Session 6A - MHS Vision


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Session 6A - MHS Vision

  1. 1. Strategy Management in the MilitaryHealth System: Achieving theQuadruple Aim - Part OneMichael Dinneen, MD, PhDDirector, Office of Strategy ManagementOffice of the Assistant Secretary of Defense for Health 6-1
  2. 2. The Problem • Imaginary interaction from the August 10th Military Health System Strategy Review and Analysis • Dr. Woodson, “If people at an MTF viewed the data that we are looking at, would they respond to make improvements and achieve the Quadruple Aim?” • Surgeon General representative, “First, I don’t think that our front line workers get to see this information, second, I am not sure we are giving them the training to make improvements even if they did, and third, I don’t think we have the right incentives in place to reward them.” 2 6-2
  3. 3. FY12 Proposed MTF Report Card Measures Readiness • % of Active-Duty PHA Completed Population Health • HEDIS Preventative Screen Index (Mammography, Cervical, Well-Child visits) Experience of Care • 3rd Available Appointment (Acute and Routine) • % of visits where MTF enrollees see their PCM • Satisfaction with Visit (Primary and Specialty Care) • HEDIS Adherence to Evidence Based Guidelines Index (Diabetes, Cardiovascular, Mental Health) Per Capita Cost • PMPM (Per Member Per Month) • ER Utilization per 100 enrollees • Cost per RWP (In Progress)- Army recommended pulling out MH MDC 19/20 exploring feasibility • Cost per Super RVU (APC* + RVU) Navy proposed breaking out PC and specialty care • Total Super RVU’s per enrollee per year *APC = Institutional component of an ER and surgical center bill 6-3
  4. 4. The Potential Power of ThisCourse!• “If you want to convert the culture of an organization, and that organization contains n people you first need to convert the square root of n.” • Brent James, MD, Intermountain Health Care• This MHS has a staff of how many? • 140,000• How many need to be converted? • 375• One problem – can we describe the needed change? Can we create a shared vision of the future.• An even bigger problem – can we accept a shared vision of reality.• Can we inspire each of you to be a change agent and transform your part of our complex system? 6-4
  5. 5. Goals for the Our TimeTogether • Remain awake, have fun and exercise your brain • Really understand the Quadruple Aim • Recognize specifically how your efforts support the achievement of the Quadruple Aim every day. • Commit to doing two things differently once you return home 5 6-5
  6. 6. Today’s Approach • Review our challenges • Provide an overview of the Quadruple Aim • Provide specifics regarding each of the aims • Definition • Imperatives • Gaps and Targets • Initiatives designed to close the gaps • What you can do! • Talk about how it all fits together • Role of the integrator • Motivating our people • Making IT work for us 6-6
  7. 7. The Changing Nature ofSupply and Demand Increase in health care demand In the next decade and specifically in 2014, more people will be insured and looking for already scarce primary care providers. In the MHS, the number of enrollees using private sector care is climbing. These new enrollees will be competing with the newly-insured for a small number of primary care providers within the private sector. Innovative thinking will be needed to create new models for delivering primary care. Insured Americans Under 65 Expected U.S. MHS Enrollees Physician Shortage 6-7
  8. 8. The Changing Nature of Supply andDemandIncreased individual utilization of health care Prevalence of the Prevalence of the diagnosis of PTSD and diabetes and obesity in the depression in adult (#29) Prevalence of US population beneficiaries in MHS obesity and diabetes in the U.S. Meeting Notes: National lifetime average is 5-10%. The increase in PTSD episodes require us to adapt to these demands. The increase in PTSD can also be due to better awareness and the reduction of stigma associated with 6-8 PTSD.
  9. 9. The Changing Nature ofSupply and Demand The direct effect of ten years of war (#25) Average number wounded Behavioral Health Outpatient in action per month Encounters Confirmed Cases of TBI We are fighting one less war, but the Both the cumulative effects of ten MHS continues to see significant years of war, as well as successful numbers of combat trauma cases. anti-stigma campaigns have driven The number of confirmed cases of demand for behavioral health Traumatic Brain Injury has slowed, 9 services to new highs for Active Duty but continues to grow. and their Families 6-9
  10. 10. Escalating Costs Healthcare cost inflation The slow but inexorable growth in health care costs in the US and in the Department of Defense continues. Recent upticks in the percentage of health care costs relative to GDP and the DoD budget reflect overall economic conditions and slowdowns in federal spending, rather than recent spikes in health spending. Yet, these external circumstances further highlight the trade-offs between health spending and other national … and national security…priorities. U.S. Spending on Unified Medical Program as Healthcare, as a a Percentage of DoD Percentage of GDP Budget 6-10
  11. 11. Escalating Costs Health care costs are shifting As the costs for private sector health insurance continue to grow, most employers have shifted some of the cost burden to employees. In 2011, DoD introduced very modest increases in TRICARE Prime enrollment fees for retirees and their families - but the increases were well below the private insurance cost growth. The trend of the last ten years – in which retirees drop their private insurance and return to TRICARE as their primary insurance is likely to continue. Private Insurance Premiums Vs. Tricare Enrollment Fee (Retiree (<65) Health (Family) Insurance Coverage 6-11
  12. 12. The Big Picture-Translating Strategy to Action 6-12
  13. 13. Big Picture –“From Strategy to Action” 2009 Quadruple Aim Strategic Imperatives 2010 Performance Gap Strategic Initiative Portfolio •PCMH 2011 •Performance Planning •Psychological Health Our Focus for the Portfolio of •IMR Programs •National Prevention Strategy upcoming year is to Strategic •… Develop & Manage an Initiatives Optimal Set of Strategic Initiatives to Improve Our Performance Local Initiatives 6-13
  14. 14. Our Strategic Goals -The Quadruple Aim 6-14
  15. 15. The Quadruple Aim • Readiness • Population Health • Experience of Care • Per Capita Cost • What is it? • What can we do about it? • Why is it important? • Exercise One – Discuss one aim then report. 6-15
  16. 16. The Quadruple Aim:The MHS Value Model Readiness Population Health Ensuring that the total military Reducing the generators of force is medically ready to ill health by encouraging deploy and that the medical healthy behaviors and force is ready to deliver health decreasing the likelihood of care anytime, anywhere in illness through focused support of the full range of prevention and the military operations, including development of increased humanitarian missions. resilience. Per Capita Cost Experience of Care Creating value by focusing on Providing a care experience quality, eliminating waste, and that is patient and family reducing unwarranted centered, compassionate, variation; considering the total convenient, equitable, safe cost of care over time, not just and always of the highest the cost of an individual health quality. care activity. 6-16
  17. 17. Readiness – Three sub-aims • Ready medical force • Casualty care, disaster relief, humanitarian assistance • Medically ready force • Fit, ready and deployable force • Family readiness • Healthy and resilient individuals, families and communities Success: Accomplish the Mission in support of Combatant Commanders 6-17
  18. 18. How We’re Doing: Readiness Readiness – Casualty CareObserved vs. Predicted Survival Rate Amputee Functional Percentage of Patients(Battle Wounds OIF & OEF Survival Ratios: JTTR U.S. Military Battle Injured Reintegration, 2002 – 2011 Admitted Hypothermic, Iraq 2003-2010in Operations Casualties January 2007 - November 2011 Observed Survival Expected Survival First Joint Theater 100 Trauma System teamEnduring & Iraqi 90 into Iraq 80 70Freedom) 60 50 40 30m%odu03eayvScrt)(i 20 10 0 a 7 M-0 a 8 M-0 a 9 M-0 a 0 M-1 a 1 M-1 r 7 a -0 r 8 a -0 r 9 a -0 r 0 a -1 r 1 a -1 a7 J -0 u7 J -0 e7 S -0 a8 J -0 u8 J -0 e8 S -0 a9 J -0 u9 J -0 e9 S -0 a0 J -1 u0 J -1 e0 S -1 a1 J -1 u1 J -1 e1 S -1 o7 N -0 o8 N -0 o9 N -0 o0 N -1 o1 N -1 M M M M M n n n n n p p p p p l l l l l v v v v v y y y y ySource: JTTR, January 2007 - November 2011 Date (month/year) of Injury In FY2011, there were 221 major limb Our providers have consistently amputations, the most of any year going back to demonstrated trauma care outcomes 2004. in Theater that exceed those of the best trauma care centers in America. 18 6-18
  19. 19. How We’re Doing: ReadinessReadiness – Individuals and FamiliesOur efforts are focused on ensuring the individual medical readiness of the total force and increasing theresiliency of Service members and their families. Individual Medical Resiliency Assessments for Readiness (IMR) Active Duty, Families, and Civilians Data through 3rd quarter Though we continue to see improvements The GAT helps individuals track and improve in IMR, our biggest challenge remains emotional, social, spiritual, family strength. periodic health assessments and dental Participation in the Army’s Comprehensive readiness in the Reserve component Soldier Fitness program GAT for Families and Civilians has almost doubled in one year (released in 2010) 6-19
  20. 20. How We’re Doing: ReadinessReadiness – Managing Psychological HealthOver the past five years we have successfully reduced resistance to referring patients for mental healthtreatment and the stigma related to receiving treatment. Through our investments in psychologicalresearch and program evaluation, we are discovering the most effective ways to treat these conditions. Post Traumatic Stress Post Traumatic Stress Post Traumatic Stress Disorder Referral Rate Disorder Engagement Disorder Remission Rate Rate Data through 2nd Quarter We are learning about the best treatment protocols for PTSD. Patients that are in our most successful program, RESPECT- MIL, have a remission rate of 19%. 6-20
  21. 21. Population Health – Three Sub-Aims • Health determinants • Health promotion and primary prevention • Environmental “adjustments” • Individual health risk • Behavioral risk • Physiological risk • Resilience • Illness and disease burden • Tertiary prevention – reducing the impact of chronic illness • Improved pathways of care for common conditions (eg PTSD and Depression) Success – We will empty our hospitals 6-21
  22. 22. Population Health Encouraging Healthy Behavior – Curbing Obesity Prevalence of Obesity Diagnosis Rate of obesity/ Counseling Rate of in MHS Beneficiaries overweight beneficiaries, diagnosed beneficiaries (Ages 40-49) FY2011 obese/overweight, FY2011The rate of obesity in active duty Service Less than a third of obese patients Of those beneficiaries diagnosed asmembers is significantly lower compared to and less than ten percent of being overweight or obese, only 10%retirees of the same age. There may be an overweight patients have a weight and 20%, respectively, are counseledopportunity to intervene to prevent waistline condition documented in their on ways to manage their weight. 22growth with retirement. medical record. 6-22
  23. 23. Population HealthEncouraging Healthy Behavior – Tobacco Cessation Tobacco CessationSmoking Rate, 18-24 Year Tobacco Use Rate, 18-24 Counseling Rate, Active Olds Year Olds Duty Latest National Smoking RateHistorically the smoking rate of active duty Recently we have expanded our 18-24 year-old active duty membersService members has been one and a half measurement to consider all types of are less likely to be counseled to quittimes higher than their non active duty tobacco use. We still see a marked smoking than older active dutypeers. Over the last five years, the MHS difference between the smoking rates of members; this is a pattern we arehas seen a decrease in the rate of smoking active duty and non active duty looking to both populations. beneficiaries. 6-23
  24. 24. Population HealthPreventive HealthOn many of the preventive measures where we have focused our improvement efforts, we are nowachieving performance in the top 10% of the nation. In the last year, we have expanded our focus tomeasuring how we care for our children, an area of significant importance to a health system that delivers2,400 births a week. Cervical Cancer Children with Six Well- Exclusive Breastfeeding Screening Rate Child Visits in First 15 During Newborn Months HospitalizationWomen are more likely to have a Well-child visits is still a maturing measure Our direct care performance is 50%documented cervical cancer screening and presents opportunity for improvement higher than the Joint Commissionif they are enrolled in one of our across the MHS. national rate.military treatment facilities. 6-24
  25. 25. Experience of Care – Six Sub-Aims“They remember me.” • Effective - evidence based interventions • Efficient – no waste • Equitable – care for everyone • Timely – no unwanted waits • Patient Centered – no helplessness • Safe – no needless death or injury Success: Patients will say, “I received all of the care I wanted/needed exactly when I wanted/needed it.” Ref: Crossing the Quality Chasm – Institute of Medicine 2000; Confessions of an Extremist, Health Affairs, Dr. Donald Berwick 6-25
  26. 26. How We’re Doing: Experience of CareSafe Care Antibiotics Administered Within 1 Wrong Site Surgeries Hour of Surgical Procedure Prophylactic antibiotics reduce the incidence of On average there are 14 wrong site surgeries per postoperative wound infection. We have seen year in our system. We are focused on eliminating consistent improvement in this measure over the through transparency, protocols, and better last two years—our goal is100% compliance. communication between patient and surgical team. 6-26
  27. 27. How We’re Doing: Experience of CareEffective & Efficient CareScreening Rates for LDL Screening Rates for Conditions with HighestCholesterol Management Diabetes HbA1c Direct Care Hospital Readmission Rates 10th Percentile 6-27
  28. 28. How We’re Doing: Experience of Care Timely Care Third Available Primary Satisfaction with Getting MEBs Completed within 35 Care Appointments Timely Care DaysTop performing, mature PCMHs: 90% forRoutine third available. Top performing PCMHs: R&A: Our satisfaction rate has remained R&A: Overall rate has been in decline; we66% for Acute third available have noticed a modest upward trend over relatively flat for the last year. the last quarter.Last Year: At over 50% of MTF primary clinics, if abeneficiary calls for an acute appointment they willbe offered at least three options within 24 hours. 6-28
  29. 29. How We’re Doing: Experience of Care Patient-Centered Care (#73) Primary Care (PCM) (#74) Satisfaction with (#69) Satisfaction with Continuity Provider Communication HealthcareOn average, enrollees to military treatmentfacilities see their assigned primary caremanager about half of the time. Note: The civilian benchmark is 93% Patients enrolled to TRICARE network but the MHS has not achieved the providers report a higher satisfaction with benchmark during the reported health care. period nor made significantTop performing/mature PCMHs: improvement.72% primary care continuity 6-29
  30. 30. How We’re Doing: Experience of CarePatient-Centered Care Satisfaction with Inpatient Care (Overall Hospital Rating) Last Year: Patients receiving obstetrical care at TRICARE network hospitals report higher satisfaction with health care. 6-30
  31. 31. Per Capita Cost – Two Sub-Aims • Reduce cost per service • Engineer efficient processes • Reduce the number of services • Eliminate waste • Substitute high cost low value services with high value, low cost services Waste is disrespectful to: •The taxpayer •Workers •Patients Success: Bend the cost curve. 6-31
  32. 32. Per Capita CostUnderstanding Our Costs The majority of MHS health care resources are spent on TRICARE Prime enrollees; per capita costs for Prime enrollees have grown significantly since 2005. Much of that growth has been due to rising ambulatory utilization. Traditionally we’ve tried to cut costs at HQ/overhead, but we need to focus our energy on private sector costs (large proportion of the MHS budget) and quality of health care - specifically cost per year per person, which is rising dramatically. MHS Budget, by Budget Activity Group Enrollee Per Year Costs Purchased Direct Consolidate Base Headquarters Care Care d Operations Health and Support Communicatio ns Educatio Information n Management and Training The total cost of providing care for an average The MHS dedicates nearly all of its budget directly to the MHS Prime enrollee is just over $3,500 care of its beneficiaries, investing $25B annually in annually, with almost two-thirds of the total TRICARE Prime enrollees. being for ambulatory services. These costs are driven by increased utilization. 6-32
  33. 33. Per Capita CostCost Drivers Reducing emergency room use and improving care management represent can viably control our costs. As we develop our data analytics capabilities, we will be better able to understand our cost drivers which will allow us to create tailored solutions. Emergency Room (ER) Utilization per 100 enrollees National Benchmark Emergency room utilization for Prime enrollees continues to climb and is more than double the rate of insured individuals in the United States. 6-33
  34. 34. 6-34
  35. 35. Per Capita CostManaging Pharmacy Costs Average Annual Prescription Projected Growth in the Costs Per Beneficiary Over 65 Population Home Delivery TrendThe MHS spends, on average, over Currently one in five MHS beneficiaries is Savings from home delivery prescriptions$2,000 per year on each senior over the age of 65, and this population is have been significant, and the use of thisbeneficiaries’ pharmaceutical costs per quickly growing. venue for delivery continues to increase35year. 6-35
  36. 36. The MHS Value Equation Experience Population Readiness + + Health of CareValue = Cost (Over a Span of Time) Creating a high value Military Health System is predicated on defining and measuring value. 6-36
  37. 37. Current State• We don’t have a fully functional health team • We wait for patients to become ill• Our health care system is fragmented • We do not reimburse for coordination of care or outcomes• Economic incentives reward sickness over health • Fee for service rewards volume over value • Up to 40% of health care spending is on waste• We fail to transfer knowledge to practice • We follow well established clinical guidelines less than half of the time • We can’t seem to cross from basic science to common practice in under a generation (it is risky)• We fail to apply principles of system engineering to health processes • “Work arounds” are the norm • Comparative and concurrent data are not part of the American health care culture 6-37
  38. 38. The Solution: Over the Next 3-5 YearsMHS Will Transition Both Payment andDelivery Systems toAchieve the Quadruple Aim Delivery System Fully Integrated Delivery Ideal System ent n of paym utio nd vol tion a -e za Co ni Level 2/3 a PCMH o rg Medical Transition Homes Volume-driven Today Performance Planning fragmented Pilots care Fee-for-service Pay for Bundled Incentive and Performance; Payment, Pay for Reimbursement Primary Care Sub- Value, Partial System 38 Capitation Capitation 6-38Adapted From “From Volume To Value: Better Ways To Pay For Health Care”, Health Affairs, Sep/Oct 2009.