Credentialing?

Executive Skills

Key Skills in an emsm Using Perspective: emsm-wide and/or MHS-wide Leading Transformation & Change Leadership Management Trusting and Relying on Partnership Cooperation/Collaboration vs Command/Control Leveraging novel workflows emsm workflow vs MTF workflow Formal vs Informal; minimizing beuracracy Find common ground Obvious consensus vs what is needed/what is right Communicating effectively Exhibiting patience, stamina, and tenacity

Key Takeaways The greatest transformation in MHS History A fully Integrated, High-Performing Health System Team While Cost is important focus on the patient and the care team is key Medically & Dentally Ready Force Ready Medical and Dental Force Quality, Clinical Outcomes and a System of Health Courage to Do the Right Thing Developing, shaping, and empowering strategically informed leaders is imperative to our success 36

Federal Healthcare Consortium