Session 10: Incorporating Improvement Into The Performance Plan

Session 10: Incorporating Improvement Into The Performance Plan Ms. Sherry Stone, MHA, CDFM Army, Office of the Surgeon General Program Analysis & Evaluation Directorate sherry.j.stone2.civ@mail.mil 14-1

Disclosure Presenter has no financial interest to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with the MedXellence Program. PESG, and MedXellence Staff, and accrediting organization do not support or endorse any product or service mentioned in this activity. PESG and MedXellence Program staff have no financial interest to disclose. 14-2

Objective 1. Provide an overview of the Performance Planning Process Why do we plan? Roles and Responsibilities Planning Guidance Performance Monitoring FY17 Business Performance Plans 2. FY18-22 Performance Planning FY18-22 Planning Timeline 14-3

Purpose The process of translating organizational strategy into action by forecasting beneficiary healthcare outcomes to include direct and purchased care in a standardized and transparent manner to maximize value and achieve quality clinical outcomes. 14-4

Why? The Government Performance and Results Act (GPRA) (P.L. 103-62) is a U.S. law enacted in 1993. It is one of a series of laws designed to improve government performance management. The GPRA requires agencies to engage in performance management tasks such as setting goals, measuring results, and reporting their progress. Agencies are required to develop five-year strategic plans that must contain a mission statement for the agency as well as long-term, results-oriented goals covering each of its major functions Agencies are required to prepare annual performance plans that establish the performance goals for the applicable fiscal year, a brief description of how these goals are to be met, and a description of how these performance goals can be verified Agencies must prepare annual performance reports that review the agency's success or failure in meeting its targeted performance goals 14-5

Sherry J Stone, DASG-DSC, 703-681-1868, sherry.j.stone2.civ@mail.mil Slide 6 MHS Governance Reform DoD Task Force on MHS Governance DEPSECDEF Planning Memo DHA Planning WG Report DEPSECDEF Nine Commandments Memo September 2011 March 2012 November 2012 March 2013 Recommended DHA model for MHS governance Directed planning for DHA implementation Provided DHA and Shared Services implementation plan for DEPSECDEF approval Directed implementation of Military Health System Governance Reform 14-6

Sherry J Stone, DASG-DSC, 703-681-1868, sherry.j.stone2.civ@mail.mil Slide 7 MHS Governance Reform March, 11 2013 DSD Memo Establish Governing Bodies Establish a Defense Health Agency Led by 3-Star Director Combat Support Agency Initial Operating Capability: 01 Oct 13 Full Operating Capability: 01 Oct 15 Establish Shared Services Transition JTF CAPMED to a Directorate within the DHA Identify Multi-Service Market Areas with enhanced authorities 5-year Performance Plans to improve healthcare and reduce cost ($1B) Eliminate dual-hatting in HA/TMA; clearer lines of policy and execution Disestablish TMA 14-7

Select SLIDE MASTER to Insert Briefing Title Here Military Health System SECRETARY OF DEFENSE Note: Gray boxes represent decision-making process Governance Navy Army AF CJCS USD(P&R) MHSER CNO CSA CSAF ASD(HA) SMMAC Navy SG BUMED Navy emsm Tidewater MTFs Army SG MEDCOM Army emsm Hawaii emsm Puget Sound MTFs Rotational Lead Army AF emsm Colorado Springs emsm San Antonio emsm Enhanced Multi-Service Market AF MAJCOMS MTFs Name/Office Symbol/(703) XXX-XXX (DSNXXX) / email address AF SG Healthcare Operations Chief Med Off - Public Health - Pharmacy - TRICARE Health Plan Joint Staff Surgeon Business Support - Facilities - Logistics - Budget Policy & Oversight Program Execution Combat Support Agency (CSA) SES DHA staff Research and Development - Medical Research & Development Defense Health Agency SES Health Information Technology - Health Information IT Dep Dir, SES Education and Training - Med Ed & Training Medical Deputies Advisory Group Walter Reed NMMC NCR Medical Directorate Ft Belvoir Com Hosp 14-8 emsm National Capital Region 11-Aug-16

MHS Governance Structure ASD(HA) Assistant Secretary of Defense for Health Affairs BUMED US Navy Bureau of Medicine and Surgery CJCS Chairman of the Joint Chiefs of Staff CMC Commandant of the Marine Corps CNO Chief of Naval Operations CSA Chief of Staff, Army CSAF Chief of Staff, Air Force DASD Deputy Assistant Secretary of Defense JSS Joint Staff Surgeon MAJCOM Major Command, Air Force MBOG - Medical Business Operations Group MDAG Medical Deputies Action Group MEDCOM United States Army Medical Command LEGEND C2 ABBREVIATIONS Coordination & Assistance MHS Military Health System MHSER Military Health System Executive Review MOG Medical Operations Group MPOG Manpower and Personnel Operations Group MTF Military Treatment Facility NCR National Capital Region PAC Policy Action Council PDASD Principal Deputy Assistant Secretary of Defense SG Surgeon General SMMAC Senior Military Medical Action Council USD(P&R) Under Secretary of Defense for Personnel and Readiness USUHS Uniformed Services University of the Health Sciences 14-9 Kaffi Williams, kaffi.r.williams.civ@mail.mil, 703-681-3710 UNCLASSIFIED//FOUO 9

MHS Governance Reform Enhanced Multi-Service Markets (emsms) Six emsms: Represent 35% of the Direct Care Costs ($2.5B/$8.1 B) emsms are projected to be major touch points for the recovering warrior community emsm are markets with: Treatment facilities from more than one Service Large eligible populations (greater than 65K) High patient workloads Enhanced Authorities allow the emsm Managers to: Implement a market approach to advance population health Execute a 5-year business performance plan to improve care Allocate market funding where the need is greatest Disseminate clinical and business best practices across facilities to improve effectiveness Components own the Markets ASD (HA) Senior Military Medical Action Council (SMMAC) HA/Service SGs MHSER * Rotate Service-lead every 2 years Medical Deputies Action Group (MDAG) DSGs/DHA Dep. Director emsm *San Antonio emsm Hawaii emsm Puget Sound emsm Tidewater emsm *Colorado Springs emsm NCR MTFs MTFs MTFs MTFs MTFs MTFs 14-10 Sherry J Stone, DASG-DSC, 703-681-1868, sherry.j.stone2.civ@mail.mil Unclassified

What we are facing National Defense Authorization Act 2016, Section 730. Report on Plans to Improve Experience with and Eliminate Performance Variability of Health Care Provided by the Department of Defense Align performance measures for health care provided in military medical treatment facilities with performance measures for health care provided through purchased care Improve performance in the provision of health care by eliminating performance variability.. To collect and analyze data with respect to health care provided in MTFs and through purchased care to improve the quality of such care, patient safety, and patient satisfaction. To develop a performance management system, including by adoption of common measures for access to care, quality of care, safety, and patient satisfaction, that holds medical leadership throughout the Department accountable for sustained improvement of performance. Assessment of whether the above plans will improve health outcomes, create consistent health value, ensure the receipt of quality health care through purchased care, and metrics that can be used to evaluate the performance of such plans 14-11

What we are facing Proposed National Defense Authorization Act 2017, Title VII, Health Care Provisions Requires DHA to become responsible for the management of MTFs throughout DoD while preserving the responsibilities of Commanders for ensuring readiness of members of armed forces. Establishing of MTFs to support medical readiness, an updated MHS Modernization Study report to Congress, and NLT 2 years provide an implementation plan to restructure/align MTFs IAW 1073d. Ensure urgent care is available through 11 pm at appropriate MTFs or TRICARE network providers. Expand access to primary care during the week and weekend beyond standard business hours of installations. Ensure MTFs implement and consistently practice the following requirements: first call resolution, standardized appointment scheduling, increased provider productivity, and managed appointment utilization through maximizing use of telehealth and secure messaging. 14-12

We say we are less efficient and more costly because of our readiness requirements. How much money do we spend on readiness? How do we know our uniformed staff are ready to perform the required missions in a deployed environment? Why can t we meet primary care access to care standards or the primary care needs of our beneficiaries? 14-13

25 Total Market Initiatives *(including MILPERS) Impact on Quadruple Aim Readiness Health Healthcare Cost 21 of 25 14 of 25 19 of 25 19 of 25 initiatives initiatives initiatives initiatives address address address address Financial Impact ($M) FY17 FY18 FY19 FY20 FY21 5-Yr Total Army Medicine Mission: Army Medicine provides sustained health services in support of the Total Force to enable readiness and conserve the fighting strength while caring for our Families, civilians and Soldiers for Life. Army Medicine Vision: Army Medicine is the Nation's premier expeditionary and globally integrated medical force ready to meet the ever-changing challenges of today and tomorrow. Financial (F): F1. Optimize Financial Resources Organizational Capacity (OC): OC1. Improve & Empower Highly Effective Work Teams OC2. Balance & Align MEDCOM in Support of the Army & Joint Force OC3. Improve Physical, Ethical & Cultural Environments OC4. Optimize Process Based Management in an Operating Company OC5. Enhance Communication, Knowledge Mgmt. & Decision Support Internal Process (IP): IP1. Optimize Soldier Protection in All Environments IP2. Improve Joint & Global Health Partnerships & Engagements IP3. Improve Operational Professional Readiness IP4. Leverage Health Information Technology (HIT) to Enhance Expeditionary Medicine IP5. Improve Integrated Disability Evaluation System Processing IP6. Improve Care, Quality & Safety in a High Reliability Organization IP7. Manage the Direct Care System IP8. Improve Primary & Specialty Care IP9. Improve Healthy Behaviors, Communities, & Environments IP10. Leverage Medical Research, Development & Logistics Management Financial Impact (Savings) ($M) Total MOD Study RVU FY15 FY17 FY18 FY19 FY20 FY21 5- Yr Target by Actual Change FY19 829K $110.5M $96.1 M $99.5 M $102.3M $104.2M $105.6M $21.7M Service Targeted Annual Enrollment (K) Total FY15 5-Yr Enrollment Change FY17 FY18 FY19 FY20 FY21 Target by FY19 1,039K 905K 905K 907K 908K 908K 3,074 Annual Recapture ($M) Mod Study Target Total Recapture FY17 FY18 FY19 FY20 FY21 (Cumulative) $274.6M $182 M $203 M $211 M $212 M $212 M $1,019.8 B **Excludes all pharmacy-related dollars, as pharmacy is not included in the Mod Study target Patient/Customer/Stakeholder (CS): A. Quality, Outcomes-Based Care for All We Serve B. Responsive Medical Capabilities C. Medical Readiness of the Total Army D. Healthy & Satisfied Families & Beneficiaries The Strategic Framework Strategy: Objectives, Initiatives, Measures Capability Overview FY15 Population Direction, Resources emsm/mtf Business PerformancePlan FY17-21 Business Performance Plan Executive Summary # MTFs: 49 # ORs: Physical: 143 Staffed: 119 # Total Beds: Physical: 1,749 Staffed: 1,510 # Skill Type 1 & 2: 4871 Total DHP Direct Care Funding*: $5.3B MTF- MCSC- Eligible Enrolled Enrolled 1,696,650 838,022 92,296 Total 5-Yr Net Estimate $701 M Savings $169 M $189 M $201 M $205 M $207 M $971 M Costs $48 M $53 M $56 M $56 M $57 M $270 M Net $121 M $136 M $145 M $149 M $150 M $701 M 11 May 2016 Current Conditions Means UNCLASSIFIED Lines of Effort Campaign Objectives Readiness And Health (Decisive Operation) Healthcare Delivery (Shaping Operation) Force Development (Shaping Operation) Take Care of Ourselves, our Soldiers for Life, DA Civilians, & Families (Sustaining Operation) Total 5-Yr Productivity Change (Work RVU) Skill Type 1 Military FY15 RVUs: 3.0M 5 YR RVU Change: 656K 271,859 Total 5-Yr Prime Enrollment Change FY15 Enrollment: 902K FY21 Enrollment: 908K 5 YR Change: 3K Total 5-Yr Recapture Projected: $1.02 B** 5 1 6 7 8 9 4 F1 OC 2 10 1-5 3 Ways pwc 4 5 6 7 8 9 End State: Army Medicine of 2025 and beyond, as an integrated system for health, is the Nation's first choice for prompt and sustained expeditionary health services. HQs Oversight Assess Performance Market Execution Enrollment Access Network Leakage Patient Safety Satisfaction Efficiency Data Quality. Productivity Sherry Stone, OTSG PA&E (703)681-1868 sherry.j.stone2.civ@mail.mil A B C D D Ends Internal Feedback Deployment Medicine and Casualty Care Readiness and Health of the Force Ready and Deployable Force Health of Families and Retirees Performance Monitoring t Level Potential Risks Electronic Health Record ICD-10 implementation Federal Health care Changes Force Restructure Accountability MHS Dashboard PERFORMANCE MEASURE Individual Medical Readiness (IMR) Risk Adjusted Mortality Inpatient - Recommend Hospital Outpatient - Overall Satisfaction with Care Diabetes Care Index HEDIS A1c Screening HEDIS A1c <8 - Good Control MHS Acute Conditions Composite HEDIS Use of Imaging Studies for Low Back Pain HEDIS Appropriate Testing for Children with Ph iti HEDIS Appropriate Treatment for Children with URI Cancer Screening Index HEDIS Breast Cancer Screening HEDIS Cervical Cancer Screening HEDIS Colorectal Cancer Screening HEDIS Follow Up after 30 Days of Hospitalization for Mental Illness HEDIS All Cause Readmissions ORYX Index CAC 3 HMPC Document Given to Patient/Caregiver HBIPS 6a Post Discharge Continuing Care Plan Created HBIPS 7a Overall Post Discharge Rate Continuing Care Plan Transmitted to Next Level of Care Provider Upon Venous Thromboembolism Discharge Instructions PQI Index PQI 01 Diabetes Short Term Complications PQI 02 Perforated Appendix PQI 03 Diabetes Long Term Complications PQI 05 COPD or Asthma in Older Adults PQI 07 Hypertension PQI 08 Congestive Heart Failure PQI 10 Dehydration PQI 11 Bacterial Pneumonia PQI 12 Urinary Infections PQI 13 Angina without Procedure PQI 14 Uncontrolled Diabetes PQI 15 Adult Asthma PQI 16 Lower Extremity AMP Among Patients with PCM Continuity Primary Care Leakage Days to Third Next Available Acute Appointment Days to Third Next Available Future Appointment Percent of Direct Care Enrollees in Secure Messaging Outpatient - Satisfaction with Care AIR MHS ARMY DHA-NCR NAVY TRO FORCE 89.34 % 85.14 % 89.30 % 0.65 0.81 0.70 0.79 1.08 77.1% 79.48 % 71.48 % 83.57 % 73.45 % 94.0% 96.27 % 92.48 % 93.68 % 94.73 % 55.00% 80.00 % 66.00 % 77.00 % 81.00 % 20.00 % 84.60% 90.80 % 89.78 % 91.25 % 91.98 % 75.86 % 67.07% 69.17 % 65.06 % 66.90 % 67.07 % 49.33% 58.67 % 38.00 % 59.33 % 72.67 % 34.00 % 75.02% 78.11 % 70.44 % 76.84 % 79.94 % 73.32 % 73.98% 76.81 % 72.09 % 75.95 % 80.01 % 71.95 % 91.24% 93.80 % 91.49 % 95.11 % 95.41 % 85.09 % 72.00 % 72.00 % 87.33 % 75.33 % 86.67 % 33.33 % 71.78% 73.36 % 78.07 % 80.11 % 78.80 % 65.72 % 75.04% 77.53 % 79.97 % 78.97 % 80.39 % 65.66 % 70.96% 74.12 % 77.59 % 66.40 % 74.59 % 65.64 % 81.00% 81.72 % 88.04 % 85.75 % 86.67 % 63.85 % 1.29 1.30 1.25 1.71 1.21 50.00% 70.00 % 45.00 % 60.00 % 50.00 % 75.00% 50.00 % 57.14 % 40.00 % 68.18 % 92.35% 100.00 % 91.07 % 90.38 % 97.37 % 63.70% 98.15 % 59.34 % 88.46 % 89.47 % 87.50% 85.71 % 72.73 % 100.00 % 41.67 % 94.23% 94.23 % 92.31 % 86.54 % 94.23 % 2.25 2.18 2.59 2.61 1.78 22.04 27.02 20.37 25.16 18.78 2.68 2.46 3.08 1.75 2.72 2.14 2.59 2.25 2.05 1.57 4.02 3.32 4.58 4.06 4.03 14.24 11.94 15.73 9.58 16.59 8.51 8.10 9.91 5.37 7.50 14.31 14.45 16.02 12.39 11.60 13.43 11.55 15.65 16.20 11.24 2.25 1.57 2.87 2.64 2.06 0.44 0.43 0.37 0.87 0.44 0.89 0.64 1.14 0.44 0.84 0.29 0.22 0.41 0.00 0.27 59.51% 57.37 % 60.12 % 54.00 % 62.25 % 25.10% 27.70 % 23.00 % 26.10 % 25.40 % 1.26 1.68 1.25 0.93 0.61 6.36 6.70 6.10 9.37 5.47 41.25% 43.75 % 34.05 % 47.00 % 48.63 % 85.4% 96.27 % 92.48 % 93.68 % 94.73 % Army MTF Budget 14-14

Performance Planning Roles and Responsibilities Health Affairs (HA)/Defense Health Agency Operating Group (DHA OG) Establish enterprise-level performance targets Provide annual Performance Planning guidance and communication of the MHS Strategy to the Services Update, develop and monitor all enterprise level performance measures Provide Services with monthly MTF level performance reports Support knowledge management and best practice transfer through various training venues Service Headquarters/eMSM Market Managers Communicate the guidance and the strategy to their local MTFs Review and approve MTF level performance targets and plans Review and aggregate MTF performance projects to determine Service performance Submit approved performance plans to HA /DHA Communicate identified best practices to HA/DHA Distribute HA/DHA OG performance measure reports to MTFs MTFs Complete performance plans and submit them to Service HQs/ emsm Market office. Establish action plans to achieve applicable performance measures Provide an explanation of how you plan to coordinate beneficiary care 14-15

MHS Performance Planning Guidance Enroll to Capacity as defined by MHS and Service standards; Increase operating room utilization, Ambulatory Procedures, and Surgical Relative Weighted Products (RWPs) through complex cases performed by military providers with a corresponding decrease in purchased care surgical procedures and RWPs while supporting readiness; Increase utilization of staffed inpatient capacity through capture of more complex specialty care, thereby supporting readiness while decreasing purchased inpatient care; Reduce overall Market pharmacy expenditures (retail) Decrease Market primary care and non-emergent Emergency Room and Urgent Care Center (direct and purchased care) costs; Reduce the Per Member Per Month (PMPM) average for each emsm. Improve effectiveness of disease management, particularly for diabetes, cardiovascular disease, and behavioral health; Provide special attention to high utilizers through medical management in order to reduce demand while improving their health; Demonstrate reductions in unhealthy behaviors in our enrolled population, resulting in a healthier population; Foster an environment of Health through the Patient Centered Medical Home to enhance communication, learning and Patient-Provider engagement resulting in an overall increase in inpatient and outpatient satisfaction. 14-16

14-17 CORE COMPETENCY If we do not get this right we won t get this right 14-17

MHS Modernization Study This Study was directed by the Deputy Secretary of Defense to: Develop a modernization strategy for the [MHS] that leverages the most promising commercial and military healthcare clinical and business tools, organizational models, and processes, and...focus on improving the efficiency and effectiveness of the MHS. The initial approach of the Study was to identify the fewest number of MTFs needed to support military mission and a ready medical force. 14-18

Study Approach 1. Established Markets Based on catchment/prism areas and historical use patterns 2. Measured and modeled population demand based on cohorts 14 Cohorts based on Beneficiary Category, gender, etc Combination of historical and national average utilization rates used 3. Set goals for market share percentage based on peer performance Modeled markets closing gap between their performance vs their highest performing peer Market-gap floors of 30% for Prime, 15% for Standard and 7.5% for TFL 4. Distributed Physicians into markets to meet market share goals Set 40% of the MGMA Median Provider Productivity Floors as a proxy for currency Modeled Authorizations for Operational/Deployable Specialties 14-19

Outcome (Modernization- Recapture Targets) 14-20 14-20

Productivity Target Setting Skill Type 1 Providers Modernization Study Based on MGMA Standards Sample MHS Average in FY12, and projected FY17 Average (work RVUs) MGMA % of MGMA Median Provider Specialty Current Provider Level Future Provider Level % Increase Median Current Modeled 260102 ALLERGY/IMMUNOLOGY 1,462 1,965 34% 4,277 34.2% 45.9% 260103 EMERGENCY MEDICINE 2,568 2,920 14% 6,266 41.0% 46.6% 260107 DERMATOLOGY 2,331 3,237 39% 7,840 29.7% 41.3% 260113 NEUROLOGY 2,090 2,197 5% 4,862 43.0% 45.2% 260115 OBSTETRICS/GYNECOLOGY 3,150 3,289 4% 6,714 46.9% 49.0% 260117 OPHTHALMOLOGY 3,936 4,154 6% 8,573 45.9% 48.5% 260119 OTORHINOLARYNGOLOGY 2,889 3,125 8% 7,118 40.6% 43.9% 260124 COLON AND RECTAL SURGERY 1,808 3,222 78% 8,056 22.4% 40.0% 260125 PSYCHIATRY 1,279 1,569 23% 3,539 36.1% 44.3% 260130 GENERAL SURGERY 2,101 2,761 31% 6,812 30.8% 40.5% 260131 NEUROLOGICAL SURGERY 2,257 3,894 73% 9,548 23.6% 40.8% 260132 ORTHOPEDIC SURGERY 2,783 3,231 16% 7,981 34.9% 40.5% 260133 PLASTIC SURGERY 2,020 2,897 43% 6,410 31.5% 45.2% 260134 CARDIAC/THORACIC SURGERY 2,529 3,688 46% 9,167 27.6% 40.2% 260136 UROLOGY 2,796 3,178 14% 7,533 37.1% 42.2% 260138 PERIPHERAL VASCULAR SURGERY 1,928 3,522 83% 8,805 21.9% 40.0% 260140 PULMONARY DISEASE 1,632 2,654 63% 6,625 24.6% 40.1% 260141 GASTROENTEROLOGY 3,412 3,876 14% 8,492 40.2% 45.6% 260142 CARDIOLOGY 2,314 3,784 64% 9,406 24.6% 40.2% 260143 NEPHROLOGY 1,620 2,523 56% 6,168 26.3% 40.9% 260144 HEMATOLOGY AND ONCOLOGY 1,455 1,951 34% 4,726 30.8% 41.3% 260145 ENDOCRINOLOGY 1,588 1,998 26% 4,695 33.8% 42.6% 260146 RHEUMATOLOGY 1,160 2,005 73% 4,825 24.0% 41.5% 260147 CRITICAL CARE/TRAUMA, MEDICINE 1,617 1,664 3% 3,825 42.3% 43.5% 260804 OPTOMETRY 3,837 4,011 5% 8,573 44.8% 46.8% 14-21

Productivity Targets Skill Type II Provider productivity targets for Skill Type II Providers (Military and Civilian) Measure Description Target Derivation Measure assesses provider productivity growth as compared to productivity targets listed below If the market is below 40% of the MGMA median for military providers or 50% for civilian providers, the target should be to reach this level. If the market is already performing above this level, the market should aim to be at or above its current productivity Skill Type II Productivity Targets Direction Higher is Better Direction Higher is Better Market Military Target Civilian Target Market Military Target Civilian Target OB/GYN NURSE PRACTITIONER 2,430 2,890 PHYSICIAN ASSISTANT ER 2,506 2,639 CERTIFIED NURSE MIDWIFE 2,624 3,176 PHYSICIAN ASSISTANT GI 1,910 2,012 PSYCHIATRIC NURSE PRACTITIONER 1,079 1,652 PHYSICIAN ASSISTANT NEURO 2,652 2,784 CLINICAL PSYCHOLOGIST 1,150 1,496 PHYSICIAN ASSISTANT DERM 3,155 3,324 SOCIAL WORKER (PROVIDING THERAPY) 978 1,356 PHYSICIAN ASSISTANT ENT 2,574 2,712 AUDIOLOGIST 633 762 PHYSICIAN ASSISTANT UROLOGY 2,045 2,154 SPEECH THERAPIST N/A 1,156 PHYSICIAN ASSISTANT ORTHO 2,124 2,400 PODIATRIST 2,151 2,420 PHYSICIAN ASSISTANT CARDIO 1,081 1,339 CHIROPRACTOR N/A 3,811 PHYSICAL THERAPIST 2,079 2,190 OCCUPATIONAL THERAPIST 1,318 1,388 14-22

FY16 emsm Provider Productivity (Skill Type 1 Military - 40% of MGMA Median) AUG 2015 JUL 2016 Provider Production Report as of August 2016 14-23 14-23

MHS Performance Dashboard https://carepoint.health.mil/sites/mhsp4i/sitepages/home.aspx? HomePage=true The MHS Dashboard presents a core set of Military Health System Enterprise measures for monitoring and improving patient access, quality of care, and patient safety for the medical components of the Army, Navy, Air Force and DHA. This shared service dashboard is an ongoing collaboration driven by the 2014 Secretary of Defense MHS Review mandate to establish clear enterprise performance goals with a standardized measurement tool supporting continuous improvement The MDAG has approved the MHS Dashboard tool as the primary source of data for emsm performance metrics The updated MHS Dashboard was released in April 2016 Since the implementation emsm metrics are still a work in progress and updated as issues are identified 14-24

emsm Performance Review Measure Lower is Better As of Yellow Green Blue emsm Colorado Springs Hawaii National Capital Region Puget Sound San Antonio Tidewater Recommend Hospital Mar-16 72% 73% 75% 76.68% 75.48% 64.88% 85.11% 74.63% 85.24% 73.67% PCM Continuity Dec-16 55% 65% 75% 57.61% 56.28% 56.69% 54.87% 56.69% 59.55% 58.97% Primary Care Leakage Yes Sep-16 28.0% 24.0% 20.0% 25.5% 22.4% 20.6% 28.3% 22.2% 27.3% 27.4% Future Appts Yes Dec-16 8 7 2 6.77 8.21 9.23 8.21 9.59 7.32 5.01 24 Hour Appts Yes Dec-16 1.50 1 0.80 1.75 2.21 4.12 1.87 1.51 1.13 2.44 Secure Messaging Dec-16 37% 50% 75% 45.58% 44.58% 61.07% 52.08% 46.38% 55.35% 51.08% Messaging Utilization Dec-16 4% 5% 8% 5.10% 4.23% 4.55% 6.85% 6.26% 8.04% 5.41% Getting Care When Needed Sep-16 - - - 82.44% 80.21% 82.81% 83.31% 81.24% 87.59% 81.68% PMPM Yes Mar-16-3.20% 0% 4.34% 5.08% 4.85% 2.60% 5.82% 3.08% 3.93% Total Purchased Care Cost Yes Sep-16 - - - 5.7% $17.5 M $7.0 M $35.9 M $24.9 M $21.3 M $39.1 M Private Sector Care Cost Yes Mar-16 3.21% 3.20% 0% 0.33% -3.94% 7.64% 3.67% 3.55% 4.93% 13.72% Total Enrollment Dec-16-0.0% 5.0% -0.3% -0.7% -0.7% 0.1% 0.2% 0.5% -0.2% Pharmacy Percent Retail Yes Oct-16-30.0% 25.0% 26.1% 30.4% 16.0% 20.1% 17.9% 20.3% 23.7% Productivity Targets Jun-16 - - - 96% 91% 93% 92% 96% 93% 95% Source: MHS Dashboard (6 February 2017) Notes: PMPM, Private Sector Care Cost and Secure Messaging are calculated at the Parent DMIS level. Non-eMSM MTFs are included in the calculations. Recommend Hospital, PMPM and Private Sector Care Cost measures performance excluded due to data lag 14-25 25

Colorado Springs Measure Lower is Better As of Yellow Green Blue Colorado Springs Market Observations Recommend Hospital Mar-16 72% 73% 75% 75.48% PCM Continuity Dec-16 55% 65% 75% 56.28% Primary Care Leakage Yes Sep-16 28.0% 24.0% 20.0% 22.4% Future Appts Yes Dec-16 8 7 2 8.21 24 Hour Appts Yes Dec-16 1.50 1 0.80 2.21 Secure Messaging Dec-16 37% 50% 75% 44.58% Messaging Utilization Dec-16 4% 5% 8% 4.23% Getting Care When Needed Sep-16 - - - 80.21% PMPM Yes Mar-16-3.20% 0% 5.08% Total Purchased Care Cost Yes Sep-16 - - - $17.5M Private Sector Care Cost Yes Mar-16 3.21% 3.20% 0% -3.94% Total Enrollment Dec-16-0.0% 5.0% -0.7% Pharmacy Percent Retail Yes Oct-16-30.0% 25.0% 30.4% Productivity Targets Jun-16 - - - 91% POTENTIAL BEST PRACTICES (BLUE) Sharp decrease in number of low acuity ED visits MITIGATION STRATEGIES (RED) Standardizing Appointing processes across the Market to address primary care access Enrollment declines due to reduction in Active Duty footprint Retail Pharmacy Spend down from 38% to 30% Source: MHS Dashboard (6 February 2017) 14-26 26

Hawaii Measure Lower is Better As of Yellow Green Blue Hawaii Recommend Hospital Mar-16 72% 73% 75% 64.88% PCM Continuity Dec-16 55% 65% 75% 56.69% Primary Care Leakage Yes Sep-16 28.0% 24.0% 20.0% 20.6% Future Appts Yes Dec-16 8 7 2 9.23 24 Hour Appts Yes Dec-16 1.50 1 0.80 4.12 Secure Messaging Dec-16 37% 50% 75% 61.07% Messaging Utilization Dec-16 4% 5% 8% 4.55% Getting Care When Needed Sep-16 - - - 82.81% PMPM Yes Mar-16-3.20% 0% 4.85% Total Purchased Care Cost Yes Sep-16 - - - $7.0 M Private Sector Care Cost Yes Mar-16 3.21% 3.20% 0% 7.64% Total Enrollment Dec-16-0.0% 5.0% -0.7% Pharmacy Percent Retail Yes Oct-16-30.0% 25.0% 16.0% Productivity Targets Jun-16 - - - 93% Source: MHS Dashboard (6 February 2017) Market Observations POTENTIAL BEST PRACTICES Well-established Oahu Pharmacy & Therapeutics Committee Focuses on formulary conversions that are safe for patients and cost effective Uniformed formulary across all MTFs on Oahu $850K saved in FY2016 by converting telmisartan (Victoza) and liraglutide (Micardis) MITIGATION STRATEGIES Access to Care Future Appts and 24 Hour Appts DQ Issues created new MEPRS clinics beginning Sep 16 thru Dec 16 but appointments not available until Jan 17; overstates ATC Total Enrollment Reflects Army downsizing at Schofield with conversion of Stryker Brigade 98% Prime enrolled to MTF; Only 2% or <2K Prime enrolled to MCSC 14-27 27

National Capital Region (NCR) Measure Lower is Better As of Yellow Green Blue National Capital Region Market Observations Recommend Hospital Mar-16 72% 73% 75% 85.11% PCM Continuity Dec-16 55% 65% 75% 54.87% Primary Care Leakage Yes Sep-16 28.0% 24.0% 20.0% 28.3% Future Appts Yes Dec-16 8 7 2 8.21 24 Hour Appts Yes Dec-16 1.50 1 0.80 1.87 POTENTIAL BEST PRACTICES (BLUE) PHARMACY PERCENT RETAIL NCR has a robust, common formulary throughout the region Multiple locations well spread geographically Secure Messaging Dec-16 37% 50% 75% 52.08% Messaging Utilization Dec-16 4% 5% 8% 6.85% Getting Care When Needed Sep-16 - - - 83.31% PMPM Yes Mar-16-3.20% 0% 2.60% Total Purchased Care Cost Yes Sep-16 - - - $35.9 M Private Sector Care Cost Yes Mar-16 3.21% 3.20% 0% 3.67% Total Enrollment Dec-16-0.0% 5.0% 0.1% Pharmacy Percent Retail Yes Oct-16-30.0% 25.0% 20.1% Productivity Targets Jun-16 - - - 92% MITIGATION STRATEGIES (RED) PRIMARY CARE ACCESS FBCH has developed a new centralized approach for scheduling which has resulted in much better 24 hour access evaluating for extension to other facilities Established a Primary Care Market Service Leader (NHC Quantico) for primary care management Focus has been on keeping care in the Direct Care System 71% of leaked primary care is acute (UCC or ER) in the network Source: MHS Dashboard (6 February 2017) 14-28 28

Puget Sound Measure Lower is Better As of Yellow Green Blue Puget Sound Recommend Hospital Mar-16 72% 73% 75% 74.63% PCM Continuity Dec-16 55% 65% 75% 56.69% Primary Care Leakage Yes Sep-16 28.0% 24.0% 20.0% 22.2% Future Appts Yes Dec-16 8 7 2 9.59 24 Hour Appts Yes Dec-16 1.50 1 0.80 1.51 Secure Messaging Dec-16 37% 50% 75% 46.38% Messaging Utilization Dec-16 4% 5% 8% 6.26% Market Observations POTENTIAL BEST PRACTICES (BLUE) % Retail Pharmacy Blue since DHA legislative changes for compound meds. HI emsm Pharmacy best practice shared with our Market for continued success Getting Care When Needed Sep-16 - - - 81.24% PMPM Yes Mar-16-3.20% 0% 5.82% Total Purchased Care Cost Yes Sep-16 - - - $24.9 M Private Sector Care Cost Yes Mar-16 3.21% 3.20% 0% 3.55% Total Enrollment Dec-16-0.0% 5.0% 0.2% Pharmacy Percent Retail Yes Oct-16-30.0% 25.0% 17.9% Productivity Targets Jun-16 - - - 96% MITIGATION STRATEGIES (RED) 3 rd Next Available Appointment in Primary Care Efforts underway at the MHS and Service level to address these areas Future average days <4 at NHB, NHOH & 62 nd Med, 11.5 at MAMC 24HR average days <.8 at NHB & NHOH, <2 at MAMC and 62 nd Med Source: MHS Dashboard (6 February 2017) 14-29 29

San Antonio Measure Lower is Better As of Yellow Green Blue San Antonio Recommend Hospital Mar-16 72% 73% 75% 85.24% PCM Continuity Dec-16 55% 65% 75% 59.55% Primary Care Leakage Yes Sep-16 28.0% 24.0% 20.0% 27.3% Future Appts Yes Dec-16 8 7 2 7.32 24 Hour Appts Yes Dec-16 1.50 1 0.80 1.13 Secure Messaging Dec-16 37% 50% 75% 55.35% Messaging Utilization Dec-16 4% 5% 8% 8.04% Getting Care When Needed Sep-16 - - - 87.59% PMPM Yes Mar-16-3.20% 0% 3.08% Total Purchased Care Cost Yes Sep-16 - - - $21.3 M Private Sector Care Cost Yes Mar-16 3.21% 3.20% 0% 4.93% Total Enrollment Dec-16-0.0% 5.0% 0.5% Pharmacy Percent Retail Yes Oct-16-30.0% 25.0% 20.3% Market Observations POTENTIAL BEST PRACTICES (BLUE) Secure Messaging Utilization Emphasis & reinforcement through processes/battle rhythm Pharmacy Percent Retail Distributed primary care clinics with extended hours for patient convenience Reduction of Recapturable Purchased Care Inpatient: reduced by $8.5M compared with FY12 baseline Outpatient: reduced by $12M compared with FY12 baseline MITIGATION STRATEGIES (RED) Productivity Targets Jun-16 - - - 93% Source: MHS Dashboard (6 February 2017) 14-30 30

Tidewater Measure Lower is Better As of Yellow Green Blue Tidewater Recommend Hospital Mar-16 72% 73% 75% 73.67% PCM Continuity Dec-16 55% 65% 75% 58.97% Primary Care Leakage Yes Sep-16 28.0% 24.0% 20.0% 27.4% Future Appts Yes Dec-16 8 7 2 5.01 24 Hour Appts Yes Dec-16 1.50 1 0.80 2.44 Secure Messaging Dec-16 37% 50% 75% 51.08% Market Observations POTENTIAL BEST PRACTICES (BLUE) PHARMACY PERCENT RETAIL Beneficial Impact of the implementation of the Enhanced Mail/MTF Pharmacy Initiative Messaging Utilization Dec-16 4% 5% 8% 5.41% Getting Care When Needed Sep-16 - - - 81.68% PMPM Yes Mar-16-3.20% 0% 3.93% Total Purchased Care Cost Yes Sep-16 - - - $39.1 M Private Sector Care Cost Yes Mar-16 3.21% 3.20% 0% 13.72% Total Enrollment Dec-16-0.0% 5.0% -0.2% Pharmacy Percent Retail Yes Oct-16-30.0% 25.0% 23.7% Productivity Targets Jun-16 - - - 95% MITIGATION STRATEGIES (RED) 3 rd Available 24 Hour Appointment Currently, 1.62 for 24-Hour Appointments. 7 enrollment sites are Blue, 5 Green, 1 Amber, and 3 Red. USAF Hospital Langley is an outlier (currently at 3.62). However, trending downward over time (55%). Fluctuations in primary care managers has resulted in currently being over enrolled. Implemented new clinic templates (1 Feb 17) Source: MHS Dashboard (6 February 2017) 14-31 31

Impact of FY17-21 Business Plans Successes Services/DHA able to adjudicate/fund emsm Market Initiatives, POM Issues 5-year investment of $263M for 25 market initiatives projected to save $976M in PSC spending Productivity projected to exceed 5-Year target at 4 of 6 emsms Market initiatives will continue movement of workforce/workload between MTFs to match healthcare capacity to demand PSC recapture projected to exceed Mod Study target at 4 of 6 emsms Continue/expand multiple initiatives that have been effective in bring care back to MTFs: PCMH optimization, improve acute care access, centralized referral mgt, increase after hours/weekend care Challenges FY17 enrollment projected to be short of FY19 target at all 6 emsms Changes to force structure/adfms impacting emsms ability to reach enrollment targets 14-32

Business Performance Plan Executive Summary Capability Overview FY14 Population Initiative # MTFs: 3 MTFs and 12 Branch Clinics # ORs: Physical: 27 Staffed: 27 # Total Beds: Physical: 340 Staffed: 247 # Skill Type 1 & 2: 805 Total DHP Direct Care Funding*: $948.4M *(including MILPERS) Impact on Quadruple Aim Readiness Health Eligible MTF-Enrolled MCSC-Enrolled 408K 162K 53K Health Care Cost Net Cost Savings ($000) Implementation Costs ($000) Total Productivity Change Total Enrollment Change Total Recapture ($000) Total 5-Yr Net Estimated Savings $63.3M Financial Impact (Savings) ($M) FY15 FY16 FY17 FY18 FY19 5-Yr Total Savings 4.9 8.6 15.9 18.6 18.6 66.7 Costs 0.2 0.3 1.0M 1.0 1.0 3.4 Net 4.7 8.3 14.9 17.6 17.7 63.3 Productivity Target Total 5-Yr Productivity Change 107K Targeted Annual Productivity (work RVUs) (M) FY15 FY16 FY17 FY18 FY19 Total 5-Yr Change Initiative 1 Inpt Initiative 2 PC Initiative 3 Spec X X X $23.7M $0.4M 3.6K Admits X X X X $17.2M $3.0M 228K RVUs X X X X $22.3M N/A 85K RVUs N/A $24.1M 40.8K $20.3M N/A $22.3M 82.9K 2.59M 2.63M 2.66M 2.70M 2.70M 107K Enrollment Target Total 5-Yr Enrollment Change 41K Targeted Annual Enrollment (K) FY15 FY16 FY17 FY18 FY19 Total 5-Yr Change 200K 159K 172K 200K 200K 200K 41K Initiative 4 OR X X X * * N/A N/A * TOTAL: $63.3M $3.4M 3.6K/ 313K - Inpatient and Specialty recapture initiatives incorporate Surgical Services related savings. - Cumulative Total 5 Year Productivity change is 313K from baseline FY13. - Targeted Annual Enrollment increase for FY 15 is projected at 7K. 40.8K $66.7M Mod Study Target Recapture Total 5-Yr Recapture $66.7M Annual Recapture ($M) FY15 FY16 FY17 FY18 FY19 Total 14-33 71.6 4.9 8.6 15.9 18.6 18.6 66.7 14-33

FY17-21 Business Performance Plan Impact on Savings and emsm Core Measures Initiative Initiative 1 Extended Hours Primary Care Clinic Initiative 2 Surgical Services Optimization Initiative 3 Market Service Optimization Initiative 4 Purchased Care Recapture ER/UC to EACH Initiative 5 Pain Management for Low Back Pain TOTAL SAVINGS Savings FY15 Planned FY16 Planned FY17-21 Financial Impact (Savings)($) FY17 FY18 FY19 FY20 FY21 Total 1.2M 1.2M 1.2M 1.2M 1.2M 6.0M Costs NEW 1.0M 1.0M 1.0M 1.0M 1.0M 5.0M Net 0.2M 0.2M 0.2M 0.2M 0.2M 1.0M Savings 0.7M 1.0M 1.0M 1.0M 1.0M 4.7M Costs NEW 0.1M 0.1M 0.1M 0.1M 0.1M 0.5M Net 0.6M 0.9M 0.9M 0.9M 0.9M 4.2M Savings 1.0M 1.0M 3.9M 3.9M 3.9M 3.9M 3.9M 19.5M Costs 0.1M 0.1M 1.2M 1.2M 1.2M 1.2M 1.2M 6.0M Net 0.9M 0.9M 2.7M 2.7M 2.7M 2.7M 2.7M 13.5M Savings 5.0M 5.0M 1.8M 1.8M 1.8M 1.8M 1.8M 9.0M Costs 1.1M 1.1M 0.3M 0.3M 0.3M 0.3M 0.3M 1.5M Net 3.9M 3.9M 1.5M 1.5M 1.5M 1.5M 1.5M 7.5M Savings 5.3M 5.3M 1.3M 1.3M 1.3M 1.3M 1.3M 6.5M Costs 1.6M 1.6M 0.8M 0.8M 0.8M 0.8M 0.8M 4.0M Net 3.7M 3.7M 0.5M 0.5M 0.5M 0.5M 0.5M 2.5M Savings 11.3M 11.3M 8.9M 9.2M 9.2M 9.2M 9.2M 45.7M Costs 2.8M 2.8M 3.4M 3.4M 3.4M 3.4M 3.4M 17.0M Net 8.5M 8.5M 5.5M 5.8M 5.8M 5.8M 5.8M 28.7M 1. Total Purchased Care 2. Private Sector Care Cost per Prime Enrollee 3. Operating Room Utilization 4. Prime Enrollment 5. PCM Empanelment Targets 6. Non-prime Enrollee Primary Care Workload 7. Overall Satisfaction with Healthcare Inpatient emsm Core Measures Core Measures Impacted 1,2,9,10,12,13 1,2,3,9,11,13 1,2,9,10,11,12,13 1,2,3,9,10,11,12,13 1,2,9,10,12 8. Overall Satisfaction with Healthcare Outpatient 9. Per Member Per Month (PMPM) 10. Percent Retail Pharmacy Spend 11. Productivity Targets (military and civilian skill types 1 & 2) 12. Primary Care Leakage 13. Recapture 14-34

Market Successes (NCRs) Embedded Physical Therapy Cost Per Member Per Month (PMPM) FBCH / MGMC OB Care $2.5 M $2.0 M $1.5 M $1.0 M $0.5 M $0.0 M Average quarterly PSC$ down $662K FY14 to FY16 and down an additional $260K FY15 to FY16 2014 2014 2014 2014 2015 2015 2015 2015 2016 2016 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 LOWER IS BETTER Growth Rate from FY13-FY16 20.0% 15.0% 10.0% 5.0% 0.0% -5.0% -10.0% CO Springs Tidewater Puget Sound San Antonio NCR Hawaii $700K $600K $500K $400K $300K $200K $100K $0K Eliminated $2M PSC ERSA 2014 2014 2014 2014 2015 2015 2015 2015 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 500 450 400 350 300 250 200 150 100 50 0 NCR MD Supporting Market Needs with 11 new PT Providers Physical Therapy accepts 95% of all referrals -15.0% $200 $250 $300 $350 $400 $450 $500 $550 $600 $650 PMPM Southern Maryland Costs Southern Maryland Admissions Live Births at FBCH 14-35

Market Successes PSMHS Transfer Center $$ by Facility NHB: $1,855,434 (43.2%) Harrison: $ 370,845 (8.6%) ST Peter: $ 309,253 (7.2%) ST Joseph: $ 181,356 (4.2% All others: $1,577,276 (36.7%) Source: MAMC Transfer Data, 3 OCT 2016 Dave Moeller, PSMHS, david.e.moeller.civ@mail.mil 14-36

FY18 Performance Planning: Update FY17 Initiatives with focus on Access & Medical Readiness 14-37 Milestone: 1) emsm Strategic Summit: TBD 2) Publish Guidance: 31 Oct 16 3) Services Review Plan: 2 Feb 27 Feb 17 4) Final Plans Due MBOG: Late Mar 17 5) MDAG Reviews Plan: Early Apr 17 6) SMMAC Approval: Mid Apr 17 Late Mar 17 2 Feb 27 Feb 17 1 Oct 22 Dec 15 Early Apr 17 Early Apr 17 21 Sep 30 Nov 16 Conduct emsm Site Visits Joint Review of Market Plans Final Plans due to MBOG 31 Oct 16 Finalize emsm Performance Plan Guidance SMMAC Approval of Plans MDAG Reviews Plans Services review draft plans emsms Develop Plans 15 Aug 16 Produce Market Product Line Targets & Goals 15 July 16 Notify emsm / Services (Summit) August 16 Engage with emsm to Capture Lessons Learned Complete or suspense met Working Incomplete or suspense not met Decision Point 14-37

14-38 Our Purpose If we do not get this right, it does not matter what else we get right 14-38

Service POCs Name Organization MAJ Joy Spiller Ms. Penny Cheagle Ms. Sherry Stone Ms. Kaffi Williams AFMOA / SGHC AFMOA/ SGHC Army Army Mr. Justin Sweetman DHA Mr. Thomas Bickett Ms. Sherie Eva Kim Navy Navy 14-39