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Session 15: Incorporating Improvement Into The Performance Plan

Ms. Sherry Stone, MHA, CDFM Army, Office of the Surgeon General Program Analysis & Evaluation Directorate sherry.j.stone2.civ@mail.mil

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Disclosure

Presenter has no financial interest to disclose.

This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with the MedXellence Program. PESG, and MedXellence Staff, and accrediting organization do not support or endorse any product or service mentioned in this activity. PESG and MedXellence Program staff have no financial interest to disclose.

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Objective

1. Provide an overview of the Performance Planning Process

• Why do we plan? • Roles and Responsibilities • Planning Guidance • FY16 Core Measures

2. FY17-21 Performance Planning • FY17-21 Planning Timeline

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Purpose

The process of translating organizational strategy into action by forecasting beneficiary healthcare outcomes to include direct and purchased care in a standardized and transparent manner to maximize value and achieve quality clinical outcomes.

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Why? • The Government Performance and Results Act (GPRA) (P.L. 103-62) is a

U.S. law enacted in 1993. It is one of a series of laws designed to improve government performance management. The GPRA requires agencies to engage in performance management tasks such as setting goals, measuring results, and reporting their progress.

• In order to comply with the GPRA, agencies produce strategic plans, performance plans, and conduct gap analyses of projects. The foundation of GPRA is based on the following three elements as follows:

• Agencies are required to develop five-year strategic plans that must contain a mission statement for the agency as well as long-term, results-oriented goals covering each of its major functions

• Agencies are required to prepare annual performance plans that establish the performance goals for the applicable fiscal year, a brief description of how these goals are to be met, and a description of how these performance goals can be verified

• Agencies must prepare annual performance reports that review the agency's success or failure in meeting its targeted performance goals

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Steps in Planning for Performance

• Analysis or assessment • Understanding internal and external environment

• Strategy formulation • High level strategy is developed and a basic organization

level strategic plan is documented • Strategy execution

• Where high level plan is translated into more operational planning and action items

• Evaluation or sustainment/management phase • Ongoing refinement and evaluation of performance, culture,

communications, data reporting, and other strategic management issues

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Analysis/Assessment Understanding the Environment

• External • Budget Deficits • Army Down-sizing • MHS/MEDCOM strategic direction

• Tri-Service Provider Productivity targets (sustain clinical skills) • Primary Care Empanelment targets (organizational efficiencies) • Patient Safety, Quality and Access (organizational effectiveness) • Pay for Performance

• MHS • IRIS

• Internal • Population changes (EBSMIV) • Population Demand • Command priorities

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• The Earlier Drawdown (1989-1996): RAPID CONTRACTION • Army Medicine lost ~6K AD Authorizations • MCCUs • “Capitation” Funding Attempted

• The Transition (1997-2001): INTERNAL REFLECTION • Recognition that our Data Quality was horrible • Emphasis on improving basic data entry • Recognition that we had very few standardized measures to look at value • Stand-up of the Decision Support Center

• The War: Phase I (2002-2006): GROWTH • GWOT (OCO) • Army Medicine performed very well down range • Pressure from higher for improved productivity • “Hire what you need …”

• The War: Phase II (2007-2011): MORE GROWTH • Walter Reed and the WTU situation • Perspective Payment System (PPS) & Performance Based Budgeting (PBAM) • Massive infusion of OCO funding and Special Program growth • Grow The Army • BRAC

The Past …

Understanding the DoD Business

Cycle

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• The War: Phase III (2012....): Fiscally Constrained Readiness • Uncertainty • Cost Control – Looming Sequester • Retrenchment Pressure • 2012: “The Small Hospital Study” => MHS Modernization Study • December 2012: MEDCOM staff reductions programmed for 2014-2018 • January 2013: Sequestration unleashed & DHP not exempted • Shared Service Savings & the formation of the Defense Health Agency • December 2013 Restoral of 2,727 FTEs and about $260M per year • February 2014: Release of DoD’s PB15 Benefit Reform Proposal • January 2015: Release of the Military Compensation & Retirement

Modernization Study • February 2015: Release of DoD’s PB16 Benefit Reform Proposal

Today’s Business Cycle Phase

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Today’s Environment • Fiscal Environment: Smaller Army, Personnel Reductions, Sequestration

• MHS remains well resourced – Labor is the constraint

• MHS Modernization Study (2013)

• Low volume, low value locations • Readiness over Benefit Delivery

• Military Compensation & Retirement Modernization Commissions (2015)

• Not able to remain ready / Can’t prove readiness • Beneficiaries want choice • Healthcare costs too much

• MHS Review: Quality & Safety in question

• Perception of poor access: “Acute care barriers are a widespread problem”; “Confusing and inconsistent policies”

• Stakeholders want change; Willing to be innovative

• TF Futures reorganizations: PRMC/WRMC, WTC, DENCOM, PHC

• MHS Governance & the DHA – Shared Service Savings & eMSMs

• Peace isn’t breaking out

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MHS Governance Transition

Unclassified

March 2013 DSD Memo • DSD signed, ‘Implementation of Military Health System Governance Reform’, memo 11 March 2013.

• Directs implementation of MHS Governance Reform outlined in March 2012 DSD memo.

• Sets key transition deadlines, including DHA Initial Operation Capability deadline of 1 October 2013 and Full Operational Capability deadline of 1 October 2015.

• Establishes 6 eMSMs

• 5-year Performance Plans to improve healthcare and reduce cost ($1B)

Sherry J Stone, DASG-DSC, 703-681-1868, sherry.j.stone2.civ@mail.mil

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C2

ASD(HA) – Assistant Secretary of Defense for Health Affairs BUMED – US Navy Bureau of Medicine and Surgery CJCS – Chairman of the Joint Chiefs of Staff CMC – Commandant of the Marine Corps CNO – Chief of Naval Operations CSA – Chief of Staff, Army CSAF – Chief of Staff, Air Force DASD – Deputy Assistant Secretary of Defense JSS – Joint Staff Surgeon MAJCOM – Major Command, Air Force MBOG –- Medical Business Operations Group MDAG – Medical Deputies Action Group MEDCOM – United States Army Medical Command

MHS – Military Health System MHSER – Military Health System Executive Review MOG – Medical Operations Group MPOG – Manpower and Personnel Operations Group MTF – Military Treatment Facility NCR – National Capital Region PAC – Policy Action Council PDASD – Principal Deputy Assistant Secretary of Defense SG – Surgeon General SMMAC – Senior Military Medical Action Council USD(P&R) – Under Secretary of Defense for Personnel and Readiness USUHS – Uniformed Services University of the Health Sciences

Coordination & Assistance

LEGEND

ABBREVIATIONS

Unclassified Sherry J Stone, DASG-DSC, 703-681-1868, sherry.j.stone2.civ@mail.mil

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Unclassified

What are we dealing with: Enhanced Multi-Service Markets (eMSMs)

Six eMSMs: Represent 35% of the Direct Care Costs ($2.5B/$8.1 B) • eMSMs are projected to be major touch points for the recovering warrior community

• eMSM are markets with: • Treatment facilities from more than one Service • Large eligible populations (greater than 65K)

• High patient workloads • “Enhanced” Authorities allow the eMSM Managers to:

• Implement a market approach to advance population health • Execute a 5-year business performance plan to improve care

• Allocate market funding where the need is greatest • Disseminate clinical and business best practices across facilities to improve effectiveness

eMSM *San Antonio

eMSM Hawaii

eMSM Puget Sound

eMSM Tidewater

eMSM *Colorado Springs

eMSM NCR

MTFs MTFs MTFs MTFs MTFs MTFs

Medical Deputies Action Group (MDAG)

DSGs/DHA Dep. Director

Senior Military Medical Action Council

(SMMAC) HA/Service SGs

ASD (HA) MHSER

Sherry J Stone, DASG-DSC, 703-681-1868, sherry.j.stone2.civ@mail.mil

eMSM NCR

* Rotate Service-lead every 2 years

Services own the Markets

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Performance Planning Roles and Responsibilities

• HA/DHA • Establish enterprise-level performance targets • Provide annual Performance Planning guidance and communication of the MHS Strategy to the Services • Update, develop and monitor all enterprise level performance measures • Provide Services with monthly MTF level performance reports • Support knowledge management and best practice transfer through various training venues

• Service Headquarters/eMSMMarket Managers • Communicate the guidance and the strategy to their local MTFs • Review and approve MTF level performance targets and plans • Review and aggregate MTF performance projects to determine Service performance • Submit approved performance plans to HA/TMA • Communicate identified best practices to HA/TMA • Distribute HA/TMA performance measure reports to MTFs

• MTFs • Complete production plans and submit them to Service HQs • Establish projections with action plans to achieve applicable performance measures • Provide an explanation of how you plan to coordinate beneficiary care in your MSM.

MHS Performance Dashboard Report as of 10 SEPT 2015

Developmental Status: A = Accountability; I = Improvement; E = Exploratory *NPIC calculates + provides the MHS w/ MHS, Service + MTF status relative to the NPIC database average

**Indicates Process Improvement Priority ▼ Lower is better Indicates measure

under development - 20 -

STRATEGIC ALIGNMENT PERFORMANCE MEASURE DEV.

STATUS MHS PERFORMANCE THRESHOLDS COMPONENT PERFORMANCE

AIM OBJECTIVE RED GREEN BLUE A N AF NCR MD PSC AS OF DATA ENTRY

Readiness

Medically Ready Force (PLS1) Individual Medical Readiness (IMR) I 87% <75% ≥85% 90% 84% 90% 89% N/A N/A Jun 15 Sept 15

Ready Medical Force (PLS2) TBD --- --- --- --- --- --- --- --- --- --- ---

Better Health

Healthy People (PLS3) TBD --- --- --- --- --- --- --- --- --- --- ---

Improve Healthy Behaviors (IP5) HEDIS Cancer Screening Index I 63% 50% 70% 90% 88% 94% 73% 79% 36% May 15 Sept 15

Better Care

Improve Clinical Outcomes and Consistent Patient Experience (PLS4)

▼ Risk Adjusted Mortality (All Cause) E .82 TBD TBD TBD .89 .74 .63 .98 Mar 15 Sept 15 Inpatient: Recommend Hospital (Satisfaction) I 75% <71% ≥73% ≥75% 71% 75% 80% 85% 73% Mar 15 Sept 15

Overall Satisfaction w/Healthcare (Outpatient) I 94% Service Specific Service Specific Service Specific 92% 95% 96% 93% 92% Mar 15 Sept 15

Improve Safety (IP9)

▼ **HAI (CLABSI) I 14 N/A N/A 0 9 4 1 0 N/A Jun 15 Sept 15

▼ **PSI 5 - Retained Surgical Item or Unretrieved Device Fragment Count (Per Year) I 11 N/A N/A 0 10 1 0 0 N/A Dec 14 Jun 15

▼

National Surgical Quality Improvement Program (NSQIP) (30 Day) All Case Morbidity Index I 82% of

MTFs green 10th percentile 11th - 89th percentile 90th percentile Multiple scores per service N/A Dec 14 Sept 15

CAUTI 14 TBD TBD TBD 12 1 1 0 N/A Jun 15 Sept 15 Wrong Site Surgery 11 TBD TBD TBD 7 0 1 3 N/A Jun 15 Sept 15

Improve Condition-Based Quality Care (IP7)

**HEDIS Diabetes Index I 54% 50% 70% 90% 68% 80% 76% 80% 20% May 15 Sept 15 **HEDIS Appropriate Care Index (Low Back Pain, Pharyngitis, URI) I 47% 50% 70% 90% 41% 67% 63% 61% 31% May 15 Sept15

▼ NPIC Post-Partum Hemorrhage* E 3.9% 2σ above NPIC avg.(3.3%)

within 2σ of NPIC avg. (3.3%)

2σ below NPIC avg.(3.3%) 3.8% 3.6% 4.3% 5.6% N/A Dec 14 Sept 15

▼ NPIC Vaginal Deliveries w/Coded Shoulder Dystocia Linked to a Newborn ≥ 2500 grams w/Birth Trauma* I 10.9.% 2σ above NPIC

avg.(12.5%) within 2σ of NPIC

avg. (12.5%) 2σ below NPIC

avg.(12.5%) 11.2% 7.1% 16.7% 0% N/A Dec 14 Sept 15

HEDIS (30-Day) Mental Health Follow-Up I 79% 50th percentile (74%)

75th percentile (81%)

90th percentile (85%) 87% 86% 78% 85% 61% May 15 Sept 15

▼ HEDIS All Cause Readmission E 1.45 50th percentile (0.79)

75th percentile (0.73)

90th percentile (0.68) 1.46 1.39 1.27 1.80 N/A Nov 14 Jun 15

ORYX Transition of Care Index (Asthma, VTE, Inpt Psy(2)) I 50% 60% 75% 100% 44% 56% 50% 63% N/A Sept 14 Jun 15

AHRQ Prevention Quality Indicator (PQI) Index I 94% 70% 80% 90% 94% 94% 94% 94% N/A Dec 14 Sept 15

Improve Comprehensive Primary Care (IP8)

PCM Continuity I 61% 55% 65% 81% 61% 63% 61% 54% N/A Apr 15 Jun 15 PCM Empanelment E <1,100:1 1,100:1 >TBD

▼ Primary Care Leakage I 25.3% >24% 24% to > 20% ≤ 20% 22.8% 26.6% 27.5% 26.3% N/A May 15 Sept 15

▼ **Avg. No. of Days to Third Next Available Future Appointment (Primary Care) I 7.6d >7d 7.0d 2.2d 6.4d 6.8d 8.8d 11.0d N/A Aug 15 Sept 15

▼ **Avg. No. of Days to Third Next Available 24 Hour Appointment (Primary Care) I 1.7d >1d 1.0d 0.8d 1.9d 0.9d 2.0d 2.5d N/A Aug 15 Sept 15

Optimize & Standardize Access & Other Care Support Processes (IP10)

**Percent of Direct Care Enrollees in Secure Messaging I 37% <50% ≥50% ≥60% 29% 45% 42% 40% N/A July 15 Sept 15

**Satisfaction with Getting Care When Needed (Service Surveys) I 86% Service Specific Service Specific Service Specific 83% 90% 91% 83% 90% Mar 15 Sept 15

Lower Cost

Improve Stewardship (PLS5)

▼ PMPM I $370 10.6%

>2.8% yearly growth

2.8% to > 0% yearly growth ≤ 0% yearly growth 13.2% 5.4% 9.4% -3.9% 11.6% Mar 15 Sept 15

▼ Total Purchased Care Cost E $-47.7M -2.5% Service Specific Service Specific Service Specific -7.0% -0.8% 0.3% -3.6% N/A Dec 14 Mar 15

▼ Private Sector Care Cost per Prime Enrollee I $194 17.3%

>2.8% yearly growth

2.8% to > 0% yearly growth ≤ 0% yearly growth 33.0% 22.2% 17.3% 2.8% 13.2% Mar 15 Sept 15

OR Utilization E

**Total Enrollment I 3.58M -0.1% <0% yrly growth 0% to < 5% yrly

growth ≥ 5% yrly growth -0.9% 3.1% -2.0% 1.4% N/A Aug 15 Sept 15

▼ Pharmacy Percent Retail Spend I 54.7% >40% 40% to > 35% ≤35% 57.1% 57.4% 51.3% 41.0% N/A Apr 15 Sept 15 Productivity Targets I 93% Service Specific Service Specific Service Specific 94% 93% 93% 80% N/A Jun 15 Sept 15

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Evolution of the Approved eMSM Core Measures

“Medically Ready Force…Ready Medical Force”

1. Ambulatory RVUs per 100 Enrollees

2. Unfilled Appointments 3. No Show Rates 4. Percent Retail Pharmacy

Spend 5. Total Purchased Care Spend 6. Bed Days per 1000 Enrollees 7. Average Daily Patient Load 8. OR Utilization (# of Cases,

IP/OP Breakdown, Surgical IP CMI)*

9. ROFR 10.Prime Enrollment

1. Fully Individual Medical Rate

2. Surgical Currency 3. Case Mix Index 4. Framingham Risk Score 5. Prevalence of Health

Related Behaviors 6. Patient Safety Score 7. Clinical / Functional

Outcomes for Behavioral Health

8. AHRQ Prevention Quality Indicator

9. Primary Care Leakage 10. Overall Satisfaction

with Healthcare – Inpatient

11. Overall Satisfaction with Healthcare – Outpatient

12. PMPM 13. Private Sector Care

Cost per Prime

Enrollee

14. Percent Retail Pharmacy Spend

15. Productivity Targets 16. PCM Empanelment

Targets

FY14 Business Performance Plan

Measures Proposed FY15 eMSM Core Measures – Under

Development

In FY 14 the Quarterly Performance Reviews measured the original “9+1” measures

1. Primary Care Leakage 2. Overall Satisfaction with

Healthcare – Inpatient 3. Overall Satisfaction with

Healthcare – Outpatient 4. PMPM 5. Private Sector Care Cost per

Prime Enrollees

6. Percent Retail Pharmacy Spend 7. Total Purchased Care 8. Productivity Targets 9. PCM Empanelment Targets

10. Prime Enrollment 11. Recapture 12. Operating Room Utilization

MDAG-Approved eMSM Core Measures for FY15 Quarterly Review

The Strategic Action Group (SAG) and Analytics Cell jointly identified the FY15 eMSM Core Measures. However, several are still being refined, and have not been approved by the MDAG

*Note: Measures in bold are captured in the MDAG-approved core measures for FY15 Quarterly Review

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MHS Performance Planning Guidance

• Enroll to Capacity as defined by MHS and Service standards; • Increase operating room utilization, Ambulatory Procedures, and Surgical Relative Weighted Products

(RWPs) through complex cases performed by military providers with a corresponding decrease in purchased care surgical procedures and RWPs while supporting readiness;

• Increase utilization of staffed inpatient capacity through capture of more complex specialty care, thereby supporting readiness while decreasing purchased inpatient care;

• Reduce overall Market pharmacy expenditures (retail) • Decrease Market primary care and non-emergent Emergency Room and Urgent Care Center (direct

and purchased care) costs; • Reduce the Per Member Per Month (PMPM) average for each eMSM. • Improve effectiveness of disease management, particularly for diabetes, cardiovascular disease, and

behavioral health; • Provide special attention to high utilizers through medical management in order to reduce demand

while improving their health; • Demonstrate reductions in unhealthy behaviors in our enrolled population, resulting in a healthier

population; • Foster an environment of Health through the Patient Centered Medical Home to enhance

communication, learning and Patient-Provider engagement resulting in an overall increase in inpatient and outpatient satisfaction.

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Productivity Target Setting

• Modernization Study Based on MGMA Standards • Sample MHS Average in FY12, and projected FY17 Average (work RVUs)

Provider Specialty Current Provider Level Future Provider Level % Increase Current Modeled260102 ALLERGY/IMMUNOLOGY 1,462 1,965 34% 4,277 34.2% 45.9%260103 EMERGENCY MEDICINE 2,568 2,920 14% 6,266 41.0% 46.6%260107 DERMATOLOGY 2,331 3,237 39% 7,840 29.7% 41.3%260113 NEUROLOGY 2,090 2,197 5% 4,862 43.0% 45.2%260115 OBSTETRICS/GYNECOLOGY 3,150 3,289 4% 6,714 46.9% 49.0%260117 OPHTHALMOLOGY 3,936 4,154 6% 8,573 45.9% 48.5%260119 OTORHINOLARYNGOLOGY 2,889 3,125 8% 7,118 40.6% 43.9%260124 COLON AND RECTAL SURGERY 1,808 3,222 78% 8,056 22.4% 40.0%260125 PSYCHIATRY 1,279 1,569 23% 3,539 36.1% 44.3%260130 GENERAL SURGERY 2,101 2,761 31% 6,812 30.8% 40.5%260131 NEUROLOGICAL SURGERY 2,257 3,894 73% 9,548 23.6% 40.8%260132 ORTHOPEDIC SURGERY 2,783 3,231 16% 7,981 34.9% 40.5%260133 PLASTIC SURGERY 2,020 2,897 43% 6,410 31.5% 45.2%260134 CARDIAC/THORACIC SURGERY 2,529 3,688 46% 9,167 27.6% 40.2%260136 UROLOGY 2,796 3,178 14% 7,533 37.1% 42.2%260138 PERIPHERAL VASCULAR SURGERY 1,928 3,522 83% 8,805 21.9% 40.0%260140 PULMONARY DISEASE 1,632 2,654 63% 6,625 24.6% 40.1%260141 GASTROENTEROLOGY 3,412 3,876 14% 8,492 40.2% 45.6%260142 CARDIOLOGY 2,314 3,784 64% 9,406 24.6% 40.2%260143 NEPHROLOGY 1,620 2,523 56% 6,168 26.3% 40.9%260144 HEMATOLOGY AND ONCOLOGY 1,455 1,951 34% 4,726 30.8% 41.3%260145 ENDOCRINOLOGY 1,588 1,998 26% 4,695 33.8% 42.6%260146 RHEUMATOLOGY 1,160 2,005 73% 4,825 24.0% 41.5%260147 CRITICAL CARE/TRAUMA, MEDICINE 1,617 1,664 3% 3,825 42.3% 43.5%260804 OPTOMETRY 3,837 4,011 5% 8,573 44.8% 46.8%

% of MGMA MedianMGMA Median

Skill Type 1 Providers

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FY15 eMSM Provider Productivity (Skill Type 1 Military)

20 20

* * * Critical Care is in Emergency Medicine.

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Productivity Targets – Skill Type II

Skill Type II Productivity Targets Direction Higher is Better Direction Higher is Better Market Military

Target Civilian Target

Market Military Target

Civilian Target

OB/GYN NURSE PRACTITIONER 2,430 2,890 PHYSICIAN ASSISTANT – ER 2,506 2,639

CERTIFIED NURSE MIDWIFE 2,624 3,176 PHYSICIAN ASSISTANT – GI 1,910 2,012

PSYCHIATRIC NURSE PRACTITIONER 1,079 1,652 PHYSICIAN ASSISTANT – NEURO 2,652 2,784

CLINICAL PSYCHOLOGIST 1,150 1,496 PHYSICIAN ASSISTANT – DERM 3,155 3,324

SOCIAL WORKER (PROVIDING THERAPY) 978 1,356 PHYSICIAN ASSISTANT – ENT 2,574 2,712

AUDIOLOGIST 633 762 PHYSICIAN ASSISTANT – UROLOGY 2,045 2,154

SPEECH THERAPIST N/A 1,156 PHYSICIAN ASSISTANT – ORTHO 2,124 2,400

PODIATRIST 2,151 2,420 PHYSICIAN ASSISTANT – CARDIO 1,081 1,339

CHIROPRACTOR N/A 3,811 PHYSICAL THERAPIST 2,079 2,190

OCCUPATIONAL THERAPIST 1,318 1,388

Measure Description

Measure assesses provider productivity growth as compared to productivity targets listed below

Target Derivation

If the market is below 40% of the MGMA median for military providers or 50% for civilian providers, the target should be to reach this level. If the market is already performing above this level, the market should aim to be at or above its current productivity

Provider productivity targets for Skill Type II Providers (Military and Civilian)

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+

eMSM Recapture: Planned, Modernization Target, and Potential

Potential Inpatient Recapture Methodology

• Recapture model was created by TRO-South and approved by all Services

• Inpatient MTF results have been aggregated to the market level

• In order to be considered recapturable: − DRG must have been performed at least

once in the MTF in FY13 − Each procedure (by ICD-9 code) in the

claim must have been performed at least once in the MTF over FY11-FY13

Below is a comparison of planned recapture from eMSM initiatives at full run rate in FY19, full run rate Modernization Study recapture targets in FY19, and combined modeled annual inpatient and outpatient potential recapture

Potential Ambulatory Recapture Methodology

• Recapture model was created by BUMED and approved by all Services

• Facility results have been aggregated to the market level

• In order to be considered recapturable: − Each procedure (by CPT code) in the claim

must have been performed at least 15 times in the MTF in FY12

Total Potential Recapture

• Sum of Potential Inpatient Recapture and Potential Ambulatory Recapture by Market =

*

Projected market recapture may include inpatient-related recapture. NH Oak Harbor and NMCL Everett do not have inpatient capacity to recapture the $2.35M in recapturable inpatient care associated with those catchments.

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31.8

120.7

564.8

75.7

271.9

107.0

20.0 45.7

261.0

75.7

343.6

82.9

0.0

100.0

200.0

300.0

400.0

500.0

600.0

ColoradoSprings

Hawaii NCR PugetSound

San Antonio Tidewater

PA R

VUs—

(K)

PRODUCTIVITY Projected 5-Year Productivity Increase v. Productivity Increase

Target

Projected 5-Year Productivity Increase Productivity Increase Target

eMSM Five-Year Projections The graphs below summarize proposed market impact on enrollment, recapture, productivity and savings

121 112

300

179

140

200

121 137

271

172

138

200

0

50

100

150

200

250

300

350

ColoradoSprings

Hawaii NCR Puget Sound San Antonio Tidewater

Num

ber E

nrol

led

(K)

ENROLLMENT Projected FY19 Enrollment v. FY19 Enrollment Target

FY19 Enrollment FY19 Enrollment Target

69.5 48.6

583.6

77.0

173.3

63.3

0.0100.0200.0300.0400.0500.0600.0700.0

ColoradoSprings

Hawaii NCR PugetSound

San Antonio Tidewater

Savi

ngs—

($M

)

SAVINGS Total 5-Year Net Estimated Savings

Savings

43.4 64.4

583.6

77.0

247.6

66.7 25.8

92.4

424.9

74.3

272.3

71.6

0.0

100.0

200.0

300.0

400.0

500.0

600.0

700.0

ColoradoSprings

Hawaii NCR PugetSound

San Antonio Tidewater

Rec

aptu

re—

($M

)

RECAPTURE 5-Year Projected Recapture v. Cumulative 5-Year Mod Target

Recapture (minus Rx) Cumulative 5-Yr ModernizationTarget

Slide 23

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eMSM Performance to FY15 Plan

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eMSM Performance to FY15 Plan

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Executive Summary San Antonio eMSM

FY16 FY17 FY18 FY19 FY20 Total Net Estimated Savings ($M)

Savings $49.8 $52.1 $52.5 $53.0 $53.4 $260.8 Costs $16.9 $17.6 $17.8 $18.0 $18.2 $88.6 Net $32.9 $34.4 $34.7 $34.9 $35.2 $172.1

Productivity Change Productivity

Target Targeted Annual Productivity (PA Work RVU) 5-Yr Change

2.4M 2.3M 2.4M 2.4M 2.4M 2.4M 111K Enrollment Change

Enrollment Target

Targeted Annual Enrollment (Prime) 5-Yr Change

133,465 133,465 133,465 133,465 133,465 133,465 0 Recapture

Recapture Target

Annual Recapture ($M) Total

$272.3M $49.8 $52.1 $52.5 $53.0 $53.4 $260.8M

Initiative

Impact (Insert an “X” to those that apply)

Net Cost

Savings Potentia

l ($M)

Imple- mentatio

n Costs ($M)

Total Product

- ivity

Change

Total Enroll- ment

Change

Total Recap-

ture ($M) Readiness Healt

h

Health

Care Cost Access Qualit

y Safet

y

Orthopedic Recapture x x x x x $3.2 $1.4 $4.6

Behavioral Health Recapture x x x x x x x $8.8 $12.0 $20.8

Pharmacy Recapture x x - - -

Enrollment Growth x x x x x - - 0 -

Inpatient Transfer Service x x x x $16.7 $7.2 $23.9

Transform Access (Productivity Enhancement) x x x x x x x $131.3 $56.3 111K $187.5

Physical Therapy x x x x x $12.1 $11.9 $24.0

Total $172.1 $88.6 $260.8

Capability Overview

# MTFs

# ORs # Total Beds Skill Type 1 & 2

Providers

Total DHP Direct Care

Funding* Physical Staffed Physical Staffed

10 32 32 446 366 786 $990.9M

* Includes MILPERS FY15 Population

Eligible All

MTF-Enrolled Prime

MCSC-Enrolled

Prime

232.6K 126.4K 11.8K

FY16 Market Business Performance Plan Mission, Vision, Anticipated Changes San Antonio eMSM

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Mission

As an enhanced multi-service market, the SAMHS delivers a coordinated continuum of preventive and curative services that are safe, accessible, high quality, and patient centered while promoting patient health, readiness, education, training, and research.

Vision

To be the DoD’s premier system for health and our patients’ first choice for healthcare.

Anticipated Changes

• No significant changes projected to mission, population, facilities, or competitive landscape at this time.

• The new Wilford Hall Ambulatory Surgical Center is scheduled for IOC in CY 16; other than transition to a new space, no changes in capabilities are expected except the addition of six sleep beds (from 10 to 16 total)

• A new Community Based Medical Home (Westover Hills Clinic) will open in July 15 with the capability to enroll 7K Prime and 2K T-Plus

• SAMHS is pursuing the addition of one new MRI and retaining an existing MRI (increase from 5 to 7 total)

• Aggressive deployment of distributed community based portals of care by network partners (i.e. UCCs, ERs, Imaging, Pharmacy, etc.)

Mission, Vision, Anticipated Changes San Antonio eMSM

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Market Profile San Antonio eMSM

• 240K beneficiaries (includes ~8K trainees not in M2)

• 10 MTFs (includes Center for The Intrepid) under two Service Components – Army and Air Force

• DoD’s largest appointing center with ~90K inbound/ outbound patient contacts per month

• DoD’s only CONUS Level I trauma center—supports 26K square mile coverage for South Texas

• DoD’s largest outpatient ambulatory surgical center

• Operates USTRANSCOM’s Midwest Hub Aeromedical Staging Facility

• 33 Skill Type I/II GME programs

• 57 Nursing/Allied Health training programs

• Top three inpatient network leakage for our enrolled

beneficiaries in FY14 • Inpatient by major diagnostic category: 1) mental

health/substance abuse and 2) musculoskeletal • Outpatient by product line: 1) orthopedics, 2) IM

subspecialties, 3) ER and 4) behavioral health

• Lack of surgical leakage

Category Eligibles Enrolled to MTF Enrolled to MCSC Not Enrolled AD 35,528 22,005 137 13,386

ADFM 46,269 39,545 979 5,745

RET & OTH <65 100,191 64,886 10,501 24,804

RET & OTH >65 50,664 13,349 17 37,298

Total 232,652 139,785 11,634 81,233

Enrollment as of Dec 2014

MDC

2014 Network Inpatient Cost (MTF Prime/ Plus/Reliant)

Mental Health/ Substance Abuse 7,791,279$ Musculoskeletal 2,844,867$

Product Line

2014 Outpatient Network Cost (MTF Prime/ Plus/Reliant)

ORTHO 6,595,173$ IMSUB 6,352,758$ ER 4,519,639$ BH 4,256,464$

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Market Challenges San Antonio eMSM

• Integrating comprehensive PT services, within multi-Service platforms, in a community distributed CONOPS (i.e. one Service’s FTEs working in/for another Service’s MTF)

• Potential shortfalls to recruit and retain qualified PT FTEs in San Antonio

• National shortage of Behavioral Health FTEs—San Antonio’s market as difficult as other to recruit and retain

• Unknown impacts of Pharmacy benefit modification or impacts after actual implementation

• Difficulty in enticing/incentivizing segments of beneficiary population that have “voted with their feet” re: choice of healthcare platform delivery (i.e. Retirees enrolled to MCSC and Standard/Extra beneficiaries)

• Continued economic disincentive reality of network partners to transfer safe and stable patients to Direct Care System

• Continued disconnects across MTFs/Services of basic business process views/actions (i.e. referrals, deferrals, medical management, end of day processing, no-shows, definitions, etc.)—in turn, these do impact integrated and focused efforts for market-wide product lines to achieve HHQ mandated MGMA production standards

• Lack of similar market-wide accreditation—creates barriers and variance to governance, quality, and standardization

• Lack of common IM/IT platform

• Balancing care between enrollees, other beneficiaries, GME, and Readiness Training requirements

• Base access and our limited ability to compete with network partner’s deployment of distributed community based portals of care (i.e. UCCs, ERs, Imaging, Pharmacy, etc.)

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Initiative Overview San Antonio eMSM

Initiative

FY2016 – FY2020 Savings

Potential ($M) Investment

Requirement ($M)

Net Savings ($M)

Orthopedic Recapture $4.6 $1.4 $3.19

Behavioral Health Recapture $20.8 $12.0 $8.8

Pharmacy Recapture See Shared Services

See Shared Services

See Shared Services

Enrollment Growth - - -

Inpatient Transfer $23.9 $7.2 $16.7

Transform Access (Productivity Enhancement) $187.5 $56.3 $131.3

Physical Therapy $24.0 $11.9 $12.1 Total $260.8 $88.62 $172.1

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San Antonio eMSM: Initiative 1 Orthopedic Recapture

Problem Statement:

• FY13 Ortho Recapture Opportunity ~$16-17M

• Inpatient ~$6-7M

• Outpatient~$9.3M

• Total joints, physical therapy, spinal fusion, and podiatry

Rationale for Problem Prioritization:

• Total Joints, physical therapy, spinal fusion, and podiatry offered opportunity for readiness, GME, and cost recapture

Current State:

• Total joint recapture is nearing maturity (recommend closure)

• PT has ~$7M annual network costs (see PT Initiative)

• Spinal Fusion has ~$1.5M annual inpatient network costs

• Podiatry has ~$1.3M in annual outpatient network costs

Key Steps for Implementation:

• Focused attention on deferrals and ROFRs for readiness, GME, and cost impacts

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San Antonio eMSM: Initiative 2 Behavioral Health Recapture

Problem Statement:

• Behavioral Health product line was the #1 leakage specialty in the market

• FY13 MTF Enrolled Leakage

• Outpatient ~$5M

• Inpatient ~$20.6M

Rationale for Problem Prioritization:

• Inpatient and Substance Use Disorders offered opportunity for readiness, GME, and cost recapture

Current State:

• ~$34M purchased care costs

• Difficult national environment overall for the recruitment and retention of qualified FTEs

• RTF effort halted due to insufficient FTEs for safe and sustainable care

• eMSM inpatient demand appears to be decreasing while outpatient demand is increasing

Key Steps for Implementation:

• Aggressive and focused FTE hiring campaign

• Once staff numbers stabilized, RTF will restart with initial 4 bed capacity and end state goal of 12

• Re-evaluation of potential IOP-based initiatives

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San Antonio eMSM: Initiative 3 Pharmacy Recapture

Problem Statement:

• Requirement to maximize direct care and home delivery pharmaceutical benefits and reduce Retail expenditures

• ~$80M Retail Pharmacy Spend

Rationale for Problem Prioritization:

• Direct Care and Home Delivery methods provide savings over Retail costs

Current State:

• Retail costs are ~30% of total eMSM expenditures

• $6M per quarter retail prescription for MTF enrolled patients with specialty medications and compounds contributing to bulk of the cost

Key Steps for Implementation:

• Explore community based direct care system distribution points

• Standardize MTF formularies and add offerings that increase recapture and containment

• Target high dollar users for education on Direct Care and Home Delivery benefits

• Educate providers on Direct Care and Home Delivery options vs. Retail

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San Antonio eMSM: Initiative 4 Enrollment Growth

Problem Statement:

• The requirement to maximize beneficiaries enrolled to the direct care system

Rationale for Problem Prioritization:

• Greater direct care system enrollment supports readiness, GME, and should decrease purchase care expenditures

Current State:

• ~ 7K new MTF prime enrollees untapped in market (CBMH)

• ~11.7K Ret/Ret FM enrolled to MCSC

Key Steps for Implementation:

• Completed a direct in campaign for AD/ADFM from MCSC Prime to MTF

• Opening of new Community Based Medical Home to distribute primary care in the community

• Possible need to re-locate North Central Federal Clinic

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San Antonio eMSM: Initiative 5 Inpatient Transfer Service

Problem Statement:

• Requirement to maximize direct care inpatient admissions

Rationale for Problem Prioritization:

• Greater direct care system admissions supports readiness, GME, and should decrease purchase care expenditures

Current State:

• Transfer service quickly approaching full potential

• ~1.5 patients per day

• Network partners have concerns over further impacts to their bottom line

Key Steps for Implementation:

• Stood up inpatient transfer service to facilitate admissions from the network facilities to SAMMC

• Delivered letter to TRO-S detailing requirement for network partners to transfer (safe and stable) all AD and to offer the choice to all other beneficiary categories (will be placed in MOU)

• Pending evaluation of MCSC proposal for existing network hospitalists to push/encourage additional transfers (above & beyond current levels)

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San Antonio eMSM: Initiative 6 Transform Access (Productivity Enhancement)

Problem Statement:

• Numerous specialties and providers not meeting HHQ MGMA mandated production standards

Rationale for Problem Prioritization:

• If SAMHS meets our patient access and Service’s expectations for cost containment, we anticipate that patient quality, patient satisfaction, cost reductions, and productivity will be realized

Current State:

• Minimal, by specialty, market-wide views or lines of effort to address beneficiary access and the integrated means to achieve production standards

• PSC Cost - $66.6M for MTF enrolled, T-Plus and Reliant

• 33% patient complaints detail dissatisfaction with referral process

• Only 45% of MIL/CIV providers meet MGMA standards

Key Steps for Implementation:

• Action teams, product line by product line, to review and assess COAs for improvement to achieve HHQ MGMA mandated production standards

• Business process teams to review and assess COAs for improvements to remove duplicative/counter/outdated policies that inhibit/prevent provider productivity (access, referrals, etc.)

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San Antonio eMSM: Initiative 7 Physical Therapy Recapture

Problem Statement:

• PT presently staffed for AD care only while we have ~$7M in PSC costs market-wide

Rationale for Problem Prioritization:

• MEDCOM advancing plan to address PT shortfalls within SAMHS

• Analysis suggests ~$5M recapture potential

Current State:

• 43% of referred population non-AD Prime age 45-64

• 25% of network PT consists of pediatric, neurological rehab, vestibular rehab, and other PT outside of SAMHS capability

Key Steps for Implementation:

• Establish PT recapture clinic at the FSH Primary care Clinic (4 PTs, 8 PTAs, 3 MSAs, 1 GS administrator)

• Position PT assets within three clinics (3 PTs, 3 PTAs)

• Fully staff SAMMC inpatient PT service (2PTs, 2 PTAs)

• Increase PT staffing at WHASC and RAFB (3 PTs, 6 PTAs)

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Guidance Overview

Update of FY16 business performance plan • Improve effectiveness of disease management, particularly for diabetes, cardiovascular

disease, and behavioral health; • Provide special attention to high utilizers through medical management in order to reduce

demand while improving their health; • Demonstrate reductions in unhealthy behaviors in our enrolled population, resulting in a

healthier population; • Foster an environment of Health through the Patent Centered Medical Home to enhance

communication, learning and Patient-Provider engagement resulting in an overall increase in inpatient and outpatient satisfaction.

• Enroll prime and empanel others to capacity as defined by MHS and Service standards; • Increase operating room utilization, Ambulatory Procedures, and Surgical Relative Weighted

Products (RWPs) through complex cases performed by military providers with a corresponding decrease in purchased care surgical procedures and RWPs while supporting readiness;

• Increase utilization of staffed inpatient capacity through capture of more complex specialty care, thereby supporting readiness while decreasing purchased inpatient care;

• Reduce Overall Market pharmacy expenditures (direct, retail, and mail order); • Decrease Market primary care and non-emergent Emergency Room and Urgent Care Center

(direct and purchased care) costs; • Reduce the Per Member Per Month (PMPM) average for each eMSM

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Guidance Overview New Measures

• *Diabetes Management • Imaging Studies for Low Back Pain • Mental Health Follow-Up • Unfilled Appointment Rate • Breast Cancer Screening • Cervical Cancer Screening • Well Child Visits

• Non-prime Enrollee Primary Care Workload • Productivity Targets (military and civilian

skill types 1 and 2)

Core Measures‏ Total Purchased Care‏ Private Sector Care Cost per Prime Enrollee‏ Operating Room Utilization‏ Prime Enrollment‏ PCM Empanelment Targets‏ Overall Satisfaction with Healthcare – Inpatient‏ Overall Satisfaction with Healthcare – Outpatient‏ Per Member Per Month (PMPM)‏ Percent Retail Pharmacy Spend‏ Productivity Targets (military skill type 1)‏ Primary Care Leakage‏ Recapture‏

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15 July 15 Notify eMSM / Services (Summit)

FY17 Performance Planning Timeline

Complete or suspense met Incomplete or suspense not met Decision Point

30 June 15 Engage with eMSM to Capture Lessons Learned

Working

8 July 15 Brief MBOG on eMSM Strategic Summit

13 July 15 Brief JOG on eMSM Strategic Summit

15 Aug 15 Produce Market Product Line Targets & Goals

21 Sep – 20 Nov 15 Conduct eMSM Site Visits

15 Sep 15 Finalize eMSM Performance Plan Guidance

10 Feb 16 Final Plans due to MBOG

SMMAC Approval of

Plans

Early Mar 16 MDAG Reviews Plans 17 Feb 16

Milestone: 1) eMSM Strategic Summit: 1-3 Sep 15 2) Publish Guidance: 15 Sep 15 3) Services Review Plan: 15 Jan – 3 Feb 16 4) Final Plans Due MBOG: 10 Feb 16 5) MDAG Reviews Plan: Early Mar 16 6) SMMAC Approval: Early Mar 16

Early Mar 16

eMSM Strategic Summit 1 – 3 Sep 15

eMSMs Develop Plans 1 Oct – 22 Dec 15 Services review draft plans 15 Jan – 3 Feb 16

Joint Review of Market Plans

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Service POCs Name Organization

Lt Col. Kyle Gibson AFMOA / SGHC

Mr. Mike Squires AFMOA/ SGHC

Ms. Sherry Stone Army

Mr. Justin Sweetman DHA

Mr. Thomas Bickett Navy

Ms. Sherie Eva Kim Navy