This document discusses strategies for achieving the Quadruple Aim in the military health system. It outlines challenges like increasing health care demand and costs. It introduces the Quadruple Aim of readiness, population health, experience of care, and per capita cost. The document proposes reviewing each aim by discussing what it is, what can be done about it, and why it is important, then having participants discuss one aim and report back. The overall goal is to develop and manage initiatives to improve performance.

1. Strategy Management in the Military
Health System: Achieving the
Quadruple Aim - Part One
Michael Dinneen, MD, PhD
Director, Office of Strategy Management
Office of the Assistant Secretary of Defense for Health Affairs
michael.dinneen@ha.osd.mil
6-1

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. 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. The Potential Power of This
Course!
• “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. Goals for the Our Time
Together
• 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. 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. The Changing Nature of
Supply 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. The Changing Nature of Supply and
Demand
Increased 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. The Changing Nature of
Supply 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. 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. 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. The Big Picture-
Translating Strategy to Action
6-12

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. Our Strategic Goals -
The Quadruple Aim
6-14

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. 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. 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. How We’re Doing: Readiness
Readiness – Casualty Care
Observed 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 2003-2010
in Operations
Casualties
January 2007 - November 2011
Observed Survival Expected Survival First Joint Theater
100 Trauma System team
Enduring & Iraqi
90 into Iraq
80
70
Freedom)
60
50
40
30
m
%
o
d
u
0
3
e
a
y
v
S
c
r
t
)
(
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
y
Source: 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. How We’re Doing: Readiness
Readiness – Individuals and Families
Our efforts are focused on ensuring the individual medical readiness of the total force and increasing the
resiliency 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. How We’re Doing: Readiness
Readiness – Managing Psychological Health
Over the past five years we have successfully reduced resistance to referring patients for mental health
treatment and the stigma related to receiving treatment. Through our investments in psychological
research 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. 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. 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, FY2011
The rate of obesity in active duty Service Less than a third of obese patients Of those beneficiaries diagnosed as
members 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 counseled
opportunity to intervene to prevent waistline condition documented in their on ways to manage their weight. 22
growth with retirement. medical record.
6-22

23. Population Health
Encouraging Healthy Behavior – Tobacco Cessation
Tobacco Cessation
Smoking Rate, 18-24 Year Tobacco Use Rate, 18-24 Counseling Rate, Active
Olds Year Olds Duty
Latest National
Smoking Rate
Historically the smoking rate of active duty Recently we have expanded our 18-24 year-old active duty members
Service members has been one and a half measurement to consider all types of are less likely to be counseled to quit
times higher than their non active duty tobacco use. We still see a marked smoking than older active duty
peers. Over the last five years, the MHS difference between the smoking rates of members; this is a pattern we are
has seen a decrease in the rate of smoking active duty and non active duty looking to change.
in both populations. beneficiaries.
6-23

24. Population Health
Preventive Health
On many of the preventive measures where we have focused our improvement efforts, we are now
achieving performance in the top 10% of the nation. In the last year, we have expanded our focus to
measuring how we care for our children, an area of significant importance to a health system that delivers
2,400 births a week.
Cervical Cancer Children with Six Well- Exclusive Breastfeeding
Screening Rate Child Visits in First 15 During Newborn
Months Hospitalization
Women 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 Commission
if they are enrolled in one of our across the MHS. national rate.
military treatment facilities.
6-24

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. How We’re Doing: Experience of Care
Safe 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. How We’re Doing: Experience of Care
Effective & Efficient Care
Screening Rates for LDL Screening Rates for Conditions with Highest
Cholesterol Management Diabetes HbA1c Direct Care Hospital
Readmission Rates
10th Percentile
6-27

28. How We’re Doing: Experience of Care
Timely Care
Third Available Primary Satisfaction with Getting MEBs Completed within 35
Care Appointments Timely Care Days
Top performing, mature PCMHs: 90% for
Routine third available. Top performing PCMHs: R&A: Our satisfaction rate has remained R&A: Overall rate has been in decline; we
66% 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 a
beneficiary calls for an acute appointment they will
be offered at least three options within 24 hours.
6-28

29. How We’re Doing: Experience of Care
Patient-Centered Care
(#73) Primary Care (PCM) (#74) Satisfaction with (#69) Satisfaction with
Continuity Provider Communication Healthcare
On average, enrollees to military treatment
facilities see their assigned primary care
manager 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 significant
Top performing/mature PCMHs: improvement.
72% primary care continuity
6-29

30. How We’re Doing: Experience of Care
Patient-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. 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. Per Capita Cost
Understanding 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. Per Capita Cost
Cost 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. 6-34

35. Per Capita Cost
Managing Pharmacy Costs
Average Annual Prescription Projected Growth in the
Costs Per Beneficiary Over 65 Population Home Delivery Trend
The 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 this
beneficiaries’ pharmaceutical costs per quickly growing. venue for delivery continues to increase35
year.
6-35

36. The MHS Value Equation
Experience Population
Readiness + + Health
of Care
Value =
Cost (Over a Span of Time)
Creating a high value Military Health System is
predicated on defining and measuring value.
6-36

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. The Solution: Over the Next 3-5 Years
MHS Will Transition Both Payment and
Delivery Systems to
Achieve 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 6-38
Adapted From “From Volume To Value: Better Ways To Pay For Health Care”, Health Affairs, Sep/Oct 2009.