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MHS Stakeholder’s Report
Exp
erie
nce
of Care Population H
ealth
Per Capita Cost
Readiness
The Quadruple Aim:Working Together, Achieving Success
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3. DATES COVERED 00-00-2011 to 00-00-2011
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7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) Department of Defense,Military Health Service,Washington,DC,20319
8. PERFORMING ORGANIZATIONREPORT NUMBER
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Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18
TableofContents
1.0 AssistantSecretaryof DefenseforHealthAffairs............................................................................... 1
2.0 SurgeonGeneralof theAirForce.......................................................................................................... 2
3.0 TheSurgeonGeneral/Commander,U.S.ArmyMedicalCommand.................................................. 3
4.0 SurgeonGeneralof theNavy’sBureauof MedicineandSurgery..................................................... 4
5.0 CoastGuardDirectorof Health,SafetyandWork-Life..................................................................... 5
6.0 MHSbytheNumbers.............................................................................................................................. 6
7.0 MonitoringOurStrategicPerformance............................................................................................... 14
Readiness.................................................................................................................................................. 15
PopulationHealth................................................................................................................................... 18
Experienceof Care................................................................................................................................. 20
ManagingPerCapitaCost..................................................................................................................... 24
LearningandGrowth............................................................................................................................. 27
8.0 ScanningtheEnvironmentforFutureChallenges............................................................................. 29
9.0 ALookattheMHSStrategicInitiativesfor2011.............................................................................. 30
1
1.0 AssistantSecretaryofDefenseforHealthAffairs
Forover20years,I’vebeenproudtoweartheArmyuniform—asanofficerandphysician.Andnow,IhavethegreatopportunitytoserveinaciviliancapacityasamemberofthisAdministration,andasapartnerwithyouinleadingtheMilitaryHealthSystem.Ihavealwaysbeenattractedtothemilitaryculture’spreferenceforinnovationanddistasteforthestatusquo.Theachievementsofmilitarymedicineonthebattlefield,intheoperatingroom,andthroughoutmilitaryhospitalsandclinicsaretestamenttothisvirtue.
The2011MHSStakeholders’Reportcapturesthisfacetofourculture—anhonestappraisalofourperformance.Welookatthefacts,andathowweperformedagainstthegoalswehavesetforoursystem.BothfrommytimeinuniformandmytimeinBoston,IamdeeplyfamiliarwiththeMHS’strategicframework,theQuadrupleAim.Readinessisalwaysatthecenterofourstrategy,surroundedbythecriticalimperativesthatsupportthepatientexperienceofcare;populationhealthandproperlymanagingcostforeachmemberweserve.
Asweenterour10thyearofcombatexperience,Iknowthatweareproudofourmedicalachievements,yetreluctanttocelebratethem.Ouradvancementofmedicalknowledgehascomeatagreathumancost.Evenaswecontinuetosavemorelivesfromwarwoundsthaneverexperienced,in2011wemustcontinuetoensureourwoundedservicemembersandtheirfamiliesreceivetimelyattention,serviceandhighqualitycare—whetherfromourownmilitaryprovidersorfromourcivilianpartners.Wemustpushoursystemtounderstandanddisseminatethelatestmedicalresearchwehavesupported,particularlyintheareasofbraintrauma,behavioralhealth,andotherinjuriesandillnessesthatareadirectconsequenceofdeployment.
Withasharedstrategy,withastrongfoundationofachievement,andwithanabidingfaiththatwecanstilldobetter.Ourgoalsfor2011beginhere.
Dr.JonathanWoodson
2
2.0 SurgeonGeneraloftheAirForce
“TrustedCareAnywhere”isthemantraof theAirForceMedicalService(AFMS).OurprioritiesalignwithAirForceprioritiestoensuremissionsuccessandsupporttheQuadrupleAim.Weembraceourheritageof innovationandrelentlesslypursueadvancestoenhancesafety,effectiveness,andefficiencyof carewedelivertobeneficiariesandsupportweprovidetoCombatantCommanders.
Readinessisourmission.Byleveragingouruniqueexpeditionarycapabilitieswithourglobalaeromedicalevacua-tionsystem,theAFMShastreatedandsafelyreturnedover77,600patientsfromtheatersof operation.Togetherwithjointandcoalitionpartners,wearetransforminghomelanddefenseanddeployablecapabilitiesacrossthespectrumof operationsfrombuildingpartnershipcapabilitiestocombatoperations.
Understandingthevalueof patient-centeredcare,theAFMSisleaningforwardtobuildthelargestnetworkof Patient-CenteredMedicalHomes(PCMH)intheUnitedStates.OurfocusisonachievingBETTERHEALTHandBETTERCAREof ourairmenandtheirfamiliesthroughdeliveryof preventiveandcomprehensivecare.With340,000patientsenrolledtodaytoPCMH,wearedemonstratingBESTVALUEthroughreducedemergencyroomvisits,increasedaccess,continuityof care,patientsatisfaction,andbetterinformationforprovidersandhealth-careteamstomakedecisions.
Sustainabilityisessentialandweareinvestingineducation,trainingandresearchtoensureasteadypipelineof medicswillalwaysbeREADYforournation’scall.Wepartnerwithcivilianinstitutions,Veteran’sAffairsandjointpartnerstobuildthenextgenerationof careandcapability.Throughtheseefforts,wesustaincurrency;improvesurvivabilityof ourwoundedwarriors,andenablethetransferof knowledgetochangethepracticeof medicine.
Trustisthefoundationof ourmilitaryandmedicalprofessions.Byexecutingourstrategies,weareconfidenttheAFMSwillcontinuetoprovideworldclasscareandcontinuetoshapethefutureof militaryhealthcare.
Lt.Gen.CharlesB.Green
3
3.0 TheSurgeonGeneral/CommanderU.S.ArmyMedicalCommand
ArmyMedicinecontinuestomakegreatstridesinpromoting,sustainingandenhancingsoldierwell-beinganddeliveringleading-edgehealthservicestoourwarriorsandtheirfamilies.Weareleveragingtechnologyandinnovationtotrain,developandequipourmedicalforcetosupportfullspectrumoperations.Toprovidevaluetoourstakeholders,ArmyMedicineisshiftingfromahealthcaresystemthatmeasuressuccessby
thenumbersof patientstreatedandproceduresperformedtoasystemof healththatpromotesandprotectshealth—asystemthatpreventspatientsfromneedingtreatment,andtreatsthemasreliablyandeffectivelyaspossibleshoulditberequired.Wehavechangedoursystemfromafocusonepisodesof caretoalifelongcommitmenttooptimalclinicaloutcomesof thecareweprovide.Thisisadramaticchangefromtheoldwayof doingbusiness,butwebelieveitiswhatourpatientsandfamiliesexceptof us.Webelieveitwillalsoresultinthemostefficientuseof resourceswithintheArmyhealthcaresystem.Werecentlylaunchedaseriesof initiativesgearedtowardimprovingthecareforoursoldiersandtheirfamilies.
AmongtheseinitiativesistheComprehensiveBehavioralHealthSystemof Care(CBHSOC)whichwillstandardize,coordinateandsynchronizebehavioralhealthservicesacrosstheArmyandthroughouttheArmyForceGeneration(ARFORGEN)cycle.Anothermajorinitiativerecentlyundertakenwasthecreationof thePainManagementTaskForce,thegoalof whichistoimplementacomprehensivepainmanagementstrategythatisholistic,inter-disciplinaryandmultimodalinitsapproachandprovidesoptimalqualityof lifeforpatientswithacuteandchronicpain.Inaddition,werealignedandconsolidatedourregionalmedicalcommandswiththeTRICAREregionsandcreatedaPublicHealthCommandtoprovidecentralcontrolforhealthpromotion,preventivemedicineandveterinaryservices.Finally,wearereturningtotherootof servicetoourpatients:A“Cultureof Trust”withinArmyMedicinewhichtightensthebondtothesoldiersandfamiliesweserve.Ourgoalandourpledgeisnothinglessthantoprotectthehealthof oursoldiersandfamiliesandtoprovidethe
absolutebesthealthcarepossible.ArmyMedicine:BringingValue…InspiringTrust!
Lt.Gen.EricB.Schoomaker
4
4.0 SurgeonGeneraloftheNavy’sBureauofMedicineandSurgery
NavyMedicineisathriving,globalhealthcaresystemfullyengagedandintegratedinprovidinghighqualityhealthcaretobeneficiariesinwartimeandinpeacetime.OurhighlytrainedpersonneldeploywithsailorsandMarinesworldwide—providingcriticalmissionsupportaboardship,intheair,undertheseaandonthebattlefield.Atthesametime,NavyMedicine’smilitaryandcivilianhealthcareprofessionalsareprovidingcareforuniformedservices’familymembersandretireesatmilitarytreatmentfacilitiesaroundtheglobe.Everyday,nomatterwhattheenviron-ment,NavyMedicineisreadytocareforthoseinneed,providingworldclasscare,anytime,anywhere.Asweenter2011,wefindourselvesatanimportantcrossroadsformilitarymedicine.Theoperationaltempoof
today’smilitaryhasbeenunrelenting.Meetingtheincreaseddemandforhealthcareprovidersbothinthemilitaryandcivilianworldisachallengefacingusall.Howwecollectivelyrespondtothesechallengeswilllikelysetthestagefordecadestocome.DuringthelongwarsinIraqandAfghanistan,we’vemadeincredibleadvancementsinhowwecareforandtreatourheroesandourcaregivers,includingthelowestmortalityrateamongsttraumavictimscomingoutof thewar.AsoperationsinIraqwinddown,wemustmaintainkeenfocusonourcontributionstoAfghanistanandourcommitmenttoourwoundedwarriorsandtheirfamilies.Wemustanticipatecaringforthemfortherestof thiscentury,whentheyoungsailorsandMarinesof todaymatureintoouragingheroesof tomorrow.Regardlessof thechallengesahead,NavyMedicineiswell-positionedforthefuture.AsIcompletemylastyearas
theNavy’sSurgeonGeneral,Iamconfidentthatwewillovercomeanyobstaclesinourabilitytomeetourworld-wideoperationaldemandsandcontinueourcommitmenttoprovidehigh-qualitypatient-andfamily-centeredcaretoourgrowingnumberof beneficiaries.
ViceAdm.AdamJ.Robinson
5
5.0 CoastGuardDirectorofHealth,SafetyandWork-Life
AsAmerica’spremierMaritimeGuardian,theCoastGuardisamilitary,multi-missionforceAlwaysReadytorespondtoallhazardsandthreats.TheCoastGuardHealth,SafetyandWork-Life(HSWL)DirectorateguardstheGuardians,continuouslyensuringCoastGuardpersonnelareAlwaysReadytoaccomplishthemission.Whetherrespondingtocatastrophicnaturaldisasters,unprecedentedoilspills,operationalmishapsoraninfluenzapandemic,HSWLteammembersensureCoastGuardGuardiansarecontinuouslyabletomeetoperationalrequirements.TheHSWLDirectorate’s2011strategicvisionandbusinessplanalignswiththeMHSQuadrupleAimandprovides
thestrategiccompassthatguidestheprogramintheexecutionof itsmission.Undertheguidanceof theQuadAim,theHSWLprogram’sfocusfor2011is:• ProvidingforamedicallyreadyandprotectedCoastGuardActiveDutyandReserveForce(Readiness)• Maintaininganddevelopinganoperationalcapabilityandoperationallyreadymedicalforce(Readiness)• Implementingastate-of-the-artelectronicandpersonalhealthrecordthatfacilitatesreadiness,pophealth,enhanceddocumentationandbillingtransparency(allQuadAimelements)
• IncreasingCoastGuardmembers’andtheirfamilies’resiliencethroughextensiveuseof theHealthRiskBehaviorsurveyresults,improvementsintheCoastGuard’sSexualAssaultPreventionandResponseProgramandassuranceof individualmedicalreadinessfactors(ReadinessandPopHealth)
• StandinguptheCoastGuardPatient-CenteredMedicalHomeprogramtoimplementpolicyandpracticesthatimproveoutcomes,qualityandpatientsatisfaction(Experienceof Care)
• ImplementingtheMedicalEncounterReviewSystem(MERS),astandardized,empiricalpatientsatisfactionsurveytiedtoaproviderpeerreviewthatfullyassessestheexperienceof care
• Maturingourbusinessplanningprocesstotiebudgetaryallocationswithstrategicinitiatives(PerCapitaCost)TheCoastGuardwillcontinuetoworkcloselywiththeMHStofullyrealizeallinitiativesguidedbytheQuadAim.
TheHealth,SafetyandWork-LifeDirectoratewillensureCoastGuardGuardiansarecontinuouslyabletomeettheexpectationsof allstakeholders.
RearAdm.MarkJ.Tedesco
6
6.0
MHSbytheNumbers-AWeekintheLifeoftheMHS
TheMilitaryHealthSystem(MHS)isa$49billionorganizationthatprovideshealthservicesto9.6millionbeneficiariesacrossarangeof carevenues,fromtheforwardedgeof thebattlefieldtotraditionalhospitalsandclinicsatfixedlocations.Togetabettersenseof thesize,complexityandamountof carebeingdelivered,hereisanumericalsnapshotof aweekinthelifeof theMHS.
ThenextseveralpagesprovidealookatthetrendsthatreflectthechanginghealthcareenvironmentatMHS.
23,300 inpatient admissions• 5,100directcare• 18,200purchasedcare
1.8 million outpatient visits • 809,000directcare• 1.001millionpurchasedcare
2,400 births • 1,000directcare• 1,400purchasedcare
12.6 million electronic health record messages
2.6 million prescriptions • 924,000directcare• 1.44millionretailpharmacy• 228,000homedelivery
231,000 behavioral health outpatient services• 52,000directcare• 179,200purchasedcare
3.5 million claims processed
7
0
10
20
30
40
50
60
1997 1999 2001 2003 2005 2007 2009 2011
In B
illio
ns
Total MHS Budget
6.0
MHSbytheNumbers–OverallCostTrends
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
2000 2005 2006 2007 2008 2009
Total TRICARE Health Care Cost & Beneficiary Share (Family of Three)
Beneficary Expense Government Cost Beneficary Share
-
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Eligible & Enrolled Population (Retiree and Retiree Family Members Under Age 65)
Eligibles Enrollees
Thetotalcostof operatingtheMHShasrisenoverthepast10years,butthetotaloutof pocketexpenseforTRICAREbeneficiarieshasnotincreased.TheMHSisseekingwaysto“bendthecostcurve”whilecontinuingtoimprovereadiness,populationhealthandhealthcareoutcomes.
OutofpocketcostsforTRICAREbeneficiarieshavedecreasedslightlyatatimewhenmembersofotherhealthplanshaveseenrisinghealthcarecosts.
Between1998and2010moreretirees/retireefamilymembershavetakenadvantageoftheTRICAREPrimebenefit.
Overthepast15years,theMHSbudgethasgrowntomorethan$49Bperyearduetorisinghealthcarecosts,moreusers,theongoingwarsinIraqandAfghanistanandotherfactors.
8
TheeligiblepopulationfortheMHShasgrownby400,000since2007andtheproportionof eligiblebeneficiarieschoosingTRICAREPrimehasalsogrown.Atthesametime,thedirectcaresystemhascontracted,droppingfrom70hospitalsin2004to59in2009.Whiledirectcareoutpatientworkloadhasbeenrelativelyconstant,purchasedcareworkloadhasgrownsignificantlytohandletheincreaseinusersandtheincreaseinutilization.
6.0
MHSbytheNumbers–MilitaryTreatmentFacility(MTF)andPurchasedCareContributionstoCareDelivery
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
2005 2006 2007 2008 2009 2010
Wei
ghte
d Vi
sits
(Ave
rage
Per
Day
)
MHS Outpatient Weighted Visits
Direct Care Weighted Visits Purchased Care Weighted Visits
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
2005 2006 2007 2008 2009 2010
Enro
llees
MHS Enrollment Trends
Military Treatment Facility Health Care Support Contractor
0
50
100
150
200
250
300
350
400
450
500
2004 2005 2006 2007 2008 2009 2010 2011
Medical & Dental Treatment Facilities
Bedded Facilities Medical Clinics Dental Clinics
9
6.0
MHSbytheNumbers–TheDirectCareHealthTeamTheMHSisoneof thelargesthealthcaresystemsintheworld,employingalmost140,000military,civilianandcontractpersonnelwhoworkinthe
MilitaryTreatmentFacilitiesandotherMHSsettingsaroundtheglobe.Thisteamworksinpartnershipwithanetworkof morethan380,000civilianproviders.
Health Care Specialists Health Care Officers
-
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
Total of MHS Personnel Deployed
2004 2005 2006 2007 2008 2009
9.6%
32.8%
33.6%
23.9%
Distribution of Active Duty Health Care Providers
Mental Health Primary Care Specialty Training
0
20
40
60
80
100
120
140
160
2004 2005 2006 2007 2008 2009 2010
Pers
onne
l in
Thou
sand
s
Total MHS Workforce
Officer Enlisted Civilian Contract
TheMHSemploysover14,000activedutyproviders.Theprimarycareteamnowincludesover1,300physiciansassistantsandnearly500nursepractitioners,inadditionto2,900primarycarephysicians.Therearealmost1,400activedutymentalhealthprovidersandnearly5,000physiciansfromotherspecialties.Closeto25%ofprovidersareinformalpost-graduatetraining.
ThetotalMHSworkforcenowincludesmorecivilianandcontractemployees.
Nearly10%oftheentireworkforcehasbeendeployedinsupportofcombatoperationsatanygiventimeoverthepast8years.
1 0
OverthepastnineyearstheMHShasprovidedcontinuousmedicalsupportforcombatoperations;theuseof improvisedexplosivedevicesinIraqandAfghanistanhasresultedinalargenumberof traumaticbraininjuries,amputationsandextremelycomplexinjuries.
6.0
MHSbytheNumbers–CasualtyCare
Amputees with Major Limb Amputations (Operations Enduring & Iraqi Freedom)
0
50
100
150
200
250
2004 2005 2006 2007 2008 2009 2010
0
100
200
300
400
500
600
700
800
900
1,000
0
200
400
600
800
1,000
1,200
1,400
1,600
2008 2009 2010
Surg
ical
Enc
ount
ers
Bed
Days
Bed Days & Surgical Episodes in Theater
Bed Days in Theater Surgical Episodes
Projection(Current datathrough Q3)
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
2003 2004 2005 2006 2007 2008 2009 2010
Conf
irmed
Cas
es
Traumatic Brain Injuries (TBI)
Confirmed Cases of TBI
Sincethebeginningof2010therehasbeenmorethana50%increaseintheatersurgicalepisodesandhospitalbeddaysperquarter.
ThenumberofconfirmedcasesofTraumaticBrainInjuryhascontinuedtoincrease.
Afteradeclinein2008and2009,thenumberofmajorlimbamputationsincreasedin2010asoperationsinAfghanistanintensified.
1 1
6.0
MHSbytheNumbers–CareintheTheaterofOperationsTheongoingwarsinIraqandAfghanistancontinuetoproducebothphysicalandemotionalinjuries.Withtherecentincreaseinintensityof operations
inAfghanistan,thenumberof casualtieshasincreased.
0
200
400
600
800
1000
1200
2007 2008 2009 2010
Per Q
uarte
r
Battle Injuries
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
2009 2010
Mental Health Encounters in Theater
0
50
100
150
200
250
2005 2006 2007 2008 2009 2010
Mental Health Evacuations from Theater
Eachquarterapproximately5,000deployedservicemembersreceiveabout14,000mentalhealthencounterswhileinthetheaterofoperations.
Thenumberofservicemembersevacuatedfromthetheaterofopera-tionsduetomentalillnesspeakedin2009andbegantodecline,butthemostrecentdatasuggestthatitmayberisingagain.
Followingadropin2008,thenumberofbattleinjurieshasrisenin2009and2010.
1 2
Continuouscombatoperationsoverthepastnineyearshaveplacedincreaseddemandsonthehealthsystemforhealthassessments,morecomplexinpatientcareanddisabilityevaluations.
6.0
MHSbytheNumbers–LifeCycleCare
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
2003 2004 2005 2006 2007 2008 2009
Disability Evaluation System Dispositions
Permanent Disability Retired List Temporary Disability Retired List Other
0
50000
100000
150000
200000
250000
300000
350000
400000
450000
500000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Post Deployment Health Assessments (PDHA) &Post Deployment Health Reassessments (PDHRA)
PDHA PDHRA
Average Inpatient Length of Stay (Active Duty at the Three Largest Casualty Receiving Centers)
0.0
2.0
4.0
6.0
8.0
10.0
12.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Days
Brooke Walter Reed Bethesda
In2010,theMHSconductedover700,000postdeploymentscreen-ingsaspartoftheprogramforidentificationandmanagementofdeployment-relatedconditions.
AveragelengthofstayforactivedutymembersatthemajorcasualtycarereceivingcentersincreasedduringthemostintenseoperationsinIraqanddeclinedfollowingthesurge.LengthofstayisonceagainincreasingasoperationsintensifyinAfghanistan.
Overthepastseveralyears,thenumberofservicemembersreceivingamedicalretirementhasincreased.Thenumberofservicememberswhoenterthedisabilitysystembutdonotreceiveamedicalretirementhasdeclined.
1 3
6.0
MHSbytheNumbers–BehavioralHealthCareOverthepastfiveyears,servicemembersandtheirfamilieshavesoughtandreceivedanincreasingnumberof mentalhealthservices.Since2005,the
annualcostof behavioralhealthcarefortheforceandtheirfamilieshasincreasedfrom500milliontoover$1billion.
$-
$100,000,000
$200,000,000
$300,000,000
$400,000,000
$500,000,000
$600,000,000
$700,000,000
$800,000,000
2005 2006 2007 2008 2009 2010
Total Spending on Behavioral Health
Active Duty Family Member Active Duty
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
2005 2006 2007 2008 2009 2010
Behavioral Health Outpatient Visits/Encounters
Active Duty Family Member Active Duty
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
200,000
2005 2006 2007 2008 2009 2010
Tota
l Bed
Day
s
Behavioral Health Inpatient Days
Active Duty Family Member Active Duty
1 4
7.0 MonitoringOurStrategicPerformance
Thecenterpieceof theMHSstrategyistheQuadrupleAim—readiness,bettercare,betterhealth,responsiblymanagedcosts.In2010theMHScreatedaperformancemanagementframeworkbasedonTheQuadrupleAim,
designedtoputstrategytoaction.Overthepast12monthswehaveworkeddiligentlytofinalizeover15performancemeasures,establishedbaselinesandsetaggressivetargetsextendingoutto2014.Overthenextfewpageswewilldescribeourvisionandshowsomeof theindicatorsthatweuseto
determineoursuccessinachievingTheQuadrupleAim.
The MHS Quadruple Aim:Readiness Ensuringthatthetotalmilitaryforceismedicallyreadytodeployandthatthemedicalforceisready
todeliverhealthcareanytime,anywhereinsupportof thefullrangeof militaryoperations,includinghumanitarianmissions.
Population HealthReducingthegeneratorsof illhealthbyencouraginghealthybehaviorsanddecreasingthelikelihoodof
illnessthroughfocusedpreventionandthedevelopmentof increasedresilience.
Experience of CareProvidingacareexperiencethatispatient-andfamily-centered,compassionate,convenient,equitable,
safeandalwaysof thehighestquality.
Per Capita CostCreatingvaluebyfocusingonquality,eliminatingwasteandreducingunwarrantedvariation;considering
thetotalcostof careovertime,notjustthecostof anindividualhealthcareactivity.
Exp
erie
nce
of Care Population H
ealth
Per Capita Cost
Readiness
1 5
7.0 MonitoringOurStrategicPerformance
Readiness
Wemaintainanagile,fullydeployablemedicalforceandahealthcaredeliverysystemsothatwecanprovidestate-of-the-arthealthserviceanytime,anywhere.Weusethismedicalcapabilitytotreatcasualtiesandrestorefunctionandtosupporthumanitarianassistanceanddisasterrelief,buildingbridgestopeacearoundtheworld.Inaddition,wepartnerwithcommandersandindividualservicememberstocreateandsustainthemosthealthyandmedically-preparedfightingforcetobuildresilienceandachievetotalforcefitness.
1 61 6
7.0MonitoringOurStrategicPerformanceReadiness–CasualtyCarefromPreventiontoRehabilitationToaccomplishourmedicalreadinessmission,wemustensurethattheforceismedicallyreadytodeployandthatthehealthteamisreadytoprovide
thefullspectrumof healthservicesfrombattlefieldcasualtycaretorehabilitationandreintegrationservicesforthemostseverelyinjured.
0%
20%
40%
60%
80%
100%
Civilian (FunctionalllyActive & Reintegrated)
Full Duty (Active or Reserve)
Medically Retired (Significant Limitation)
Perc
ent o
f Tot
al M
ajor
Lim
b Am
puta
tions
Amputee Functional Reintegration Rate (Cummulative as of 30 September 2010)
Data through 3rd Quarter
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
2006 2007 2008 2009 2010
Individual Medical Readiness
Active Component Reserve Component
75%
80%
85%
90%
95%
100%
2007 2008 2009 2010
Observed vs. Predicted Survival Rate (Battle Wounds in Operations Enduring & Iraqi Freedom)
Predicted Survivors Observed Survivors
Overall,wehaveseensteadyimprovementinReadinesswithfocusedserviceeffortsstartingtonarrowthegapandaddressourbiggestchallenge,periodichealthassessmentsanddentalreadinessintheReserveandGuardcomponents.
OurprovidershaveconsistentlydemonstratedtraumacareoutcomesinTheaterthatexceedthoseofthebesttraumacentersinAmerica.
Ofthosemajorlimbamputeesforwhomweknowthestatus,80%havebeenretainedonactivedutyorreturnedtofull-timecivilianwork,educationorparentingactivities.
1 7
7.0 MonitoringOurStrategicPerformanceReadiness–ManagingPsychologicalInjuriesOverthepastfiveyears,theMHShasimplementedacomprehensivehealthassessmentprogramthatincludesmentalhealthscreening.Theassessment
processoftenresultsinareferralforamorecompletediagnosisand,if indicated,ongoingtreatment.
Post Traumatic Stress Disorder Engagement Rate
2005 2006 2007 2008 2009 2010 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
65%
Active Duty Reserve Total
Post Traumatic Stress Disorder Screening Rate
2005 2006 2007 2008 2009 2010 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
12%
Active Duty Reserve Total
Post Traumatic Stress Disorder Referral Rate
2005 2006 2007 2008 2009 2010 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
49%
Active Duty Reserve Total
Overthepastfiveyears,therateofpositivescreensforPostTraumaticStressDisorderhasvariedbetween10%and20%amongservicemembersreturningfromdeployment.
Therateatwhichapositivescreenresultsinareferralforadditionalcarehasrisenfrom20%to50%.
Thepercentofservicememberswithadocumentedmentalhealthvisitfollowingareferralhasrisenfrom40%toover65%.Ourdatadoesnotreflectthosewhochosetoseekcarefromachaplain,MilitaryOneSourceoreventheVeteran’sAffairssothetruerateofengagementishigher.
1 8
7.0 MonitoringOurStrategicPerformance
PopulationHealth
Improvedhealthistheresultof aneffectivepartnershipbetweenahealthsystemandaperson.Healthybehaviorsimprovequalityof life.Alternatively,suchunhealthybehaviorsassmoking,over-eating,asedentarylifestyle,alcoholabuseandfamilyviolencereducewell-beingandreadiness.TheMHSstrivestoengagewithallbeneficiariesandenablethemtotakecontrolof theirhealth,sothattogetherwecreateamorerobustandresilientmilitarycommunity.
1 9
7.0 MonitoringOurStrategicPerformancePopulationHealth–ReducingHealthRisksOureffortstoeducatebeneficiariesandencouragehealthybehaviorshaveyieldedpositiveresultsinmostareas.However,fortruebreakthroughperformance
wemustdoabetterjobinunderstandingtherelationshipsandinteractionsbetweenourhigh-riskpopulationsandultimatelywhatdrivestheirlifestylechoices.
90th Percentile
50%
55%
60%
65%
70%
75%
80%
85%
90%
2008 2009 2010
Rate
Cervical Cancer Screening Rate
Direct Care Enrolled Network Enrolled
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2007 2008 2009 2010
Smoking Rates for Ages 18-24
Active Duty Non Active Duty
0%
10%
20%
30%
40%
50%
60%
Active Duty Non Active Duty
Rates as of 3rd Quarter, 2010
Prevalence of Obesity in Adults (Ages 40-49)
The18-24year-oldactivedutymembers’smokingrateishigherthanfornon-activedutybeneficiaries.
Theaverageactive-dutyrateofobesityissignificantlylowercomparedtoretireesofthesameage.Theremaybeanopportunitytointervenetopreventwaistlinegrowthwithretirement.
Womenaremorelikelytohaveadocumentedcervicalcancerscreeningiftheyareenrolledtooneofourmilitarytreatmentfacilities.
2 0
7.0 MonitoringOurStrategicPerformance
ExperienceofCare
Ourbeneficiariesdeservecarethatissafe,highquality,equitableandevidencebased.Theydeserveaccesstohealthcareinareasonabletimeframe,withoutadministrativehassles.Ourpatientshaveuniqueneedsandtheyshouldhavethefreedomtochoosefromavarietyof qualityproviderswhocandeliverindividualizedsolutions.Asweprepareforthefuture,westrivetoseethroughtheeyesof ourbeneficiariesinordertodesignoursystemsof caretomeettheirexpectations.Wewilldemonstratehowourqualitycompareswiththebestof civilianhealthcare.
2 1
7.0MonitoringOurStrategicPerformanceExperienceofCare–ClinicalQualityandSafetyOveralltheMHSisperformingatorabovenationalbenchmarksonselectedmeasuresof evidence-basedcare,thoughevenbetterperformanceis
possible.
90th Percentile
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
2007 2008 2009 2010
Rate
Management of Lipids in Diabetics (LDL < 100mg/dL)
Direct Care Enrolled
90th Percentile
75%
80%
85%
90%
95%
100%
2008 2009 2010
Rate
Appropriate Treatment of Asthmatic Patients
Direct Care Enrolled
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2006 2007 2008 2009 2010
Antibiotics Administered Within 1 Hour of Surgical Procedure
TheMHS’commitmenttotheevidence-basedguidelinesforasthmatreatmenthasresultedinperformancebetterthan90%ofU.S.healthsystems.
TheMHSisensuringtheadministrationofantibioticswithinonehourpriortosurgicalincisioninaccordancewiththebestmedicalevidence.Ourgoalis100%compliance.
TheMHSisstrivingtoensurethatthelipidlevelsofdiabeticpatientsarewellmanaged,butthishasprovenmorechallengingthansomeothermeasures.
2 2
7.0MonitoringOurStrategicPerformanceExperienceofCare–AccessandContinuityAswereengineerprimarycareandimplementPatient-CenteredMedicalHomes,ourgoalisforeachenrolleetobeabletohavetimelyaccessand
receivemostof theirprimarycareattheirenrollmentsite.
0
2
4
6
8
10
12
2009 2010
RVUs
Potential to Recapture Primary Care Workload
Primary Care By Team Primary Care by Others ER Care Urgent Care
0%
10%
20%
30%
40%
50%
60%
70%
80%
2009 2010
Primary Care (PCM) Continuity
Percent of Time Patients See Their Primary Care Manager
2009 20100%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Third Available Primary Care Appointments (Routine & Acute)
Acute Routine
Onaverage,enrolleestomilitarytreatmentfacilitiesseetheirassignedprimarycaremanagerlessthanhalfofthetime.
Atover50%ofMTFprimarycareclinics,ifabeneficiarycallsforanacuteappointmenttheywillbeofferedatleastthreeoptionswithin24hours.
Ourenrolleesarereceivingasmuchas25%oftheirprimarycareoutsideoftheirenrollmentsite.
2 3
7.0MonitoringOurStrategicPerformanceExperienceofCare–SatisfactionTheMHSmaintainsafocusedefforttomonitorandimproveourpatients’satisfactionwithcare.Asaresult,wearenowseeingincremental
improvements.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
2007 2008 2009 2010
Satisfaction with Health Care
Direct Care Network
0%
10%
20%
30%
40%
50%
60%
70%
2008 2009 2010
Favorable MEB Experience
0%
10%
20%
30%
40%
50%
60%
70%
80%
Medical Obstetric Surgical
2006 2007 2008 2009 2006 2007 2008 2009 2006 2007 2008 2009
Satisfaction with Inpatient Care (Overall Hospital Rating)
Direct Care Network Care
Servicememberswhoareinthedisabilityevaluationprocessreportthattheirexperienceisfavorableabout50%ofthetime.
PatientsreceivingobstetricalcareatTRICAREnetworkhospitalsreporthighersatisfactionwithhealthcare.
PatientsenrolledtoTRICAREnetworkprovidersreportahighersatisfac-tionwithhealthcare.
2 4
7.0 MonitoringOurStrategicPerformance
ManagingPerCapitaCost
Wecreatevaluebyenhancingreadiness,improvingpopulationhealthandenhancingtheexperienceof care.Wereducethetotalcostof healthservicesbyoptimizingourinvestmentsinhealthpromotion,preventionandthedevelopmentof resilience,ensuringaccesstofullspectrumprimarycare,focusingonqualityandreducingunwarrantedvariation.Wealsoreducecostsbyseekingthemostcompetitivepricesforpurchasedservicesandensuringthemostappropriatevenueof careforhealthcaredelivery.
2 5
7.0MonitoringOurStrategicPerformanceManagingPerCapitaCostThemajorityof MHShealthcareresourcesarespentonTRICAREPrimeenrolleesandthepercapitacostsforPrimeenrolleeshavegrownsignificantly
since2002.Muchof thatgrowthhasbeenduetoanincreaseinboththecostof individualambulatoryservicesandrisingambulatoryutilization.
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
2005 2006 2007 2008 2009
Per Member Per Month Breakdown (Inpatient, Ambulatory and Pharmacy)
Inpatient Ambulatory Pharmacy
-
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
2002 2003 2004 2005 2006 2007 2008 2009 2010 (Q2)
Cost
TRICARE Prime Enrollee Cost Per Member Per Year
$0
$5,000,000,000
$10,000,000,000
$15,000,000,000
$20,000,000,000
$25,000,000,000
Prime Standard TRICARE for Life
Expense Breakdown by Plan
Pharmacy Inpatient/Outpatient
ThetotalcostofprovidingcareforanMHSenrolleehasrisenbyroughly70%since2002.
TheMHSinvestsnearly$25BperyearinthecareofTRICAREPrimeenrollees. ThetotalcostofprovidingcareforanaverageMHSPrimeenrolleeisjustover$3,000annually,withalmosttwo-thirdsofthetotalbeingforambulatoryservices.
2 6
7.0MonitoringOurStrategicPerformanceManagingPerCapitaCostThreeviablestrategiesforcontrollingcostsaregreateruseof homedeliveryforprescriptions,reductioninemergencyroomuseandcaremanagement.
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
2005 2006 2007 2008 2009 2010
Visi
ts
AD >
100
Vis
its
Active Duty Members > 100 Visits in Fiscal Year
AD Visits
-5%
0%
5%
10%
15%
20%
25%
30%
500
600
700
800
900
1,000
1,100
1,200
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Grow
th R
ate
# of
Rxs
(rou
nded
, in
thou
sand
s)
Home Delivery Growth Trend (Year over Year)
2007 2008 2009 2010 Historic avg growth rate '09 to '10 growth rate
Benchmark (Insured Population)
0
10
20
30
40
50
60
2006 2007 2008 2009 2010
Emergency Room (ER) Utilization
MTF Enrollees HCSC Enrollees
Savingsfromhomedeliveryprescriptionshavebeensignificant,andtheuseofthisvenuefordeliverycontinuestoincrease.
EmergencyroomutilizationforPrimeenrolleescontinuestoclimbandismorethandoubletherateofinsuredindividualsintheUnitedStates.
Thenumberofactivedutymemberswithgreaterthan100visitsinayearhasmorethantripledoverthelastfiveyears,whilecareassociatedwiththosepatientsnowaccountsformorethanonemillionvisitsperyear.
2 7
7.0 MonitoringOurStrategicPerformanceLearningandGrowthTheMHSstrivestoleadtheworldintrainingforcombatcasualtycareand
deliveringhumanitarianassistance.Weseektoserveasbothaglobalandnationalleaderinthemanagementof combat-relatedconditions,thatincludes(butisnotlimitedto)infectiousdisease,psychologicalhealth,eyeinjuries,traumaticbraininjuryandamputations.Wefocusoureducationandresearcheffortsonservinguniquemilitary
missions.Ourmedicalresearchleadstodiscoveriesthatbenefittheworld.Weshareourknowledgeanddiscoveriesfreelywithourmilitaryandciviliancol-leagues.TheMHSdemonstratesthatinadditiontotrainingexpertsandmanagers,its
realvalueisintrainingleaders.Wereflectoursuccessinthequalityof thepeoplewhoselecttheMHSastheiremployeeof choice.
2 8
7.0MonitoringOurStrategicPerformanceLearningandGrowthTobeatruelearningorganizationthatcansustainandimproveperformanceovertime,theMHSmustdeliverinformationeffectivelytoinformbetter
decisions.Weareworkinghardtoimprovethereliability,speedandutilityof ourelectronichealthrecord.Informationwillleadtobetterperformanceif itisdeliveredinausablewaytoacapableandcommittedworkforce.Weneedtoensurewearerecruitingandretainingthebestpossiblehealthteammembers.
0%
20%
40%
60%
80%
100%
120%
2005 2006 2007 2008 2009 2010
Health Professions Scholarship Program (HPSP) and Financial Assistance Program (FAP) Fill Rates
HPSP FAP
204.6
46.4
0
50
100
150
200
250
2009 2010
Down
Tim
e in
Hou
rs
Armed Forces Health Longitudinal Technology Application (AHLTA)
Clinical Data Repository Reliability
4.190
4.159
4.000
4.050
4.100
4.150
4.200
4.250
2009 2010
AHLTA Average Speed (Screen Refresh Time in Seconds)
Between2009and2010,therehasbeenasignificantreductioninAHLTAdowntime.
ThescreenrefreshtimeforAHLTAremainsabovefoursecondsforcomplextasks.
Followingincreasesinbonusesandstipendsin2008,bothHPSPandFAPfillratesareapproaching100%.
2 9
8.0 ScanningtheEnvironmentforFutureChallenges
Population Health Trends• If currenttrendscontinue,asmanyasoneinthreeadultscouldhavediabetesby2050(CDC)
• 42percentof theU.S.adultpopulationmaybeobeseby2050(MIT/Harvardstudy)
• Thepopulationage65andolderasapercentageof thepopulationaged20-64isprojectedtorisefromjustover20percenttodaytoover35percentby2035
DoD Health Care Spending Trends• Approximately9percentof thetotalDoDbudget($712B)willbespentonhealthcare
• Absentanychangesinhealthcarepolicy,thisamountisexpectedtogrowto$70B(over12percentof thetotalDoDbudget)by2020
• TheSecretaryof DefenseintendstocutDoDbudgetgrowthfrom3.5percentperyearto1percentperyearoverthenextseveralyears
National Health Care Reform• Withexpandedcoverageof 35millionAmericans,thereispredictedtobeashortageof primarycareproviderscreatingchallengesforaccess
• Opportunitiestoexperimentwithinnovativecaredeliverymodelsandmethodsof reimbursement
• Likelyrapidexpansionof thePatient-CenteredMedicalHomeinprimarycarewillinfluenceplanningforthenextgenerationof TRICAREcontracts
3 0
9.0 ALookattheMHSStrategicInitiativesfor2011Readiness• Supportingpsychologicalhealthandresiliencefortheforceandtheirfamilies• Improvingindividualmedicalreadiness
Population Health• Reducingobesity• Reducingtobaccouse
Experience of Care• ImplementingPatient-CenteredMedicalHome• Improvingcarecoordinationforpatientswithcomplexmedicalandsocialproblems
Per Capita Cost• Implementingvalue-basedreimbursement• Reducingemergencydepartmentutilization• Reducingwastebyfocusingonclinicalvariation• Reducingpharmacyexpendituresbyincreasinghomedeliveryandappropriateuseof generics
Learning and Growth• Centersof Excellence• EHRWayAhead• Completeimplementationof BRAC
Exp
erie
nce
of Care Population H
ealth
Per Capita Cost
Readiness
3 1
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