1. Patient Centered Medical Home (PCMH) Performance Measures May 2012 Office of the Chief Medical Officer TRICARE Management Activity

2. Overview Strategy Review Governance Current Performance Measures Opportunities Constraints 2

3. Strategy Review Major drivers – Rising Costs – more beneficiaries, more entitlements and higher utilization – Persistently low satisfaction relative to private sector care Foundational step to MHS’ transformation to an ]Accountable Care Organization Goal – Implement PCMH model of care at all 470+ primary care practices – Near term – improve PCM continuity, access to care and patient satisfaction – Mid term – manage demand, reduce primary care leakage and ED/primary care/specialty care utilization, improve HEDIS measures and medically readiness – Longer-term impacts – Improve beneficiary health status, increase MTF capacity and enrollment and improve MTF resource optimization 3

4. PCMH Governance Tri-Service PCMH Working Group Tri-Service PCMH Sub-Working Groups (SWG) Performance Measures PMPMAccess To Care IM/IT Private Sector Care PCMH Ad Hoc (Staff Satisfaction, 4 th Letter MEPRS)

5. Tri-Service PCMH Performance Measures Sub-Working Group Multi-disciplinary, Tri-Service and JTF CAPMED –Gina Julian and Dylan Stearns (TMA/PCMH) –CDR Chris Hunter (TMA/Behavioral Health) –Justin Sweetman (TMA/Office of Strategy Management) –LTC Sharon Pacchiana (TMA/HPA&E) –Army, Navy, AF and JTF CAPMED Service leads and analysts Track, monitor and verify measures –Aggregate into PCMH/Non-PCMH practices –Develop target and range recommendations Recommend new performance measures Outreach – 600 clinical leaders trained so far (another 500 scheduled for 2d half of FY12) –PCMH, Recognition and PMPM Guidebooks –Practice/real-world experience 5

6. Strategic Imperative Exec SponsorPerformance Measure Development Status Previous Performanc e Current Performanc eChange FY2011 Target FY2012 Target FY2014 Target Strategic Initiatives Readiness Improve Individual and Family Medical Readiness FHPCMedically Ready to Deploy75% -81%82%85% Implement Policies, Procedures & Partnerships to Meet Individual Medical Readiness Goals TBDMeasure of Family Readiness (i.e., PHA for families) Enhance Psychological Health & Resiliency FHPCPTSD Screening, Referral and Engagement (R/T)48%/64% 42%/71% -6%/+7%50%/75% Integrate & Optimize Psychological Health Programs to Increase Resilience, Wellness & Readiness Implement DoD/VA Joint Strategic Plan for Mental Health to Improve Coordination FHPCDepression Screening, Referral & Engagement (R/T)63%/69%62%/74%-1%/+5%50%/75% Population Health Engage Patients in Healthy Behaviors CPSCMHS Cigarette Use Rate (Active Duty 18-24)26%21%-5%19%18%16% Support the National Prevention Strategy to Promote Healthy Behaviors & Total Fitness CPSC Percent of Overweight/Obese Adults with Documented Weight Issue 17%/54%-30%/75%50%/90%100%/100% CPSC Percent of Overweight/Obese Adolescents/Children with Documented Weight Issue 11%/33%-30%/50%50%/75%100%/100% CPSCExclusive Breastfeeding During Newborn Hospitalization56%62%+6%65%70%80% CPSC HEDIS Index: Preventive Cancer Screens & Well Child Visits (DC/PC) 7/68/6+1/-10/1012/1415/20 Experience of Care Deliver Evidence- Based Care CPSC HEDIS Index: Cardiovascular, Diabetic & Mental Health Care (DC/PC) 23/624/5+1/-129/1836/2450/35 Support the National Partnership for Patients Effort to Improve Care, Transitions and Prevent Harm During Treatment Wounded Warrior Programs Disability Evaluation System Redesign Optimize Pharmacy Practices to Improve Quality and Reduce Cost Implement Patient Centered Medical Home Model of Care to Increase Satisfaction, Improve Care and Reduce Per Capita Healthcare Costs Create Alternative Strategy for Purchasing Care to Improve Performance in Achieving the Quadruple Aim. CPSCHospital Readmission Rate------ CPSCPatient Safety - Wrong Site Surgery------ CPSCAntibiotic Received Within 1 Hour Prior to Surgical Incision94%95%+1%98% Excel in Wounded, Ill and Injured Care CPSC Percentage of Medical Boards Completed Within 30 Days (DAR & IDES) 53%/67%41%/53% -12%/- 14% 60%/60%TBD CPSC Percent of Service Members Rating Medical Evaluation Board Experience as Favorable 51%52%+1%65%70%75% Optimize Access to Care JHOCPrimary Care 3rd Available Appointment (Routine/Acute)72%/50%66%/52%-6%/+2%91/68%92%/70%94%/75% JHOCSatisfaction with Getting Timely Care Rate76%77%+1%78%80%82% JHOC Potentially Recapturable Primary Care Workload for MTF Enrollment Sites 30%34%+4%26%24%22% Promote Patient- Centeredness JHOC Percent of Visits Where MTF Enrollees See Their PCM 51% -60%65%70% JHOCSatisfaction with Health Care59% -61%62%64% Per Capita Cost Manage Health Care Costs CFOICAnnual Percent Increase in Per Capita Costs5.8%4.3%-1.5%3.1%-- Implement Alternative Payment Mechanisms to Pay for Value CFOICEmergency Room Visits Per 100 Enrollees Per Year47/10050/100+335/10030/10025/100 Learning & Growth Enable Better Decisions CPSCEHR Usability Implement Modernized iEHR to Improve Outcomes and Enhance Interoperability Centers of Excellence Improve Governance to Achieve Better Quadruple Aim Performance in Multi-Service Markets Foster Innovation CFOIC Effectiveness in Going from Product to Practice (Translational Research) Develop Our People CFOICHuman Capital Readiness / Build Skills & Currency CFOICPrimary Care Staff Satisfaction MHS Strategic Imperatives Scorecard 6 Design PhaseApproved Funded

7. Performance Review PCMH is accountable for performance PCMH and Behavioral Health (BH) POM Funding tied to Performance against set targets PCMH – one of MHS’ Portfolio of Initiatives (GAO Review) Key measures – NCQA Recognition – Enrollees in MTF PCMHs – PCM Continuity – Access to Care – ED Utilization – Recapturable Primary Care (Leakage) – Patient Satisfaction – Staff Satisfaction

8. NCQA PCMH Recognition FY11 – 46 Level 3 PCMHs – 1 Level 2 PCMH FY12 – Army: 50 – Navy: 53 – Air Force: 25 – JTF CapMed: 2 Support – 7 training events – MHS Guide to Recognition Practice Feedback 8

9. PCMH MTF Enrollment POM performance measure Limited by amount of NCQA recognition funding Tri-Service PCMH Criteria – Enrollees in NCQA Recognized PCMHs: 540K – Tri-Service PCMH practices: 1.78M 9 Source: Services and TOC

10. PCM Continuity Leading indicator of change The “Provider Accountability” metric Improving steadily since Aug 11 – AF highest overall – Army most improved: +16% NCQA-recognized PCMHs 11% higher than MHS overall in Mar 12 – PCMH Average 62% – Above FY12 target of 60% 10 Source: TOC

11. Access to Care – Acute and Routine Access to Care key to fixing satisfaction and leakage No Third Next Available data provided – Inaccurate/sample size too small – resolution pending “Days to” better in PCMHs – Acute: 0.5 days vs 0.8 in Mar 12 (36% better in PCMHs than overall) – Routine: 6.3 days vs 6.5 in Mar 12 (5% better in PCMHs than overall) 11 Source: TOC

12. ED Utilization ED Utilization is declining as access/PCM continuity improves MHS/PCMH averages in the yellow range PCMHs have lower ED utilization than direct care overall – Lowest: AF 41.9/Navy 42.3 Large MTFs with emergency rooms (ERs) have significantly higher utilization than PCMHs in small MTFs with no ERs – Madigan is exception at 36.8 visits/100 enrollees (green) 12 Source: HPA&E

13. Potentially Recapturable Primary Care Workload for MTF Enrollment Sites Primary Care leakage has improved for three consecutive months – ED utilization declined 12.5% as a percent of all care – PC by others and UCC utilization remained steady Overall, leakage decreased from 33% in Dec 11 to 27% NCQA-recognized PCMH leakage averaged 23% – Achieved FY12 target of 24% – Retrospective data analysis underway 13 Source: HPA&E

14. Patient Satisfaction Overall Patient Satisfaction with healthcare is lower than civilian benchmark Satisfaction is higher in NCQA- recognized PCMHs – Army has highest satisfaction – Navy has greatest difference between NCQA recognized PCMHs and non-recognized Tri-Service PCMH Advisory Board working with DHCAPE to refine metric down to satisfaction with Primary Care – Best measure is 3QC – Average is 83% for both cohorts 14 Source: DHCAPE/TROSS

15. Primary Care Staff Satisfaction Dec 11 MHS R&A approved twice yearly survey Just completed first FY12 survey (Mar 12) – Lower response rate than in Sep 11 (34 vs 26%) – Satisfaction 2% lower overall at 58% (vs. 59% in Sep) Service satisfaction rates similar Correlation and cohort analysis underway 15 Source: DHCAPE/Zogby

16. Direct-Care Specific Demonstrations/Studies MHS Performance Planning Demonstration Dr. Jonathon Gruber Study – MIT Economist/chief architect of the Massachusetts and Obama Administration Healthcare Reform Legislation – Study PCMH performance impact retro and prospectively WRAMC - CMS Healthcare Innovation Challenge Grant Finalist – Data-driven team care to keep people healthy – assess risk, personalize prevention plan and use risk reduction interventions – Focus on Outcome Measures - Impact of chronic conditions, increased well- being, reduced ER visits and hospitalizations, improved patient experience, + return on investment

17. Private Sector Proposed Demonstrations Maryland Demo – TRO North to participate in Maryland Demo to test if PCMH model of care provides higher quality/less costly care and leads to higher patient/staff satisfaction – Measures: costs, satisfaction, 21 quality measures, admissions, primary care visits, ED visits – In SACCP coordination Other proposed demonstrations with our federal partners in development

18. Opportunities PCMH transformation is a process – We need continued leadership support and emphasis – MHS decisions should align with strategy Staff Communication and Outreach Beneficiary Communication and Outreach – Increase presence in beneficiaries’ “virtual space” Focus on performance – Best Practice proliferation – MTF Cost and Utilization Guidance (PMPM, etc.) – Access to Care Guidance – Focus on High Utilizers/Chronically Ill Expanding patient-centered spectrum of care through specialty care optimization and standardization 18

19. Constraints Nurse Advice Line implementation delay 4 th Letter MEPRS – embedded specialists IM/IT and Business Intelligence – Tri-Service PCMH IM/IT Sub-working Group developed and coordinated High Level Requirements (HLR) – First PCMH/IMIT Summit held 26-27 Apr 12 Needs Identified: – Alignment and decision-making between PCMH and IM/IT – $9-13M Secure Messaging unfunded requirements – More reliable, relevant, timely and actionable data – Need to make or buy tools to enhance patient-centered care Get rid of what doesn’t work to fund what can – HLR can inform development of iEHR Need better cost impact data/tool – Have access to access, continuity and satisfaction but lagging on cost impact data 19

20. Summary PCMH being implemented across not only the MHS but US government, states and private sector Foundation of MHS’ move to an accountable care organization Most measured, mature and supported MHS Initiative PCMH concept of care is data-driven –More/better data and tools needed