Capital Region Medical Directorate Market Journey...
Transcript of Capital Region Medical Directorate Market Journey...
“Medically Ready Force...Ready Medical Force”
National Capital Region Medical DirectorateEnhanced Multi‐ Service Market JourneyJohn D. O’Boyle, MD, CAPT, MC, USN
Chief Medical Officer NCR MD
March 2017
“Medically Ready Force...Ready Medical Force”
Disclosures
Presenter has no financial interest to disclose.
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“Medically Ready Force...Ready Medical Force”
MHS Governance Reform JourneyDoD Task Force on MHS Governance
September 2011 18th study over 62 years 7th rec “added central authority” DHA model for MHS governance Recommended anEnhanced MSM (eMSM)model providing budgetary and short‐term personnelmanagement authority forMSM
DepSecDefPlanning Memo
March 2012 Directed I‐Planning for MHS Governance Reform—OASD(HA)DHA Shared Services JTF‐CapMed transition eMSMs
DepSecDef“Nine Commandments”
Memo
March 2013 Directed implementation of MHS Governance Reform—OASD(HA) & TMA transitionDHA (as CSA) Shared ServicesNCR Directorate eMSMs
1949 ‐ 2006 17 studies over 57 years8 recs for unified service/unified joint command6 recs for added central authority3 recs “keep separate Service lines
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“Medically Ready Force...Ready Medical Force”
Where are the enhanced Multi‐Service Markets (eMSMs)?
eMSM Markets and Service/Department Leads
1. National Capital Region (Defense Health Agency)
2. Colorado Springs, Colorado (rotate Air Force/Army)
3. Tidewater, Virginia (Navy)
4. San Antonio, Texas (rotate Air Force/Army)
5. Puget Sound, Washington (Army)
6. Oahu, Hawaii (Army)
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2 1
3
4
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eMSMs provide over 40% of all MHS Healthcare Delivery
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“Medically Ready Force...Ready Medical Force”
2005
The Base Realignment and Closure Act (BRAC) of 2005 directed the closure of both National Naval Medical Center (NNMC) and Walter Reed Army Medical Center (WRAMC)
BASE REALIGNMENT AND CLOSURE
2013
A joint, integrated Combat Support Agency that enables the Army, Navy, and Air Force medical services to provide a medically ready force and ready medical force to Combatant Commands in both peacetime and wartime
DEFENSE HEALTH AGENCY (DHA) ESTABLISHED
2007
JTF CapMed was created in 2007 to guide the congressionally mandated consolidation of military medical facilities in the greater Washington D.C. area
JTF CAPMED ESTABLISHED
2011
Walter Reed National Military Medical Center, Bethesda opened on Sep. 15 and on Aug. 31, Fort Belvoir Community Hospital began serving patients with a patient transferred from DeWitt Army Community Hospital
WRNMMC AND FBCH OPEN
20162017
The NCR has 11 military medical treatment facilities with over 246,000 enrolled beneficiaries – focused on sustaining a ready medical force, delivering better care and an improved patient experience at a lower cost
NATIONAL CAPITAL REGION ADVANCES
Future
Title VII, Section 702 of the National DefenseAuthorization Actdirects reform of theadministration of theDefense Health Agency and military medical treatment facilities
NDAA 2017
OUR HISTORYNational Capital Region (NCR)
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“Medically Ready Force...Ready Medical Force”
eMSM CONOPS Functional Organizational Structure
Senior Market Manager
Director
Admin/ITSupport
Directorate ofClinical Operations
Appointing andReferral
Management
Direct CareOptimization/Capability
Population Health
Case & DiseaseManagement
Readiness
Health Education & Training Ancillary Services
Directorate ofMarket Analysis & Evaluation
MarketPerformancePlanning &Reporting
Data Analysis &Program Evaluation
Business ProcessReengineering
Directorate ofBusiness Operations
Manpower &Budget
Management
MCSC Operations/Recapture
Management
EmergencyResponse Planning
MOUs/MOAs/Contracting &Venture Capital
IM/IT Telehealth
FederalPartnerships/Community Relations
Market BusinessWorkloadReporting/Enrollment
Strategic Communications/
PatientSatisfaction
** Central CLRProcessing
** Central
Appointing** Expanded Functions
eMSM Functional Organizational Structure
Clinical Standardization
Quality Management
Risk Management
Patient Safety
Research
Logistics
Strategic Planning
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“Medically Ready Force...Ready Medical Force”
• Rader AHC• Kimbrough AHC• McNair AHC
• Bolling Clinic• Malcolm GrowMedical Clinic• Pentagon Flight Clinic
• NHC Annapolis• NHC Quantico• WNY Clinic
NCR eMSM
USD(P&R)ASD(HA)
CJCS
Defense Health Agency
WRNMMC FBCH JPC
NCR Medical Directorate
Tri‐Service Dental Clinic
Pentagon(DiLorenzo) Dumfries Fairfax
SEC Navy
CNO
Navy SG
BUMED
NME
MTFs
CSA
SEC Army
Army SG
MEDCOM
ARHC‐A
MTFs
CSAF
SEC Air Force
AF SG
MAJCOMS
MDW
MTFs
Secretary of Defense
Organizational Structure
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National Capital Region Academic Health and Readiness System
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“Medically Ready Force...Ready Medical Force”
Common eMSM Challenges
• Leadership: perspective, maturity, development• Strategy: eMSM Strategy vs Service priorities
– High Reliability Organization principles– The “Service‐led” eMSM
• Performance: Performance Management System– Data overload: MTFs, eMSM, regional HQ, TRO, Services, DHA, etc. = Noisy
• Drivers:– Enrollment….Access to Care…Productivity….Containment/Recapture– Patient Satisfaction– Collision of Compliance, Accreditation, and Governance
• Distribution of Assets:– Integrated manning documents– Movement of personnel, equipment, monies
• Governance Structures and Workflow:– Issue identification, Prioritization, and Decision Making
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DEFENSE HEALTH AGENCY STRATEGY MAP v2.2The Defense Health Agency (DHA) is a joint, integrated Combat Support Agency that enables the Army, Navy, and Air Force medical services to provide a
medically ready force and ready medical force to Combatant Commands in both peacetime and wartime.
Modernize TRICARE
(W11)
Strengthen Our Role as a Combat Support Agency
Strengthen Our Partnershipwith the Services
Optimize Defense Health Agency Operations
Conduct Health-Related Research (W5)
Support Integrated Training Requirements
(W3)
Deploy Solutions for 21st Century
Battlespace (W1)
Design and Prototype Health
Readiness Solutions (W4)
Respond to
Immediate Mission Needs (W2)
ENDS
WAY
SME
ANS
“I trust the DHA to deliver the support I need for mission
success.” (E2)
“DHA creates greater value through Operational
Excellence.” (E3)
Gather, Develop, and Prioritize Requirements in Support of DHA’s Current and Future Mission (W6)
Deliver and Sustain Electronic Health
Record (W8)
Optimize Existing ESAs (W12)
Improve System of DHA Accountability
(W9)
Support Service Needs for Data, Reporting, and
Analytics (W7)
READINESS
Optimize Critical Internal
Management Processes
(W18)
Implement DHA
Performance Management
System (W16)
Build Robust Improvement
Capability (W13)
Optimize Portfolio of DHA Initiatives (W14)
Strengthen Customer Focus (M1)
Shape Workforce for Success (M2)
Align Resources Against Strategic Priorities and
Ensure Fiscal Accountability (M3)
Advance a Culture of Continuous Learning
(M4)
Ready Medical Force Medically Ready Force
Operational MedicineCONOPS
Health Benefit DeliveryCONOPS
Joint Concept for Health Services
Improve Health
Outcomes and Exp.
in the NCR(W15)
“DHA supports Readiness solutions that meet joint
mission needs.” (E1)
1 March 2017
Leverage Strategic Partnerships (W10)
Maximize Value from
Suppliers and Partners (W17)
Improve Health Outcomes and Experiences in the NCR
W15
• Create an integrated learning health system across the market that brings services to the patient, not vice versa, and delivers highly reliable quality health outcomes
• Fully utilize capability and capacity in both primary and specialty care within the market
• Sustain and improve currency of the total Medical Force (including Uniformed Military, Civilians, and Contractors)
• Create a culture of proactive prevention to engage patients anywhere, anytime, and reduce the need for healthcare
• Continuously improve care processes to be responsive and respectful of our beneficiaries needs and choices
NCR Strategic Initiatives
High Reliability Culture of Quality
Seamless Patient & Team Experience
Optimizing a Fully Engaged Direct Care System
Academic Health & Readiness System
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OUR VISIONNational Capital Region (NCR)
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NATIONALCAPITALREGION
ACADEMIC HEALTH
& READINESSSYSTEM
The National Capital Region (NCR) Academic Health &
Readiness System (AHRS) is the preeminent integrated academic health system in America, connecting every federal hospital and clinic in our region to generate and
sustain a ready medical force
“Medically Ready Force...Ready Medical Force”
OUR PRIORITIESNational Capital Region (NCR)
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NATIONALCAPITALREGION
ACADEMIC HEALTH
& READINESSSYSTEM
Build and sustain a high reliability culture of qualitythat permeates throughout our organization and has the paramount goal of zero harm to patients and staff
Infuse input from our patients, caregivers, and staff into high velocity learning and rapid cycle innovation design methods in order to put the NCR AHS at the vanguard for improving caregiver wellbeing and experience, patient experience, quality and safety
Enhance the professional operational readiness of our personnel and teams through the active holistic management of both the direct and purchased care sectors of the TRICARE marketplace across the NCR
“Medically Ready Force...Ready Medical Force”
NATIONALCAPITALREGION
ACADEMIC HEALTH
& READINESSSYSTEM
The NCR AHRS is the healthcare system of choice for beneficiaries in the National Capital Region, and the employer of choice for our total workforce, active duty, civil service and contractors
The NCR AHRS leads the Military Health System in
delivering the quadruple aim – the best experience of care at the best value resulting in the best health and maximized readiness
OUR FUTURENational Capital Region (NCR)
“Medically Ready Force...Ready Medical Force”
NCR MD Critical Focus Areas
• Access to Care• Product Line Integrations and Optimization• Referral Management• Secure Messaging / Nurse Advice Line• Urgent and Emergency Care• Academic Health & Readiness System
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Data Source: TROSS (Question 32) as of 20 January 2016, TRISS (Question 21) as of 04 January 2016
Inpatient and Outpatient Satisfaction in the NCR remain higher than MHS averages and exceed Inpatient Targets
Patient Satisfaction
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Inpatient Satisfaction: How would you rate this hospital?
Outpatient Satisfaction with Care Received
92%
76%No data
reported for FY 2014 Q4
TROSS questionnairechanges implemented
“Medically Ready Force...Ready Medical Force”
MS-DRG RWP LEADERBOARDRANKED BY GROWTH FROM FY13 TO FY16
PROVIDER AGG tRVU LEADERBOARD RANKED BY GROWTH FROM FY13 TO FY16
Top 25 Growth Facilities – FY13‐16
PRODUCTIVITY GROWTH LEADERBOARDS
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Rank Parent Name GrowthGrowth
Rate1 FT BELVOIR COMMUNITY HOSP‐FBCH 526,630 25%2 WALTER REED NATL MIL MED CNTR 602,015 21%3 NH CAMP LEJEUNE 242,379 16%4 AF‐C‐59th MDW‐WHASC‐LACKLAND 232,822 14%5 AMC BAMC‐FSH 269,281 7%6 AHC MONCRIEF‐JACKSON 21,140 2%7 AF‐MC‐88th MED GRP‐WRIGHT‐PAT 19,182 2%8 ACH MARTIN‐BENNING 25,258 1%9 NH JACKSONVILLE (11,517) ‐1%10 ACH WINN‐STEWART (26,046) ‐2%11 AMC TRIPLER‐SHAFTER (71,155) ‐2%12 AMC MADIGAN‐LEWIS (116,669) ‐3%13 AMC WILLIAM BEAUMONT‐BLISS (76,093) ‐3%14 AMC WOMACK‐BRAGG (161,735) ‐6%15 NH CAMP PENDLETON (105,101) ‐6%16 AF‐MC‐60th MED GRP‐TRAVIS (61,509) ‐6%17 AMC DARNALL‐HOOD (183,630) ‐7%18 AF‐MC‐99th MED GRP‐NELLIS (73,760) ‐8%19 KIMBROUGH AMB CAR CEN‐MEADE (84,549) ‐8%20 ACH LEONARD WOOD (96,653) ‐8%21 NMC SAN DIEGO (371,661) ‐8%22 JAMES A LOVELL FHCC (94,760) ‐9%23 AHC REYNOLDS‐SILL (101,826) ‐9%24 ACH BLANCHFIELD‐CAMPBELL (181,347) ‐9%25 NMC PORTSMOUTH (458,508) ‐11%
Rank Parent Name GrowthGrowth
Rate1 NH GUANTANAMO BAY 30 35%2 ACH MARTIN‐BENNING 676 20%3 AF‐MC‐88th MED GRP‐WRIGHT‐PAT 813 19%4 ACH LEONARD WOOD 368 17%5 FT BELVOIR COMMUNITY HOSP‐FBCH 782 13%6 NH CAMP LEJEUNE 434 11%7 AF‐H‐31st MED GRP‐AVIANO 22 11%8 NH JACKSONVILLE 273 11%9 AMC WOMACK‐BRAGG 801 10%10 NH CAMP PENDLETON 286 9%11 NH NAPLES 17 8%12 ACH KELLER‐WEST POINT 57 7%13 AMC BAMC‐FSH 1,853 6%14 NH SIGONELLA 8 6%15 AMC MADIGAN‐LEWIS 824 6%16 NH OKINAWA 84 4%17 ACH EVANS‐CARSON 154 4%18 NMC SAN DIEGO 622 3%19 AF‐H‐96th MED GRP‐EGLIN 71 2%20 NH GUAM‐AGANA 25 2%21 WALTER REED NATL MIL MED CNTR 164 1%22 ACH BLANCHFIELD‐CAMPBELL (11) 0%23 AMC WILLIAM BEAUMONT‐BLISS (52) ‐1%24 AMC DARNALL‐HOOD (122) ‐2%25 ACH IRWIN‐RILEY (51) ‐3%
“Medically Ready Force...Ready Medical Force”
NATIONAL CAPITAL REGION eMSMEmbedded Physical Therapy
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0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
2013Q1
2013Q2
2013Q3
2013Q4
2014Q1
2014Q2
2014Q3
2014Q4
2015Q1
2015Q2
2015Q3
2015Q4
2016Q1
2016Q2
2016Q3
2016Q4
DC En
coun
ter e
MSM
Enrollees
PSC Am
ount Paid eM
SM Enrollees
Purchased Physical Therapy NCR Enrollee Physical Therapy Encounters
Average quarterly PSC down $1.5M FY13 to FY16and down $451K FY15 to FY16
Physical Therapy Product LineMarket Integration
The Problem
• $8M in NCR enrollee PT network care expenses in FY14 and $6.3M in FY15
• Enough referrals for 10‐12 more PTs • Limited space for rehab, no new MILCON• eMSM referral acceptance rates 80‐85%
The Solution
• Added 11 Physical Therapy FTEs across the region to recapture care
• Embedded PTs in the PCMH to maximize space utilization
• Sent the PT to the patient, not the patient to the PT
“Medically Ready Force...Ready Medical Force”
INCREASED ACCESS IN THE NCRDirect Care Optimization is adding appointments in stages – over 15,000 additional appointments to date
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Annual additional promised / projected SPEC appointments per wave
38,580 (est.)SPECs
annually
38,580 (est.)SPECs
annually
Wave 1 Wave 2 Wave 3 Wave 4• Allergy• Pediatric subspecialties
• Moved to direct booking without clinic optimization
• Orthopedics• ENT
• Completed optimization
• Reflects actual additional appointments
• Pulmonary• Dermatology• Audiology• Endocrine• Rheumatology• Speech therapy
• Completed optimization
• Reflects actual additional appointments
• Cardiology• Chiropractic• GI• General Surgery• Hem/Onc• Neurology• OB‐GYN• Ophthalmology• Optometry
• Pain• PM&R• Physical Therapy• Podiatry• Sleep• Urology• Vascular surgery• Plastic surgery• Pediatric subspecialties
• Optimization in process• Assumes all providers meet agreed encounter targets
Apr‐Aug 2016Jul‐Dec 2016
Oct ‐ Present
23,400 (est.)9,0486,132 + +
Source: Current data ‐ CHCS SPEC encounter data via Dashboard, Sep 1 – Dec 30, 2016 / Projection and Baseline data – CHCS data, Nov 2, 2016
“Medically Ready Force...Ready Medical Force”
Data Source: Health Affairs PMPM FY16 Q1 Export file
COMPARATIVE EFFICIENCYCost per Unit by Inpatient Facility – FY2016 Qtr1
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Portsmouth
Wainwright
Carson
Gordon
Benning
Stewart
Tripler
Riley
Campbell
KnoxPolk
Leonard Wood
West Point
Bragg
Sill
Jackson
Bliss
BAMC
Hood
Lewis
Irwin
Elmendorf
Travis
Eglin
Mt Home
Keesler
Nellis
Wright‐Pat
Eustis
PendletonSan Diego
29 Palms
Pensacola
Jacksonville
Lejeune
Beaufort
Bremerton
Oak Harbor
WRNMMC
FBCH
WRNMMC (FY13)FBCH (FY13)
$K
$5K
$10K
$15K
$20K
$25K
$30K
$35K
$30 $40 $50 $60 $70 $80 $90 $100 $110 $120 $130 $140 $150 $160
Cost per M
S DRG
RWP
Cost per RVU
“Medically Ready Force...Ready Medical Force”
• From FY12 – FY16 Total Obligations reduced by 4.8%
5 Year Execution Trend for NCR MD (WRNMMC & FBCH)
TOTAL GROSS OBLIGATIONSSpending Less on Direct Care
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NCRMD–FY2016
NCRMD–FY2013
MHS Navy
MCSC
ArmyAF
‐15.0%
‐10.0%
‐5.0%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
$200 $250 $300 $350 $400 $450 $500 $550 $600 $650
PMPM
Market Successes
FBCH / MGMC OB CarePer Member Per Month (PMPM)
Embedded Physical Therapy
LOWER
ISBE
TTER
Growth
Rate
0
50
100
150
200
250
300
350
400
450
500
$0K
$100K
$200K
$300K
$400K
$500K
$600K
$700K
2014 2014 2014 2014 2015 2015 2015 2015Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Southern Maryland Costs
Southern Maryland Admissions
Live Births at FBCH
Eliminated$2M PSC ERSA
NCR MD Supporting MarketNeeds with 11 new PTProviders
• Improved Patient Satisfaction• Improved PTAccess• Improved OrthoAccess• FY16 ‐ Expected $2.5M PSC
Reduction from FY14 levels
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
2014
Q1
2014
Q2
2014
Q3
2014
Q4
2015
Q1
2015
Q2
2015
Q3
2015
Q4
2016
Q1
2016
Q2
2016
Q3
2016
Q4
Average quarterly PSC$ down $852K FY14 to FY16
and down$453K FY15 to FY16
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“Medically Ready Force...Ready Medical Force”
Top Five Successes
1. Market Management & Empowered Market Leaders
– Market Initiative Champions
2. Quality of Care– Institute for Healthcare Improvement
Leadership Alliance– Partnership for Patients (PfP) – Ambulatory
Settings
3. Academic Health & Readiness System
– Tri‐Federal Cancer Initiative, an alliance between the Walter Reed Murtha Cancer Center, Uniformed Service University of Health Sciences, and the National Cancer Institute to standardize Clinical Practice Guidelines for cancer treatment
4. Operational Support & Readiness– Provided over 300 medical personnel to support
Joint Forces Headquarters National Capital Region– 46% of all Army GME programs and 28% of all
Army trainees– 34% of all Navy GME programs and 23% of all Navy
GME trainees
5. Stewardship– Reduced obligations by 6% from an FY12 base of
$1.37 billion to an FY15 base of $1.29 billion.– Decreased professional care purchased for our
enrollees by a third in the NCR eMSM, from $90M in FY13 to $64.5 M in FY15
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“Medically Ready Force...Ready Medical Force”
What’s Next
• Single market strategyo How to continue transformation to an HRO.o Distribution of Assets
• Synergy with MHS Reviewo Leadership, Safety, Performance Managemento Quality, Access, Production, Containment/Recapture
• Refining our Governance Processeso NCR as the 4th service.o Unified Department Chairso Streamlined Product lines
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National Defense Authorization Act (NDAA) 2017
A single Agency with oversight of an integrated system of health and readiness delivered through the direct management of each MTF and regional market, utilizing standardized processes and centralized budget accountability to promote transparency to the Department, beneficiaries, Services and Combatant Commands.
Section 702 ‐DHA leading
the way
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“Medically Ready Force...Ready Medical Force”
Questions
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“Medically Ready Force...Ready Medical Force”
National Defense Authorization Act (NDAA) 2017
• Readiness and Operational Support linked
• Health Benefit is means to an end, not the end itself
Readiness
Health Benefit
Operational Support
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Guiding Principles for Implementing the NDAA
• Readiness is primary
• Services are ultimately responsible for readiness supported by DHA
• DHA is responsible for the health benefit supported by the Services who will use this as a means to enable and sustain readiness
• The direct care services will be first choice to support
readiness• DHA creates healthcare
direction, policies and procedures for the direct care system
• DHA is the single source budget authority for the direct care system
• All Active Duty Personnel are tied to an operational requirement
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