2012 Leadership Outlook
MMT 2012 Volume: 16 Issue: 1 (February)
Dr. Jonathan Woodson
Assistant Secretary of Defense (Health Affairs)
Director of TRICARE Management Activity
Ensuring Coordinated Care for our Troops
As we enter 2012, our mission and our priorities are one—to ensure the medical readiness of our servicemembers and to provide a ready medical force able to deliver the best medical services anywhere in the world, under any conditions, to all of our beneficiaries.
Despite the completion of our military mission in Iraq, we remain a military engaged in combat operations in Afghanistan. Our duties in other locations in the region, and around the world, continue to require our unwavering attention to this readiness mission. As our wounded warriors return to the United States, our ongoing obligations to them and their families remain paramount. We will do everything within our ability to return them to active service, or ensure their carefully coordinated transition to ongoing care through the VA or the private sector.
Here at home, the operating platforms from which we develop our ready medical forces have been transformed. We’ve opened new, jointly staffed medical facilities in the National Capital region—at the new Walter Reed National Military Medical Center and the Fort Belvoir Community Hospital, a new tower at the San Antonio Military Medical Center and a new campus for the Medical Education and Training Center in San Antonio—and implemented a number of other physical changes to our infrastructure. These changes are driving an increased level of collaboration and jointness in operations, logistics, education and training, information technology and a host of other areas.
Partly related to this growing collaboration in the medical arena, the Deputy Secretary of Defense established a Task Force on the Governance of the Military Health System in June of last year, with the responsibility for evaluating how the MHS should be organized for the long term. Dr. Peach Taylor, of the Health Affairs staff, and Major General Doug Robb, the joint staff surgeon, led the task force through a number of organizational alternatives. The department is now working with the Comptroller General of the United States—the GAO—to provide an external assessment of the task force’s review and findings in accordance with the 2012 National Defense Authorization Act. While this review is underway, however, we will move aggressively move forward on a number of other fronts.
Readiness: In order to sustain our commitment to ready servicemembers, ready medical forces and ready families, our military medical facilities need to operate at optimum capacity. They must sustain sufficient clinical activity to maintain clinical competencies for medical readiness. This optimization is central to quality of care, provider skill currency and ensuring our medical personnel can practice to the levels for which they were trained.
Patient Centered Medical Home: We have introduced the Patient Centered Medical Home for a number of good reasons. Its successful implementation has positively affected the health and health care delivery to our patients. It also supports our graduate medical education programs, and most importantly, continues to incentivize our patients to return to MTFs. Early evidence suggests we have demonstrated superior outcomes in preventive medicine and health screening in our Patient Centered Medical Home model. We will expand this model of care this year and set the pace for the civilian sector to follow. In so doing we intend to recapture some of the primary and specialty care that has migrated to the private sector and make our patients more satisfied with the clinical experience.
Health Care to Health: We are justifiably proud of the performance of our medical personnel on the field of battle. We have developed a superb health care system for those who are sick and injured in war and in peace. But our mission is to promote and sustain health, not just respond competently when our people fall ill. There are a large number of measures that can indicate how well we are sustaining health. For the coming year, the MHS will focus on two major measures of health: tobacco use and obesity rates. In the case of tobacco, we exceed the national averages for tobacco use in our youngest servicemembers (age 18-25). We have to take action with the entire military community united in our objective. Similarly, we must promote healthy living and reduce rates of obesity in our population. Our patients are our partners in these specific endeavors, and we will give them greater tools and the capability to manage their own health.
Patient Safety: The MHS is committed to patient safety. There are processes and best practices that work—and that save lives. Our people in the DoD Patient Safety Center are coordinating a new initiative that will be unveiled in February 2012. We have the tools to succeed and to lead the nation—we are one of the most integrated delivery systems in the country; we have the benefit of a global electronic health record; we have accountable organizations who know how to implement and disseminate these processes. Patient safety and quality health care is a top priority. A Culture of Innovation: Underlying all of our efforts is our need to continue to focus on innovations—both disruptive and continuous— that can allow us to better deliver health and customer services in more imaginative and efficient ways. We are entering a period of significant re-assessment of what government can afford and not afford. In this climate, innovation is more important than ever. While we sometimes may look to the private sector for ideas or contributions, I know that most innovation comes from within our system. We will be engaging our military medical leaders in a concerted effort to identify and promulgate those innovations that present the most promise. The initiatives I have outlined do not touch on every element of the vital work in which we are engaged. There are hundreds of programs not mentioned here that require a steadfast commitment to quality work and oversight. Our TRICARE program continues to offer the most comprehensive benefits of any health plan in the country at exceptionally low out-of-pocket costs for our beneficiary population. We are studying alternative approaches to TRICARE contracting strategy that assist with our larger goals for the MHS—optimizing our military medical treatment facilities, moving from health care to health, and ensuring our focus on patient safety is shared by our private sector partners. The MHS has shown—on the battlefield and here at home—that it is perhaps the most unique, indispensable and successful health delivery systems in the world. In 2012, we are building on that legacy.
Rear Admiral Thomas McGinnis
Chief, TRICARE Management Activity
Pharmaceutical Operations Directorate
Initiatives, Programs, and Challenges for
Managing the Pharmacy Benefit 2012
The Department of Defense pharmacy program dispenses close to 2.8 million prescriptions each week and spent, in 2011, close to $7 billion. The overall DoD health budget remains an issue of concern, as health care costs have greatly increased since 2001. The responsible management of this budget, in line with the president’s initiatives to decrease overhead and wasteful spending, is a top priority. As initiatives are planned to control DoD’s future health care costs, the TRICARE Pharmaceutical Operations Directorate (TRICARE) continues to work on maximizing its efficiencies and encouraging beneficiaries to make responsible choices when receiving their prescriptions.
Specifically, TRICARE realized great success utilizing formulary management tools, such as step therapy and the Uniform Formulary’s three-tier structure, educating beneficiaries, and leveraging contracts. The implementation and ongoing evolution of the Federal Ceiling Pricing (FCP) program collected over $2.7 billion in refunds to date. These actions significantly narrowed the gap between mail order and retail pharmacy costs to DoD; however, the retail venue remains the most costly for many pharmaceuticals when compared to military treatment facilities (MTFs) and mail order. TRICARE encourages the use of cost-effective points of service while assuring equitable access to pharmaceuticals.
Effective October 1, 2011, a change in copay resulted in modifications in beneficiary behavior and market movement. The resulting dynamics of the copay change, FCP refunds, voluntary refunds, new generics becoming available due to patent expirations on branded drugs, and diligent use of formulary management tools pose additional challenges. Ultimately, these changes will reach a state of equilibrium and further strategic planning and decisions will need to be made in order to ensure continuation of a quality pharmacy program.
DoD’s Military Health System adopted the Quadruple Aim model of care to attain its main goal of readiness, cost-effective utilization of medications, supporting a healthy population and providing positive health care experiences for our beneficiary population. In 2011, the TRICARE Pharmaceutical Operations Directorate focused on managing per-member, per-year pharmacy costs as part of the Quadruple Aim and will maintain this focus for the year ahead by increasing the use of lowest-cost points of service, maximizing the use of available technology and continuing to support readiness for deployed servicemembers.
Priorities for 2012
Readiness: Continued Emphasis on Deployed Active Duty Members
Our first priority remains supporting our active duty servicemembers, with particular emphasis on deployed troops. The DoD’s Prescription Medication Analysis and Reporting Tool (PMART) rapidly and accurately assesses the medication needs of deploying servicemembers and flags patients who are on medications that may be unsuitable for the deployed environment, such as those that require frequent monitoring or refrigeration. Additionally, PMART flags servicemembers who may have conditions that require additional deployment consideration.
PMART, a menu-driven tool, is used by all of the armed services and has become invaluable in preventing deployed troops from experiencing problems related to prescription medication. In the last year, PMART provided 643 reports reviewing 7.5 million prescriptions for over 1.5 million deploying servicemembers. By identifying individual prescription needs before deployment, troops can deploy with a 6-month supply of medication and then receive refills through the TRICARE Home Delivery Program (Home Delivery). The forward clinics then do not have to stock large quantities of drugs besides those which treat acute needs, which saves a significant amount of money in supply costs by preventing the need to purchase and stock drugs that may not ever be used. This efficient practice supports readiness, responsible budgeting and safety for our deployed troops.
To further facilitate the ease and cost-savings provided by Home Delivery, the Army released an automated prescription tool for their health care providers to use when writing prescriptions for deploying soldiers. This tool replaced the wasteful paper prescription and registration forms and auto-populates the drug and soldier’s information from a secure database. The automated prescription tool is available at all Army soldier readiness sites.
Per Capita Costs: Encouraging Use of the Most Cost Effective Points of Service
TRICARE beneficiaries have three choices when filling their prescriptions. They may choose between MTF pharmacies, Home Delivery, or retail pharmacies for their prescription needs. Each location has different costs to the beneficiaries and DoD, and beneficiaries have been incentivized to choose the location with the lowest price point for themselves and the DoD. Prescriptions at the MTF pharmacy cost the least to DoD and are provided at no cost to the beneficiaries. However, since MTF locations are limited, Home Delivery is the preferred alternative to retail pharmacies, especially for our beneficiary population’s maintenance medication needs.
Retail pharmacies are the most expensive option for beneficiaries and DoD; however, they currently are the most popular point of service. Increasing the use of Home Delivery, especially for maintenance medications, will remain a priority for 2012. On average, every time a TRICARE beneficiary uses the Home Delivery option for a brand name prescription instead of the retail pharmacy option, the government saves approximately 25 percent, with no decrease in the quality or safety of the benefit.
In 2011, the TRICARE pharmacy program developed and implemented an overarching communications plan to promote the use of Home Delivery. Beyond cost savings, for beneficiaries and DoD, using a mail-order pharmacy option for maintenance medications has been shown to increase a patient’s adherence to their prescribed drug therapy, which ultimately leads to better health outcomes.
A change to pharmacy copays went into effect on October 1, 2011, and was the first change in pharmacy copays since 2001. The new copay structure, with zero copays for generics through Home Delivery, will further encourage use of this less expensive point of service.
Experience of Care: Maximizing Use of Technology
An ongoing priority is to maximize available technology to save TRICARE beneficiaries time and money and provide significant savings for DoD. TRICARE’s e-prescribing efforts will help more beneficiaries use MTFs and Home Delivery for their prescription needs, even if they seek care from civilian health care providers.
The TRICARE Pharmaceutical Operations Directorate is working toward enabling electronic prescribing, including uniform formulary status, patient eligibility and medication history from civilian providers and military treatment facilities to all points of dispensing (MTF, Home Delivery and retail). E-prescribing will utilize the DoD’s Pharmacy Data Transaction Service, which contains prescription data from all MTFs, Home Delivery and over 64,000 retail network pharmacies for all TRICARE beneficiaries who use their pharmacy benefit.
TRICARE’s current focus is on implementing electronic prescribing from civilian providers to military treatment facility pharmacies. Approximately 34 percent of all civilian providers are already electronically prescribing, and TRICARE seeks to ensure that MTFs, its least costly point of service, remain a viable option along with Home Delivery, where e-prescribing is already being used for beneficiaries and their prescribers.
Population Health: Medication Adherence
Nearly three out of four Americans do not take their medications as directed, a problem known as medication non-adherence. TRICARE has joined the National Consumer League (NCL) and other partners in launching the Script Your Future campaign to encourage patients to take their medications as directed.
According to the NCL, one in three Americans never fill their prescriptions, and a third of hospital admissions are linked to poor adherence. This is especially true for people with chronic health conditions that can worsen quickly without proper medication use. In addition, the NCL reports that up to $290 billion a year in medical costs can be attributed to poor medication adherence.
The least effective and most expensive pill TRICARE provides is the one a beneficiary never takes, and following the labeled directions for prescription medications is one of the easiest ways to help protect and improve overall wellness. The new zero copay vaccination program in 50,000 TRICARE network pharmacies is yet another way TRICARE is fostering health promotion and disease prevention for our beneficiary population.
The TRICARE Pharmaceutical Operations Directorate is committed to facing the challenges ahead, meeting its goals to enhance readiness, improving the health of the growing TRICARE beneficiary population, and continually striving to manage costs while ensuring outstanding pharmacy care.
Vice Admiral Matthew L. Nathan
U.S. Navy Surgeon General
Chief, Bureau of Medicine and Surgery
Navy Medicine Positioned to Meet the
Challenges in a Shifting Landscape
Despite the uncertain future dictated by fiscal realities, Navy Medicine is strong and is ready for the numerous challenges and opportunities in the coming year.
Navy Medicine is a global health care network of 63,000 Navy medical personnel around the world who provide high quality health care to more than 1 million eligible beneficiaries. Our people deploy with sailors and Marines, providing critical mission support aboard ships, in the air, under the sea, on the battlefield and in medical treatment facilities worldwide.
Our personnel serve all across the globe in various missions. Often it seems many people don’t recognize the very real and direct impact our people have in the ongoing conflicts abroad and even fewer recognize the sacrifices of the brave men and women of Navy Medicine. More than half of Navy personnel wounded in action and nearly one-third of those killed in action during these conflicts have been Navy Medicine, whether corpsmen or other medical personnel. These are staggering numbers and ones that I want to highlight and honor as these sailors represent the very best of what we do—service and sacrifice.
As we enter the new year, we will strive to maintain the equities and capabilities needed from our organization and take them to a new level. My goal as the new chief of the Navy Bureau of Medicine and Surgery is to foster a culture of leadership at our headquarters in Washington, D.C., that leads and is responsive to issues in our medical treatment facilities as well as those on deck plates of our warships and battlefields around the world.
Headlines evolve daily and we know we live in dynamic times, but we will always remember that support to the warfighters and their families is our top priority. As such, it is even more vital that we align our medical capability with the strategic imperatives and direction of the chief of naval operations and the commandant of the Marine Corps. It is the responsibility of our leaders, myself included, to take their direction and vision and implement it into what we do each day around the world.
I have six key areas of interest that will be the bedrock of my tenure as Navy Surgeon General. These include:
1. Combat Casualty Care and Wounded Warrior Support: Care for the warfighter is why we exist. We must provide world-class care at home and abroad. This is our top priority. Our combat casualty care capability represents a continuum of training from battlefield to bedside to rehabilitative care and support. It includes care for the caregiver and leveraging technology to optimize care.
We must widen the aperture of care as we move forward and support the whole patient and their family. We have learned much during a decade of war and our resuscitative care capability on the battlefield now rests at approximately 97 percent. In many ways, there is almost nothing we can’t do to save our wounded physically, but there is much work to do in treating the invisible wounds of war. We have made great progress in our capability and understanding of traumatic brain injury and post-traumatic stress, and I anticipate that we will learn even more in the coming year.
Care for our wounded warriors must include care for their families, as they are an integral part of the healing process. It is also vital that we care for their needs during times of great stress as well. Navy Medicine programs such as Project FOCUS (Families Overcoming Under Stress) help our military community better cope with the unique stress associated with frequent deployments, combat stress and more.
2. Readiness: The ability to be prepared to respond to the needs of our nation is inherent in our ethos. We need to maintain a persistent state of high readiness to support everything from kinetic action to humanitarian assistance and disaster response missions. One key to enhanced readiness as we move forward will be to find new ways to export lessons learned and best practices from our larger medical centers to our smaller health care facilities throughout the Navy Medicine global enterprise. Navy Medicine’s hallmark has always been we are already there or we get there soonest! When the world dials 911, it is not to schedule an appointment, and I am proud of the Navy and Marine Corps team and our role in leaning forward in this effort.
3. Value: We know we are living in a world of shifting resources and we must push hard to demonstrate the value of what we do, what we buy and how we measure resources against quality, readiness, access and capability. Navy Medicine must look intently at the value of what we provide to our beneficiaries. We must think of the concept of “quality multiplied by capability all divided by cost.” Think of “value” as the numerator or denominator goes up or down. My team should anticipate hearing me ask a lot about the value we provide. I want that to become part of their battle rhythm in all they do as they evaluate current processes and proposed ones. We will take a hard look at our unique capabilities as well as those we provide with others... and we will talk value as we make both strategic and tactical decisions.
4. Health Care Informatics: We will not make true headway on the cost or access to health care without continued leverage of information management and information technology at all levels of care. By effectively employing IT resources, we will enhance health care access, wellness and continuity of care. We have many skilled people working hard on this, but I expect our leaders to make this a priority and create that expectation at the deck plate level. We have already seen payoffs in the wounded warrior care mission where we’ve used state-of-the-art communication technology to improve patient care from theater-level medical facilities near the battlefield to tertiary medical centers in the United States.
I am fully committed to continuing the growth of our Navy Medical Home Port clinics. Optimizing our health care IT/IM capability is key to the success of this program, which is a model of primary care that emphasizes a team-based, coordinated and proactive approach. Each patient is assigned to a Medical Home Port team led by one’s provider. The patient is a part of that team which also includes a nurse educator, a care coordinator and other support staff. Providers have a greater ability to diagnose and treat patients by leveraging support staff to manage other aspects of clinic operations and patient care.
Medical Home is designed to increase access to provider and the team to allow them to better manage the health of their population. By focusing on prevention, wellness and disease management, they can drive down costs and avoid future costly disease states that are expensive to Navy Medicine and the Defense Health Program.
Recently, Naval Health Clinic Quantico, Va., became the first DoD medical treatment facility to attain Level 3 medical home certification from the National Committee for Quality Assurance. Several other naval medical facilities have quickly followed, including three clinics at Naval Hospital Pensacola, Fla., and one at the Naval Health Clinic Gulfport, Miss. This is a tremendous start, but we must continue to push forward on implementation and standardization of medical home practices if we hope to achieve all of the benefits this model presents.
5. Jointness: The synergy of creating efficiencies, removing redundancies and allowing transparency will elevate care and reduce costs. Accepting a “joint culture” does not mean loss of identity or service culture. There is amazing joint care on the battlefield and we are seeing joint staffing at major medical centers and within our graduate medical education programs. Joint command and control cannot happen overnight and must grow from the deck plates with coordinated efforts from the services and those best informed to provide input so that more light than heat is generated.
6. Global Engagement: Many of our missions have a global footprint, which is an important part of our nation’s diplomatic presence around the world. Navy Medicine is forward deployed with our war fighters overseas, and our research units with our resident scientists provide a global health benefit around the world. Navy Medicine personnel serve as ambassadors worldwide and are the heart and soul of the U.S. Navy as a “Global Force for Good.”
These are just some of the areas that I will be turning my attention towards as the 37th Surgeon General of the Navy; certainly there is much more amazing work to be done and already being done throughout the Navy Medicine enterprise. I am encouraged by the opportunities and the shaping that will occur as Navy Medicine finds its new equilibrium throughout 2012 and beyond. ♦