Merging the Military Health System and the Veterans Health Administration
Merging the Military Health System (MHS) and the Veterans HealthAdministration (VHA) into a Single Governance Structure Colonel William B. Grimes, MHA, FACHE USA, RET The views expressed in this academic research presentation are those of the author and do not necessarily reflect the official policy or position of the U.S. Government, the Department of Veterans Affairs, the Department of Defense, or any of its agencies.
Be Persistent!“Heretics Are Not All Bad!” Paul K. Carlton, Jr., MD, FACS Lt. Gen, USAF, Ret
Introduction - Argument PremiseBottom Line: Until a single management or governancestructure is clearly established from a national authority, theextent and success of collaboration efforts between DoDand VA health systems will remain limited by existing publiclaws and subject to the inherent bureaucracy of the twoorganizations.Large scale change has happened….creating theDepartment of Homeland Security required realigningassets from 22 Federal Agencies. It was accomplished insix months but it took a national emergency and directPresidential involvement.
It’s Never as Bad as it Seems None of UsWant to Face What LiesAhead of Us
Introduction - Argument Logic• If: - Increased DoD/VA collaboration improves access to care Cost - Increased DoD/VA collaboration reduces cost - Increased DoD/VA collaboration improves quality• and - Single governance improves DoD/VA collaboration Access Quality• Then: - Single governance improves access, cost, and quality …but at what risk?...is the juice worth the squeeze?
Intro - Argument ParametersIn an April 2006 response to Presidential Budget Decision(PBD) 753, the Under Secretary of Defense (Personnel and Secretary of DefenseReadiness) proposed a MHS structure with a “Unified Medical Under Secretary ofCommand” and a separate “Healthcare Command.” Defense for Personnel and Readiness Army Medical Component Assistant Secretary of Defense (Health Affairs) Army Medical Forces Unified Medical Air Force Medical Healthcare Command Command Component Air Force Medical Forces Operational Medical Modernization Command Joint Regional Offices TRICARE Contracts Command Navy Medical Component Joint Regional Force Health Protection Commands Command DoD Medical Treatment Facilities and Clinics Navy Medical Forces Medical Education and Deployable Capabilities Training Command Marine Corps Medical Component Marine Corps Medical Forces Although this proposed MHS structure was not implemented, it does validate the concept that the “benefits mission” (circled in red above) can be separated from the readiness mission of the MHS. For the purposes of this briefing, any proposed single DoD/VA governance structure involves merging only the benefits mission of the Military Healthcare System (MHS) with the Veterans Health Administration (VHA).
Background• DoD and VA - two huge healthcare systems – Combined budget of $76 billion – 300,000 personnel – 13.5 million beneficiaries – 1,600 locations world-wide – Over 20 years of legislative directives to increase collaboration• Similar Systems
Similar Systems Similar requirements = unique opportunity to explore a “seamless” approach to the delivery of health care Healthcare Venues Healthcare Specialties DoD VA DoD VA Most Acute Care Hospitals Healthcare & Specialties Medical Centers A Few A Few Specialties SpecialtiesBattlefield Domiciliary e.g., e.g., Pediatrics GeriatricsSource: Dr. Jones & Dr. Tibbits Briefing for 18/19 Mar 08 Trip
Why Now?• OEF/OIF patient population – This has changed the “politics” of the equation• Estimated cost to deliver DoD and VA health care are becoming unsustainable• Current approach to improving DoD/VA collaboration is not strategic – Redundant DoD/VA services and programs
OEF/OIF Patient Population• “As of March 2007, Veterans Health Administration (VHA) coordinatedthe transfer of over 6,800 severely injured or ill active duty servicemembers and veterans from DoD to the VA.”Testimony of Dr. Michael J. Kussman, Acting Undersecretary for Health, Department of VeteransAffairs, U.S. House of Representatives, Subcommittee of Oversight and Investigations, March8, 2007.• “As of the first half of FY 2007, approximately 263,900 returning veteranshave sought care from VA medical centers and clinics.”Testimony of the Honorable Patrick W. Dunne, Assistant Secretary for Policy and Planning, U.S.Department of Veterans Affairs, U.S. Senate, Committee on Veterans Affairs, October 17, 2007.• The Congressional Budget Office (CBO) estimates the total cost toprovide health care to OEF/OIF veterans with service connected conditionsto be between $7 and $9 billion over the next ten years.
DoD Healthcare Costs($Billions - 2005 constant dollars) Source: www.defenselink.mil/news/Feb2006/d20060206slides.pdf
VA Healthcare Costs Other VA Benefit ProgramsSource: http://www.whitehouse.gov/omb/budget/fy2008/veterans.html
DoD/VA Collaboration• Lots of help and tremendous effort… – Multiple DoD/VA Executive Councils, Coordination Offices, and Working Groups – Multiple site visits and formal studies to improve collaboration – Hundreds of National and Local Sharing Agreements …but are these permanent and temporary organizations really necessary? Is there a better way?
Joint Committees SECRETARY DEPARTMENT OF SECRETARY VETERANS AFFAIRS (VA) DEPARTMENT OF DEFENSE (DoD) VA/DoD JOINT EXECUTIVE COUNCIL (JEC) Construction Planning Committee (CPC) Coordinated Transition Working Group* Joint Strategic Planning Committee (JSPC) Communications Working Group VA/DoD BENEFITS EXECUTIVE COUNCIL VA/DoD HEALTH EXECUTIVE COUNCIL Joint Health Care Facility (BEC) (HEC) Operations Steering Group (JFSG) Benefits & Services Working Group Contingency Response Working Group Information Management Information Technology Working Group Benefits Delivery at Discharge Deployment Health Working Group Working Group Joint Facility Utilization and Resource Mental Health Working Group Sharing Working Group Information Sharing Information Technology Evidence-Based Clinical Practice Graduate Medical Education Working Group Guidelines Working Group Working Group Financial Management Working Group Acquisition & Medical Materiel Medical Records Working Group Management Working Group Continuing Education & Training Working Group Patient Safety Working Group Pharmacy Working GroupAre there too many DoD/VA Working Groups andExecutive Councils to remain effective? Is this strategic?
Senior Oversight Committee Senior Oversight Committee (SOC) Incoming from Co-Chairs: other DEPSECDEF and DEPSECVA commissions Congress & Media Overarching Integrated Full-time staff Product Team and VA Detail (OIPT) Press Releases Lines of Action (LOAs) 1 2 3 4 5 6 7 8 DoD/ VA Data Traumatic Brain Injury Sharing Clean Sheet Personnel/ Pay / PTSD Support Disability Case Facilities Legislation & System Management Public AffairsAgain, more teams, groups, and actionoffices…when will there be enough?
Resource Sharing Agreements• Three types of sharing: National Initiatives, Joint Venture, and Local Sharing Agreements “In FY 2007, 100 VA Medical Centers were involved in direct sharing agreements with 124 DoD medical facilities for a total of 280 direct sharing agreements that covered 148 unique services.” Source: VA/DoD Joint Executive Council FY 2007 Annual Report Separating the sub-agreement from the 280 master agreement results in a total of 613 active sharing agreements. This seems impressive, but how do we know the true value-added? How have they improved healthcare?
Agreements by Unique Large number of agreements but what is the real value added?
Agreements by Service Examples of Service Branch Category “noise” potentially inflating the true value added
Reimbursement Large variation between Fee and CMAC early in the sharing program
ProviderVA is the “provider” of the service in over70% of the agreements…understandablebecause the VA is bigger…
New Agreements by Year The number of new agreements may not be a good indicator of the level of effort…
Challenges and Concerns• Single Governance Challenges: – Cabinet-level departments – Very politically sensitive – Two well established healthcare systems – Requires DoD to create some form of an Unified Medical Command• VA and DoD Concerns: – VA’s concern is an unified system will “squeeze out” the veteran – DoD’s concerns are inability to separate the TRICARE mission and lack of direct control will negatively affect readiness• Fear of Change
Fear of Change• DoD experienced beneficiary “fear of change” when they excluded MEDICARE eligible beneficiaries – Resulted in TRICARE for Life (TFL) Program• Veteran’s advocacy groups fear any merger will “squeeze them out” of guaranteed access – Reasonable to predict that merger will improve access for all beneficiary populations
The MHS Mission Deploy Medical Support Deploy a Healthy Force Deploy a Healthy ForceManage Beneficiary Manage Beneficiary Manage Beneficiary Care Care Care TRICARE TRICARE TRICARE Deploy toPatient Care, Support theSustain Skills Promote & Protect to Health of the Force and Combatantand Training Commanders 9
The “New” MHS Mission - Focused on the Deployable Mission Deploy Medical Support Deploy a Healthy Force Deploy a Healthy Force Manage Beneficiary Manage Beneficiary Manage Beneficiary Care Care Care TRICARE TRICARE TRICARE...can we remove the benefits mission (i.e. TRICARE) fromDoD’s responsibility without negatively affecting readiness?
Close to Single GovernanceNorth Chicago VAMC – Great Lakes Naval Health Clinic Clear chain of command? This “hybrid” shows the limitations and restrictions of current DoD/VA collaboration public law.
Courses of Action• COA 1: Form a Federal Military Health Command by merging the brick and mortar assets of the MHS and the VHA under the direction of DoD• COA 2: Form a Federal Military Health Command by merging the brick and mortar assets of the MHS and the VHA under the direction of the VA• COA 3: Form a Federal Health Command by merging the brick and mortar assets of the MHS and the VHA under the direction of the HHS
Screen/Evaluation Criteria• Criteria for a System Merger – DoD Screening Criteria - Military readiness – VA Screening Criteria - Protect the benefit – Unity of effort – Improved Responsiveness – Reduce redundancies – Cost savings – Viability - Ease of implementation – Ability to concentrate on core mission – Number of Departments involved
System Evaluation Criteria • Criteria for a Well-Functioning System – Capacity to Innovate and Improve – Equity – Efficiency – Access – Quality – Long, Healthy, and Productive LivesSource: Commonwealth Fund Commission Key Indicators for Measuring Performance
COA 1: Combine under DoD Leadership Secretary of Defense Under Secretary of Defense for Personnel and Readiness Army Medical Assistant Secretary of Defense Component (Health Affairs) Army Medical Forces Federal Military Unified Medical Air Force Medical Healthcare Command Component Command Air Force Medical Operational Medical Forces Modernization Joint Regional TRICARE/HERO Command Command Offices Contracts Navy Medical Joint Regional Component Commands Force Health Protection Command DoD Medical VA MedicalNavy Medical Forces Deployable Treatment Facilities Treatment Facilities Capabilities and Clinics Medical Education and Clinics and Training Marine Corps Command Medical Component Existing DoD and VA facilities will be combined where possible and grouped geographically using Marine Corps the existing TRO structure Medical ForcesIs running such a large healthcare system a core mission for DoD?
COA 2: Combine under VA Leadership Secretary of Defense Secretary of Veterans Affairs Under Secretary of Defense Deputy Secretary for Personnel and Army Medical Readiness Component Under Secretary for Heath, Veterans Health Assistant Secretary of Administration Army Medical Defense (Health Affairs) Forces Federal Military Unified Medical Air Force Medical Healthcare Command Component Administration Air Force Medical Operational Medical Modernization Joint Regional TRICARE/HERO Forces Command Command Offices Contracts Navy Medical Joint Regional Component Force Health Commands Protection Command DoD Medical VA Medical Treatment Facilities Treatment Facilities Navy Medical Forces Deployable Medical Education and Clinics and Clinics Capabilities and Training Marine Corps Command Existing DoD and VA facilities will be combined Medical Component where possible and grouped geographically using the existing VISN structure Marine Corps Medical ForcesRunning a healthcare system is the core mission for VHA Recommended
COA 2 Includes a “Don’t Sell the Farm” ClauseLarge Medical Facilities run by the VHA but with a heavy militarypresence. These facilities would serve as militarycasualtyreception Centers of Excellence.
COA 3: Combine under HHS Leadership Secretary of Health and Human Services Chief of Staff Deputy Secretary Most Innovative Director, National Director, Indian Assistant Secretary Institutes of Health Health Service (HIS) for Health, HHS (NIH) Director, Agency for Director, Federal Assistant Secretary Military Healthcare Healthcare Research for Resources & System and Quality Technology Commissioner, Food Assistant Secretary and Drug Joint Regional TRICARE/HERO for Preparedness Administration (FDA) Offices Contracts and Response Director, Office of Global Health Affairs Administrator, Centers for Medicare DoD Medical VA Medical USPHS Personnel National Coordinator Treatment Facilities Treatment Facilities & Medicaid for Health and Clinics and Clinics Information Technology Existing DoD, VA, and HHS facilities and personnel will be combined Director Centers for where possible and geographically grouped using the existing HHS system Disease Control and of ten regional offices. Prevention (CDC)This option creates the most “synergy” among federal healthcare entities.
COA Comparisons COA 1 COA 2 COA 3Hybrid of Criteria DoD VA HHSUnity of effort RecommendedReduce redundanciesCost savingsViability - Ease of implementationAbility to concentrate on core missionNumber of Departments involvedCapacity to Innovate and ImproveLong, Healthy, and Productive LivesOperational Experience Running aLarge Healthcare System
Recommended Option COA 2 Phased Implementation• Phase Zero – Get senior DoD, VA, Legislative leaderships’ buy-in. Contract or have an independent governmental agency (i.e. CBO, GAO) conduct a detailed analysis of the financial and organizational implications of the recommended COA. This study would be very similar to the Center for Naval Analysis (CNA) study on the cost implications of a Unified Medical Command conducted in May 2006. Focus on resolving the issues identified executing the single VA/DoD governance structure at the North Chicago VAMC/Great Lakes Naval Clinic location.• Phase One – Determine the DoD/VA system requirements and conduct “Best of Breed” competitions among administrative, managed care, logistics, and HER systems. Begin complete merger of selected clinical programs (i.e. PM&R, Behavioral Health).• Phase Two - Merge leadership at the current Joint Venture locations or other “North Chicago-like” locations. Retain or create a position for a DoD “Deputy Commander/Associate Director for Military Readiness.”• Phase Three - Merge VHA and MHS senior leadership.
Issues to be Resolved• Requires DoD to create a Unified Medical Command• Merging VA/DoD beneficiary priorities will be difficult…who gets the one open appointment?• The “best of breed” competitions among DoD/VA/HHS for IM/IT, logistics, personnel, and other admin and clinical systems will meet resistance• Must carve-out funding streams for military medicine• Active Duty healthcare - DoD must maintain its system of troop medical clinics, shipboard, and flight line medicine
Top Ten Reasons to Execute1. Provides a definitive answer to Congressional mandates2. Addresses unsustainable costs of both VA and DoD Healthcare3. Addresses VA/DoD aging medical infrastructure4. Enhances care for all veterans - especially OEF/OIF5. Enhances VA and DoD physician retention6. Improves Undergraduate and Graduate Medical Education7. Improves ability to respond to a national emergency8. Allows both Departments to focus on their “core” mission9. Prevents future redundancies - How many more AHLTA and VISTa will there be?10. Establishes the framework for a National Healthcare System
SynergyImagine how the ability to respond to national emergencies and the abilityto gather medical surveillance data will be improved if all these Federalmedical facilities were electronically connected using the same IM/ITsystem. Even if it is just DoD and VA healthcare facilities in the same system…could be the basis for a national healthcare system
Conclusion• “Heretics Are Not All Bad!”• We are at a “tipping point” for change• Any DoD/VA single governance structure must be directed from a national authority• The VA running the merged Federal Health System is the most viable and is recommended• Incorporating other assets from the HHS can be explored later