Merging The Military Health System (Peake)

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Merging The Military Health System (Peake)

  1. 1. Merging the Military Health System (MHS) and the Veterans Health Administration (VHA) into a Single Governance Structure 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. Colonel William B. Grimes, MHA, FACHE Senior Service College Fellow
  2. 2. Merging the Military Health System (MHS) and the Veterans Health Administration (VHA) into a Single Governance Structure 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. Briefing to The Honorable James B. Peake Secretary of Veterans Affairs
  3. 3. Be Persistent! “ Heretics Are Not All Bad!” Paul K. Carlton, Jr., MD, FACS Lt. Gen, USAF, Ret
  4. 4. Introduction - Argument Premise <ul><li>Bottom Line: Until a single management or governance structure is clearly established from a national authority , the extent and success of collaboration efforts between DoD and VA healthcare systems will remain limited by existing public laws and subject to the inherent bureaucracy of the two organizations. </li></ul><ul><li>Large scale change has happened ….creating the Department of Homeland Security required realigning assets from 22 Federal Agencies. It was accomplished in six months but it took a national emergency and direct Presidential involvement. </li></ul>
  5. 5. None of Us Want to Face What Lies Ahead of Us It’s Never as Bad as it Seems
  6. 6. Introduction - Argument Logic <ul><li>If: </li></ul><ul><li>- Increased DoD/VA collaboration improves access to care </li></ul><ul><li>- Increased DoD/VA collaboration reduces cost </li></ul><ul><li>- Increased DoD/VA collaboration improves quality </li></ul><ul><li>and - Single governance improves DoD/VA collaboration </li></ul><ul><li>Then: - Single governance improves access, cost, and quality </li></ul>Cost Access Quality <ul><ul><li>… but at what risk?...is the juice worth the squeeze? </li></ul></ul>
  7. 7. Intro - Argument Parameters Healthcare Command Medical Education and Training Command Force Health Protection Command TRICARE Contracts DoD Medical Treatment Facilities and Clinics Marine Corps Medical Component Unified Medical Command Joint Regional Offices Army Medical Component Navy Medical Component Deployable Capabilities Joint Regional Commands Army Medical Forces Operational Medical Command Air Force Medical Forces Air Force Medical Component Secretary of Defense Modernization Command Under Secretary of Defense for Personnel and Readiness Assistant Secretary of Defense (Health Affairs) Navy Medical Forces 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). In an April 2006 response to Presidential Budget Decision (PBD) 753, the Under Secretary of Defense (Personnel and Readiness) proposed a MHS structure with a “Unified Medical Command” and a separate “Healthcare Command.”
  8. 8. Background <ul><li>DoD and VA - two huge healthcare systems </li></ul><ul><ul><li>Combined budget of $76 billion </li></ul></ul><ul><ul><li>300,000 personnel </li></ul></ul><ul><ul><li>13.5 million beneficiaries </li></ul></ul><ul><ul><li>1,600 locations world-wide </li></ul></ul><ul><li>20 years of legislative efforts to increase collaboration </li></ul>
  9. 9. Why Now? <ul><li>OEF/OIF patient population </li></ul><ul><ul><li>This has changed the “politics” of the equation </li></ul></ul><ul><li>Estimated cost to deliver DoD and VA health care are becoming unsustainable </li></ul><ul><li>Current approach to improving DoD/VA collaboration is not strategic </li></ul><ul><ul><li>Redundant DoD/VA services and programs </li></ul></ul>
  10. 10. OEF/OIF Patient Population <ul><li>“ As of March 2007, Veterans Healthcare Administration (VHA) coordinated the transfer of over 6,800 severely injured or ill active duty service members and veterans from DoD to the VA.” </li></ul><ul><li>Testimony of Dr. Michael J. Kussman, Acting Undersecretary for Health, Department of Veterans Affairs, U.S. House of Representatives, Subcommittee of Oversight and Investigations, March 8, 2007. </li></ul><ul><li>“ As of the first half of FY 2007, approximately 263,900 returning veterans have sought care from VA medical centers and clinics.” </li></ul><ul><li>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. </li></ul><ul><li>The Congressional Budget Office (CBO) estimates the total cost to provide health care to OEF/OIF veterans with service connected conditions to be between $7 and $9 billion over the next ten years. </li></ul>
  11. 11. DoD Healthcare Costs ($Billions - 2005 constant dollars) Source: www.defenselink.mil/news/Feb2006/d20060206slides.pdf TRICARE for Life
  12. 12. VA Healthcare Costs Source: http://www.whitehouse.gov/omb/budget/fy2008/veterans.html Other VA Benefit Programs
  13. 13. Redundant Systems Similar requirements = unique opportunity to explore a “seamless” approach to the delivery of health care Source: Dr. Jones & Dr. Tibbits Briefing for 18/19 Mar 08 Trip Battlefield Domiciliary VA DoD Healthcare Venues VA DoD Healthcare Specialties Acute Care Hospitals & Medical Centers Most Healthcare Specialties A Few Specialties e.g., Pediatrics A Few Specialties e.g., Geriatrics
  14. 14. DoD/VA Collaboration <ul><li>Lots of help and tremendous effort… </li></ul><ul><ul><li>Multiple DoD/VA Executive Councils, Coordination Offices, and Working Groups </li></ul></ul><ul><ul><li>Multiple site visits and formal studies to improve collaboration </li></ul></ul><ul><ul><li>Hundreds of National and Local Sharing Agreements </li></ul></ul><ul><ul><li>… but are these permanent and temporary organizations really necessary? Is there a better way? </li></ul></ul>
  15. 15. Joint Committees SECRETARY DEPARTMENT OF VETERANS AFFAIRS (VA) SECRETARY DEPARTMENT OF DEFENSE (DoD) VA/DoD JOINT EXECUTIVE COUNCIL (JEC) Joint Strategic Planning Committee (JSPC) Construction Planning Committee (CPC) VA/DoD BENEFITS EXECUTIVE COUNCIL (BEC) VA/DoD HEALTH EXECUTIVE COUNCIL (HEC) Contingency Response Working Group Deployment Health Working Group Benefits Delivery at Discharge Working Group Graduate Medical Education Working Group Information Management Information Technology Working Group Joint Facility Utilization and Resource Sharing Working Group Acquisition & Medical Materiel Management Working Group Patient Safety Working Group Pharmacy Working Group Information Sharing Information Technology Working Group Benefits & Services Working Group Medical Records Working Group Coordinated Transition Working Group* Continuing Education & Training Working Group Mental Health Working Group Evidence-Based Clinical Practice Guidelines Working Group Financial Management Working Group Joint Health Care Facility Operations Steering Group (JFSG) Communications Working Group Are there too many DoD/VA Working Groups and Executive Councils to remain effective? Is this strategic?
  16. 16. Senior Oversight Committee Overarching Integrated Product Team (OIPT) Full-time staff and VA Detail Incoming from other commissions Press Releases Congress & Media Senior Oversight Committee (SOC) Co-Chairs: DEPSECDEF and DEPSECVA 1 2 3 5 6 7 8 4 DoD/ VA Data Sharing Traumatic Brain Injury / PTSD Case Management Facilities Clean Sheet Legislation & Public Affairs Personnel/ Pay Support Disability System Lines of Action (LOAs) Again, more teams, groups, and action offices…when will there be enough?
  17. 17. Resource Sharing Agreements <ul><li>Three types of sharing: National Initiatives, Joint Venture, and Local Sharing Agreements </li></ul><ul><li>“ 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.” </li></ul>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? Source: VA/DoD Joint Executive Council FY 2007 Annual Report
  18. 18. Agreements by Unique Large number of agreements but what is the real value added?
  19. 19. Agreements by Service Examples of Service Branch Category “noise” potentially inflating the true value added
  20. 20. Agreements by VISN 85 Agreements with NY Army NG
  21. 21. Reimbursement Large variation between Fee and CMAC early in the sharing program
  22. 22. Provider VA is the “provider” of the service in over 70% of the agreements…understandable because the VA is bigger…
  23. 23. New Agreements by Year The number of new agreements may not be a good indicator of the level of effort…
  24. 24. Challenges and Concerns <ul><li>Single Governance Challenges: </li></ul><ul><ul><li>Cabinet-Level Departments </li></ul></ul><ul><ul><li>Very politically sensitive </li></ul></ul><ul><ul><li>Two well established healthcare systems </li></ul></ul><ul><ul><li>Requires DoD to create some form of a Unified Medical Command </li></ul></ul><ul><li>DoD and VA’s Concerns: </li></ul><ul><ul><li>VA’s concern is a unified system will “squeeze out” the veteran </li></ul></ul><ul><ul><li>DoD’s concern is losing the ability to directly influence the provision of health care and thereby negatively affect readiness </li></ul></ul><ul><ul><ul><li>“ Hospital commander, extend the clinic hours for this deploying unit” </li></ul></ul></ul><ul><ul><ul><li>“ Hospital commander, see this deploying patient first” </li></ul></ul></ul>
  25. 25. Manage Beneficiary Care TRICARE Manage Beneficiary Care TRICARE Deploy a Healthy Force 9 Manage Beneficiary Care TRICARE Deploy a Healthy Force Deploy Medical Support The MHS Mission Patient Care, Sustain Skills and Training Promote & Protect Health of the Force Deploy to Support the Combatant Commanders to and
  26. 26. The “New” MHS Mission - Focused on the Deployable Mission Manage Beneficiary Care TRICARE Manage Beneficiary Care TRICARE Deploy a Healthy Force Manage Beneficiary Care TRICARE Deploy a Healthy Force Deploy Medical Support ...can we remove the benefits mission (i.e. TRICARE) from DoD’s responsibility without negatively affecting readiness?
  27. 27. Veterans’ Concerns <ul><li>Any merger will “squeeze them out” of their system </li></ul><ul><li>Fear of change </li></ul><ul><ul><li>DoD experienced this when they excluded MEDICARE eligible beneficiaries </li></ul></ul><ul><ul><li>Resulted in TRICARE for Life (TFL) Program </li></ul></ul><ul><li>Reduction in admin overhead can result in additional clinical providers…should improve access </li></ul>
  28. 28. Close to Single Governance North 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.
  29. 29. Courses of Action <ul><li>COA 1: Combine the Healthcare Command and the Veterans Healthcare Administration (VHA) under the direction of DoD </li></ul><ul><li>COA 2: Combine the Healthcare Command and the VHA under direction of VA </li></ul><ul><li>COA 3: Combine the Healthcare Command and the VHA under direction of Health and Human Services (HHS) </li></ul>
  30. 30. Screen/Evaluation Criteria <ul><li>Criteria for a System Merger </li></ul><ul><ul><li>DoD Screening Criteria - Military readiness </li></ul></ul><ul><ul><li>VA Screening Criteria - Protect the benefit </li></ul></ul><ul><ul><li>Unity of effort – Improved Responsiveness </li></ul></ul><ul><ul><li>Reduce redundancies </li></ul></ul><ul><ul><li>Cost savings </li></ul></ul><ul><ul><li>Viability - Ease of implementation </li></ul></ul><ul><ul><li>Ability to concentrate on core mission </li></ul></ul><ul><ul><li>Number of Departments involved </li></ul></ul>
  31. 31. <ul><li>Criteria for a Well-Functioning System </li></ul><ul><ul><li>Capacity to Innovate and Improve </li></ul></ul><ul><ul><li>Equity </li></ul></ul><ul><ul><li>Efficiency </li></ul></ul><ul><ul><li>Access </li></ul></ul><ul><ul><li>Quality </li></ul></ul><ul><ul><li>Long, Healthy, and Productive Lives </li></ul></ul>System Evaluation Criteria Source: Commonwealth Fund Commission Key Indicators for Measuring Performance
  32. 32. COA 1: Combine under DoD Leadership Federal Military Healthcare Command Medical Education and Training Command Force Health Protection Command TRICARE/HERO Contracts DoD Medical Treatment Facilities and Clinics Marine Corps Medical Component Unified Medical Command Joint Regional Offices Army Medical Component Navy Medical Component Deployable Capabilities Joint Regional Commands Army Medical Forces Operational Medical Command Air Force Medical Forces Air Force Medical Component Secretary of Defense Modernization Command Under Secretary of Defense for Personnel and Readiness Assistant Secretary of Defense (Health Affairs) Navy Medical Forces Marine Corps Medical Forces VA Medical Treatment Facilities and Clinics Existing DoD and VA facilities will be combined where possible and grouped geographically using the existing TRO structure Is running such a large healthcare system a core mission for DoD?
  33. 33. Federal Military Healthcare Administration Medical Education and Training Command Force Health Protection Command TRICARE/HERO Contracts DoD Medical Treatment Facilities and Clinics Marine Corps Medical Component Unified Medical Command Joint Regional Offices Army Medical Component Navy Medical Component Deployable Capabilities Joint Regional Commands Army Medical Forces Operational Medical Command Air Force Medical Forces Air Force Medical Component Modernization Command Under Secretary of Defense for Personnel and Readiness Assistant Secretary of Defense (Health Affairs) Navy Medical Forces Marine Corps Medical Forces VA Medical Treatment Facilities and Clinics Under Secretary for Heath, Veterans Health Administration Secretary of Veterans Affairs Deputy Secretary Existing DoD and VA facilities will be combined where possible and grouped geographically using the existing VISN structure Secretary of Defense COA 2: Combine under VA Leadership Recommended Running a healthcare system is the core mission for VHA
  34. 34. COA 2 Includes a “Don’t Sell the Farm” Clause Large Medical Facilities run by the VHA but with a heavy military presence. These facilities would serve as military casualty reception Centers of Excellence.
  35. 35. COA 3: Combine under Health and Human Services (HHS) Leadership Assistant Secretary for Health, HHS National Coordinator for Health Information Technology Director, Office of Global Health Affairs TRICARE/HERO Contracts DoD Medical Treatment Facilities and Clinics Director, Indian Health Service (HIS) Joint Regional Offices Assistant Secretary for Preparedness and Response Director, Agency for Healthcare Research and Quality Commissioner, Food and Drug Administration (FDA) Director, National Institutes of Health (NIH) Assistant Secretary for Resources & Technology Secretary of Health and Human Services Director Centers for Disease Control and Prevention (CDC) Deputy Secretary Chief of Staff Administrator, Centers for Medicare & Medicaid USPHS Personnel Director, Federal Military Healthcare System VA Medical Treatment Facilities and Clinics Existing DoD, VA, and HHS facilities and personnel will be combined where possible and geographically grouped using the existing HHS system of ten regional offices. Most Innovative This option creates the most “synergy” among federal healthcare entities.
  36. 36. COA 3 - Synergy Imagine how the ability to respond to national emergencies and the ability to gather medical surveillance data will be improved if all these Federal medical facilities were electronically connected using the same IM/IT system. Even if it is just DoD and VA healthcare facilities in the same system…could be the basis for a national healthcare system
  37. 37. COA Comparisons <ul><ul><li>Unity of effort </li></ul></ul><ul><ul><li>Reduce redundancies </li></ul></ul><ul><ul><li>Cost savings </li></ul></ul><ul><ul><li>Viability - Ease of implementation </li></ul></ul><ul><ul><li>Ability to concentrate on core mission </li></ul></ul><ul><ul><li>Number of Departments involved </li></ul></ul><ul><ul><li>Capacity to Innovate and Improve </li></ul></ul><ul><ul><li>Long, Healthy, and Productive Lives </li></ul></ul><ul><ul><li>Operational Experience Running a </li></ul></ul><ul><ul><li>Large Healthcare System </li></ul></ul>COA 1 DoD COA 2 VA COA 3 HHS Hybrid of Criteria Recommended
  38. 38. Recommended Option COA 2 Phased Implementation <ul><li>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. </li></ul><ul><li>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). </li></ul><ul><li>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.” </li></ul><ul><li>Phase Three - Merge VHA and MHS senior leadership. </li></ul>
  39. 39. Issues to be Resolved <ul><li>Requires DoD to create a Unified Medical Command </li></ul><ul><li>Merging DoD/VA beneficiary priorities will be difficult…who gets the one open appointment? </li></ul><ul><li>The “best of breed” competitions among DoD/VA/HHS for IM/IT, logistics, personnel, and other admin and clinical systems will meet resistance. </li></ul><ul><li>Must carve-out funding streams for military medicine. </li></ul><ul><li>Active Duty healthcare - DoD must maintain its system of troop medical clinics, shipboard, and flight line medicine. </li></ul>
  40. 40. Top Ten Reasons to Execute <ul><li>Provides a definitive answer to Congressional mandates </li></ul><ul><li>Addresses unsustainable costs of both VA and DoD Healthcare </li></ul><ul><li>Addresses VA/DoD aging medical infrastructure </li></ul><ul><li>Enhances care for all veterans - especially OEF/OIF </li></ul><ul><li>Enhances VA and DoD physician retention </li></ul><ul><li>Improves Undergraduate and Graduate Medical Education </li></ul><ul><li>Improves ability to respond to a national emergency </li></ul><ul><li>Allows both Departments to focus on their “core” mission </li></ul><ul><li>Prevents future redundancies - How many more AHLTA and VISTa will there be? </li></ul><ul><li>Establishes the framework for a National Healthcare System </li></ul>
  41. 41. Conclusion <ul><li>“ Heretics Are Not All Bad!” </li></ul><ul><li>We are at a “tipping point” for change </li></ul><ul><li>The VA running the merged DoD/VA healthcare system is the most viable and is recommended – the VA is one step removed from DoD </li></ul><ul><li>Moving to the combined system to the HHS can be explored later </li></ul><ul><li>Any DoD/VA single governance structure must be directed from a national authority </li></ul>
  42. 42. Briefings Conducted <ul><li>4 April 2008 - Paul K. Carlton, Jr., MD, FACS, Lt. Gen, USAF, Ret, Director, Homeland Security, The Texas A&M University System, Health Science Center </li></ul><ul><li>21 April 2008 - Michael A. Kussman, MD, Under Secretary for Health, Veterans Health Administration, Edward C. Huyche, MD, FACP, Chief Officer, DoD Coordination Office, Veterans Health Administration </li></ul><ul><li>1 May 2008 - Mr. Bruce Gordon, Director, Central Texas Veterans Healthcare System, Veterans Health Administration </li></ul>

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