The document discusses performance planning in the Military Health System (MHS). It provides an overview of the performance planning process, which translates MHS strategy into action through business planning. Performance plans support budget submissions and identify enrollment projections, workload projections, and performance objectives. The goals of performance planning are to improve outcomes, experiences of care, population health, and control per capita costs. Financial incentives are being developed to reward quadruple aim performance.

1. Session 14: Incorporating
Improvement Into The
Performance Plan
Ms. Sherry Stone
Military Health System, Performance Planning
sherry.stone@us.army.mil
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2. Objectives
• Objective 1: Discuss purpose, importance
and evolution of business planning
• Objective 2: Present overview of Military
Health System Performance Planning
Process
• Objective 3: Demonstrate the steps of
deliberate business planning
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3. Performance Planning
Performance Planning Framework
Task Force
Management TRICARE ASD(HA) Quadrennial
Future of
Initiative Governance 04Mar03 Defense
Military
Decisions Plan Memo Review
Health Care
Service Service
MHS MHS
Strategy Guidance
Strategy Guidance
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4. TRICARE Governance Plan
• Established overall organizational construct, process, and objectives
• Regional Organization
• TRICARE Regional Offices (TRO)
• Regional Directors
• Market Managers - Eleven Multi-Service Markets (MSM)
• Business Planning
• Service SGs will approve business plans prior to the year of execution
• TMA Deputy Director will approve TRO Regional Business Plans prior to the year of
execution
• MTF Commander is responsible and accountable for the delivery of the
TRICARE health benefit to the population enrolled to the MTF
• The Services are also responsible for resourcing MTFs in accordance with
the approved business plans
• The intent; business plan represents a contract between the MTF and the
Service and between TMA and the TROs
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5. Remaining Attendant
What do Performance Plans Currently Support?
• Enrollment and workload projections from MTF Performance Plans are rolled-up and
directly feed
• Annual Presidents Budget - Exhibit PB-11b
• Program Objective Memorandum (POM) - Includes performance objectives
• DoD PA&E receives this
• Budget Estimate Submission (BES) - Includes performance objectives
• DoD Comptroller receives this
• PPS annual budget build
• Submissions include
• Prior year– actual
• Current year – Performance Plans
• Two future years – Performance Plans
• Other uses of MTF Performance Plans include
• Where appropriate, substantiate Service & TRO submitted Unfunded Requirements –UFRs
• Where appropriate, substantiate Service Unspecified Minor Construction and MILCON
• Performance Plans are starting to translate MHS strategy into action
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6. Role of Performance Planning
• The intent of performance planning is to translate strategy into
action
• Which strategy; MHS or Service? - Both!
• Translating MHS Strategy
• Quadruple AIM
• Readiness
• Population Health
• Experience of Care
• Per Capita Cost
• Continuous Process Improvement (CPI)
• Performance Planning is the new name for business planning
• New name same concept
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7. Creating Breakthrough Performance
in the MHS - Evolving!
Performance
Measures
Readiness Population Health
Ensuring that the total military force is
Reducing the generators of ill health
medically ready to deploy and that the
by encouraging healthy behaviors and
medical force is ready to deliver health
decreasing the likelihood of illness
care anytime, anywhere in support of
through focused prevention and the
the full range of military operations,
development of increased resilience.
including humanitarian missions.
Experience of Care Per Capita Cost
Providing a care experience that is Creating value by focusing on
patient and family centered, quality, eliminating waste, and
compassionate, convenient, reducing unwarranted variation;
equitable, safe and always of the considering the total cost of care
highest quality. over time, not just the cost of an
individual health care activity.
Strategic Plan and Effective Leadership
Strategic Plan and Effective Leadership
(Quadruple Aim)
(Quadruple Aim)
Process Budget
Improvement Each Element is essential . Incentives
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8. Expanding Pay for Performance
to Match the Vision
• Premise: MHS Value is predicated on three elements
– Outputs - the volume of work that we accomplish, measured currently
by RVUs/APCs and RWPs/Bed Days
• Incomplete
– Outcomes – often measured via factors such as HEDIS/JCAHO
– Customer Satisfaction
• Our focus to date has been centered on productivity (Outputs)
as the MHS source of value for the Department.
• Goal: Create a financial mechanism for the direct care system
that will emphasize value measures for outcomes and customer
satisfaction in a balanced fashion with outputs
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9. “Transition” In Both Payment &
Delivery Systems
Delivery
System
Fully Integrated
Delivery
System f
of o aymen
t Ideal
n
o lutio n and p
C o-ev izatio
an t
Level 2/3 Org ymen
pa
and
PCMH
Medical Homes
Transition
Primary Care Sub-
Volume-driven
fragmented care
Today Capitation
Fee-for-service
Fee-for-service
Medical Home Full Population
Prepayment
Payment
Payments
Fee-for-service
System
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10. MHS Performance Planning
Financial Incentives – Current State and Pilots
Rewards for Quadruple
Aim Performance
Rewards for
Volume
Integration
System
In this chart, “incentives” refer to financial rewards
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11. Balancing Act –
Effective Efficiency
• Health Plan Management & Utilization Management
• Clinical point of focus – Access and Quality
• Cost point of focus
• How do you reconcile the Prospective Payment System (PPS) Fee-For-
Service (FFS) construct with effective Utilization Management (UM)?
• Under PPS MTF’s are rewarded for sustaining and increasing
production
• Increasing beneficiary Access to Care
• Population Health (Disease & Case Management, Utilization
Management) can reduce utilization and consequently production
• What can you do?
• Understand business processes
• Reduce capacity (improved templates and/or enrollment)
• Increase “Right of First Refusal (ROFR)” take rate
• Realign work from Purchase Care - Recapture
• Realign resources from the product line with lowered utilization to a
product line that offers recapture potential or extend capacity
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12. Concept of Operations
Concept of Operations Performance Planning
$ Pay 4 Performance
Reconciliation
Readiness
Population Health
Experience of Care
Per Capita Cost
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13. Pay 4 Performance
Incentive Measures
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14. MTF Performance Planning Model
Population Health
Unique Unique
Users Users
Total Gov’t Paid Enrollment Business Plan
Inpatient
Outpatient Today
2006 2007 2008
Per Member Tomorrow
Per Month
ers
Us
MCSC Enrollment Space Available
Price Per RWP
Price Per RVU
Cost Per RWP
Market Share
Cost Per RVU
Inpatient
Outpatient Market Share
Inpatient
Outpatient
Access Satisfaction
Performance Quality Improvement
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15. MTF Performance
Planning Process
SECTION 1 SECTION 2 SECTION 3 SECTION 4
Evaluation of Evaluation of Analysis – The why Determination
Current Future phase Phase
Environment Environment Enrollment -Future Product Lines
DMISID = 89
-Satisfaction -HA Strategy/Guidance Enrollees
0
Plan Enrollees Plan
0 to 4 6,4 84 6,3 30 6,347 6,348
Enro l ees Plan
Bencat GenderAge GroupHisto ry FY03 FY04 FY05 Bencat Gender Age GroupHisto ry FY03 FY04 FY05 Bencat Gender Age GroupHistory FY03 FY04 FY05
0 to 4 129 122 113 109
-Enrollment
-Population alignment
0 5 to 14 8,7 99 9,0 22 8,969 8,996 5 to 14 737 756 728 701
-Access -HA/TMA Policy M
15 to 17 17 17 17 18
18 to 24 13,377 16,416 16,506 16,496
25 to 34 13,589 15,196 15,170 15,115
M
15 to 17 1,3 48 1,3 46 1,337 1,317
18 to 24 958 983 983 979
25 to 34 407 410 408 401
M
15 to 17 417 450 448 443
18 to 24 520 630 634 633
25 to 34 84 84 85 89
-Satisfaction
35 to 44 6,816 8,017 7,929 7,815 35 to 44 273 242 244 245 35 to 44 787 752 694 648
-Quality & Prevention -Service Strategy -
45 to 64 772 1,001 926 874 45 to 64 107 107 104 99 45 to 64 2,870 3,290 3,402 3,512
65+ 0 0 0 0 65+ 0 0 0 0
AD ADFM 0 to 4 6,1 99 6,0 19 6,023 6,058 Ret/Others 0 to 4 104 108 104 101
-Access
5 to 14 8,6 30 8,7 59 8,763 8,804 5 to 14 711 708 678 656
-Performance R/Y/G Service Guidance -
15 to 17 5 1 2 4 15 to 17 1,4 10 1,4 28 1,420 1,406 15 to 17 414 457 446 429
18 to 24 2,002 2,393 2,384 2,377 18 to 24 5,7 67 5,5 07 5,531 5,540 18 to 24 586 659 663 663
F F F
25 to 34 1,869 2,216 2,167 2,111 25 to 34 9,6 75 9,1 23 9,172 9,135 25 to 34 203 208 202 198
-Quality & Prevention
35 to 44 682 892 843 799 35 to 44 4,8 43 4,8 59 4,833 4,815 35 to 44 1,070 1,057 1,000 944
-Target Population Population changes -
45 to 64 87 121 113 107 45 to 64 935 928 930 918 45 to 64 3,015 3,469 3,551 3,624
0 65+ 0 65+ 0 0 0 0
Total 39,215 46,270 46,057 45,716 Total 55,8 35 55,0 63 55,063 55,063 Total 11,649 12,750 12,750 12,750
-Currency
DMISID = 123
-Enrollment Strategic Partnerships -
Empanelle d TRICARE Plu s 4,188 4,188 4,188 4,188 Enrollees
History Normative Enrollee Care for Other Space-A Space-A Plus Care TFL Care Total
Plan Demand Demand In-house Other DC Purchase Enrollees AD Non-AD <65 (65+) In-house
Primary Care 156,859 197,765 175,617 17,270 4,878 18,245 7,289 20,943 109 40,031 262,234
HistoryFY03 ChangeFY04 ChangeY05 Change
F
-OR utilization
Emergency 27,048 28,722 16,565 3,064 9,093 7,047 1,244 5,345 9 3,827 34,038
-Currency requirements Civilian Market All Bencats Mental Health/Social Work 60,390 121,569 88,550 19,794 13,226 18,859 2,803 11,017 7 3,405 124,641
106,700 114,083 7,3 83 113,8 70 (212) 113,530 (341)
Ortho/Phys Ther 47,251 83,559 50,166 28,448 4,945 15,108 3,484 7,728 17 6,099 82,602
Internal Med Sub 1,580 70,929 13,497 54,131 3,301 2,731 466 1,571 14 3,556 21,834
Surgery 9,852 21,934 5,783 15,355 796 2,091 193 793 7 2,412 11,279
-Measures
Surgery Sub 8,574 14,066 2,501 11,208 356 991 112 345 6 1,667 5,622
-OR Utilization -TRO/MCSC changes
Ophthalmology/Optometry 29,549 51,051 31,734 11,961 7,356 3,197 2,589 2,180 19 5,273 44,991
OB/GYN 28,224 41,881 21,131 20,031 718 6,008 520 2,418 16 1,734 31,827
RVUs
ENT 8,383 11,971 3,375 8,059 538 1,042 73 269 - 438 5,198
Dermatology 6,847 12,199 2,019 6,717 3,463 470 58 136 - 505 3,189
-Production
Facility 25,338 10,791 - - 10,791 - - - - - -
-Measures -Benefit changes
Radiology 5,924 1,529 - - 1,529 - - - - - -
Anesthesiology 1,445 159 - - 159 - - - - - -
Pathology 554 296 - - 296 - - - - - -
Home Health Care 765 205 - - 205 - - - - - -
Other 16,115 22,163 3,925 15,869 2,369 1,084 398 1,136 1 1,459 8,003
-Production
Total 434,699 690,790 414,863 211,907 64,020 76,875 19,230 53,879 204 70,406 635,457
SECTION 5 SECTION 6 SECTION 7 SECTION 8
Coordination Phase Develop Action Plans Write the Business Submit Template
& Production Plan Plan Plan
-Area MTFs Develop Business Plan
-TRO/MCSC -Measures & Initiatives Complete Organizational Summary
Governance Structure -Services’
-VA -CPI Projects Organizational Chart
-HA/TMA
Scope of Services
-Civilian Hospitals -Assessment Planning Partnerships and Alliances
MCSC/Network Providers
*Competitive Edge Contracted Arrangements
Veterans Administration Agreements
*Keys to Success Other DOD Facilities and Scope of Services
Conduct Market Analysis
*Important Assumptions Market demographics by risk adjusters (Age, Sex, Ben Cat) and Zip Code
*Assess Financial Impact Enrollment status by risk adjusters and Zip Code
Care Patterns (MTF work by product line, PSC by Spec and Pt zip)
PSC government cost by enrollment status, risk adjuster, zip code, and specialty sorted high to low
SECTION 9
Monitor Plan
Performance 14-15

16. Performance Plans – MTF Unique
Based upon enrollment DMIS
Service POCs:
Stephen Larsen – Air Force
Stephen.larsen@us.af.mil
Sherie Kim – Navy
Linda Niemeyer - Navy
Eva.kim@med.navy.mil
Linda.niemeyer@med.navy.mil
Sherry Stone – Army
Sherry.stone @amedd.army.mil
TMA POC:
Todd.Gibson@tma.osd.mil
Access:
triservicebps.amedd.army.mil
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17. MTFs forecast healthcare
delivery plan along with
critical initiatives for
quality and/or readiness
improvements based upon
Service guidance.
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18. MTFs forecast critical
initiatives quantatively and
qualitatively based upon
Service guidance
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19. 14-19

20. 14-20

21. Critical Initiatives
Service Specific and
Align with MHS Strategy
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22. Critical Initiatives Impact
Reflects projected
improvements and POC
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23. Capacity is determined based upon
available skill type provider 1 FTEs to
MEPRS B and/or RVUs per encounter
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24. Capacity is determined based upon
available skill type provider 1 FTEs to
MEPRS B and/or RVUs per encounter
Demand is determined based upon
beneficiary utilization of health care
by MHS product line
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25. Realities of Today
• Resources (money and people) are tight.
• US healthcare costs are four times that spent on
National Defense .
• Line Commanders note rising health care costs claim
significant portions of their budgets.
• Resource allocation in the future will receive
considerable scrutiny.
• The stakes for MTF Commanders are high.
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26. Case Study
• What are the strategic objectives (Health Affairs/Service
guidance) and MTF initiatives?
• Where are you today vs. where you need to be?
• What can you fix now vs. what takes additional
preparation?
• How can you quantitatively and qualitatively articulate
performance improvement initiatives to move your
organization closer to the strategic direction of the
organization?
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27. A Closer Look
• What resources do you actually have?
• Utilization rates and demand of population?
• Should you be doing more or less?
• What do you need to get there?
• Strategic reinvestment of resources:
• Promote the Medical Home concepts
• Improve access to care and patient satisfaction
• Should reduce costs over time
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28. Initiatives to
Improve Efficiency
• Access
• Right size empanelment to PCM availability.
• Incorporate the primary care team concept.
• Scrutinize and manage clinic templates.
• Aggressively seek continuity for routine care.
• Promote continuity with PCM.
• Avoid unnecessary appointments (labs,
consults).
• Leverage RN’s and CPG’s when appropriate.
• Are your beneficiaries satisfied with access?
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29. MTF Performance Plan
• Executive Summary
• What business are you in?
• Where am I achieving objectives
• Strengths, weaknesses, opportunities, and threats in alignment with organizational
objectives and strategies
• Targeted areas for performance improvement
• Assumptions and timetables
• Objectives
• Targets and how will you achieve them
• Market
• Demographics of total market, demand, MTF target market, and MTF market
• What can you provide and what will you send to the network or other MTFs?
• Cost
• What is the projected cost of your initiatives?
• What the projected PPS earnings for direct care services?
• What is your projected loss to the network?
• Resources
• Human capital impacts/required to achieve plan
• Facility opportunities and constraints
• How do you know when you’ve achieved your objectives?
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30. Final Thoughts
• The purpose of planning is to translate strategy into
action to maximize quality clinical outcomes
• Performance Planning involves strategies that focus on
healthy outcomes and patient satisfaction.
• Reimbursement strategies emphasize both.
• Pay for performance will measure performance in outcomes and
satisfaction
• Hitting this target will requires a strategy that ensures a
primary care infrastructure founded in a well resourced
Medical Home with appropriate subspecialty care support.
• MTF Commanders must continuously re-assess
performance and reinvest resources as necessary to meet
the needs of the population.
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