Business Plans & Performance Based Budget (PBB)
March 14, 2008
BUMED (M8)
Medical Cost Growth Drivers Impacting DHP
$70,000
Increase over FY2000 $43.8B
$60,000
$14.3B
$50,000
Benefit Changes to 65+
($M)
$40,000
$30,000
Price Inflation
s ange fi t Ch 65 Be ne w U sers < Ne sity e/Inten Volum
5 t o <6
$2.6B $4.5B $7.6B $14.9B
$20,000
$10,000
FY2000 Medical Program
FY2000 Baseline $17.4B
FY12 FY13
$0 FY00
FY01
FY02
FY03
FY04
FY05
FY06
FY07
FY08
FY09
FY10
FY11
Increased benefits mandated by Congress: • Includes TFL Benefit • Assumes no increase in benefits after FY 2007 Increase in cost per unit/visit: • Labor and technology cost increases
Increase in utilization/intensity per user: • Advances in technology • Protocol changes
Increase in users: • Percent of non Medicare eligible retirees and dependents that use TRICARE is increasing • Real costs to the beneficiaries are decreasing
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Transforming the Business
2003 – MHS Business Plans introduced. 2004 – Prospective Payment System (PPS) designed to incentivize productivity within the Direct Care System. 2005 - PPS implemented and began to influence the Service’s funding based on performance with respect to workload measures (RVUs, RWPs and Mental Health Bed Days). 2006 – The Health Quadrennial Review calls for expansion of PPS to use performance-based planning, financing and management for ALL DHP funding. 2007 – Navy Medicine conceptualizes Navy Performance Based Budgeting (PBB) as an expansion of PPS. 2008 – Navy Medicine begins to implement PBB.
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Ownership
Thru 2007 - BUMED paid PPS losses centrally. 2008 – Activities own their own PPS results.
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How it will be used
1.
2.
Execution Year adjustments at midyear review. Programmatic adjustments to future year annual planning figures (APFs).
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Composition of PBB
NAVY Quality Driven Metrics PPS Workload Adjustments
EBHC Navy Performance Based Budget = PPS
IMR
Bed Fill Rates
Public Health
Deployment
+ 10%
+
5%
+
5%
+
5%
+
Staffing Mitigation
+
Latitude During Review Discussions
Note: PBB calculates each individual metric at the Parent Level. Adjustments are based upon the “Planned” O&M budget across All BAGS and each metric may adjust up/down a maximum percentage based from the planned budget.
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Potential Impact
PBB calculates each individual quality metric at the Parent MTF Level. Adjustments are based upon the “Planned” O&M budget and each metric may adjust up/down a maximum percentage based from the planned budget:
Measure • EBHC • IMR • Inpatient Bed Fill • Public Health Max Adjustment (-10% to +10%) (-5 % to + 5%) (-5 % to + 5%) (-5 % to + 5%)
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Resources and Quality
The O&M funding of an MTF can be impacted up to 25% as a consequence of the PBB quality metrics and PBB review discussions. Comptroller and Care-giving Communities are jointly and keenly interested in the performance of these metrics, linking resources, performance and quality outcomes. Incentive for achieving uniform quality of excellence with respect to these measures across Navy Medicine.
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1. Metrics Utilized
Evidence Based Health Care (EBHC)
o o Asthma Diabetes A1c level, Diabetes A1c test, Diabetes LDL Breast Screening (Colorectal & Cervical Cancer to be added during FY09 review).
PBB Applied to CONUS Facilities Only
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o o
EBHC
Health Affairs is aggressively pursuing putting EBHC measures in the PPS model. This may be implenented very soon after HA mid-year review They will be utilizing all 7 EBHC metrics that we currently measure or shadow in PBB with some possible variation on their calculations such as percentile marks.
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2. Metrics Utilized
Public Health
Current: Execution Rate to Plan based upon PE 0807705. o Does not encourage or promote increased emphasis on healthy behaviors or population health. FY09 approved by ADM Flaherty (March 3):
o o o
o
Tobacco Cessation (all MTF beneficiaries) Physical Readiness Program PFA(PRT/BMI) compliance (BSO-18 only), Healthy Weight/Ship Shape/Obesity (BSO-18 only)
PBB Applied to CONUS Facilities Only
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PH – Tobacco Cessation
1) The # of individuals screened for nicotine/tobacco dependence 2) The # of individuals diagnosed with nicotine/tobacco dependence 3) The # of nicotine/tobacco users who were provided counseling
These metrics will be applicable to all beneficiaries receiving care in the MTF. Will use specified ICD-9, CPT, and HCPCS codes. Will run historical data for FY 2007 to establish a baseline.
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PH - Physical Readiness Program
1) Ratio of service members unaccounted for in PRIMS as compared to the number of active duty on board. This metric helps encourage accurate PRIMS reporting. Verify PRIMS data with BUMED manning document or use noncompliance report. 2) The # of individuals who have failed either portion of the PFA (BCA or PFT) at the Command for 2 or more consecutive times. This would exclude failures who have moved on but would capture those who were at the Command for more than two PFAs and for whom the Command was not successful in getting them to pass.
These metrics are for BSO-18 only. PRIMS data would be used for these measures and the metric could be calculated biannually to account for Spring and Fall PFA. Will run historical FY 2007 data to establish a baseline.
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PH - Healthy Weight/Ship Shape/Obesity
1) The # of service members who enroll in ShipShape vs. the # who complete the course. 2) The percent of individuals who complete ShipShape and who are within BCA standards within 6 months (monitor only-no incentives). 3) The total # of BCA failures vs. the # who enroll in ShipShape (monitor this metric only- no incentives).
These metrics will be based on BSO-18 only PRIMS data and will be biannual to coincide with PFA cycles.
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3. Metrics Utilized
Individual Medical Readiness (IMR)
o
o
BSO 18 Personnel Only. Focused on Percent “Indeterminate”. FY09 May focus on:
o
o
additional categories (eg. Fully Medically Ready). All Navy Operational Forces, by specialty branch
PBB Applied to CONUS Facilities Only
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4. Metrics Utilized
Inpatient Bed Fill Rate
o o Based on “Active/Staffed” Beds (excluding OR, ER, Newborn/Basinet beds) fill rate as compared to MTF bed capacity. Low bed fill rates imply excess capacity which consuming resources inefficiently.
PBB Applied to CONUS Facilities Only
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Early Results
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EBHC Changes
EBHC Measures have continued to get better. Number of measures above HEDIS 90th Percentile (Green) have increased and those below HEDIS 75th Percentile (Red) has decreased.
EBHC Trends
Number in Category
70 60 50 40 30 Jun 07 Nov 07 Green 40 47 Yellow 46 42 Red 61 58 Jun 07 Nov 07
Green: Above 90th Percentile Yellow: Between 90th and 75th Percentile Red: Below 75th Percentile
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Public Health
Public Health
• No significant change in the current metric (execution rate)
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IMR Status
IMR Improvements (BSO 18)
• Indeterminate Category improved/reduced to 6% • Fully Medically Ready Category improved/increased to 73%
Much of this was accomplished thru:
• • • MTFs proactivley getting personnel screened in their birth month as well as increased action on those personnel delinquent in factors post birth month. MTFs increased focus on real-time updates to data and becoming more familiarized with the new MRRS system. MTFs scrubbing personnel and removing members in MRRS system no longer attached to them. Navy Medicine MTF IMR Status: Percent Personnel in IMR Categories 17 Oct 07 Fully Medically Ready Indeterminate 56.3% 19.5% 30 Jan 08 73.5% 6.1%
Note: Only “indeterminate” is valued in PBB, but we also administratively shadow Fully Medically Ready to see how close we are to 75% goal set by DoD Inst 6025.19
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Bed Fill Rate
Little change to NavMed Avg
• Nov 07: 61.6% Feb 08: 62.4% • Is being addressed as MTFs/Regions develop FY09 Business Plans.
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Web Site & POC
https://NMO.med.navy.mil/PBB
PBB Concept: • Mr. Marshall, Comptroller, Navy Medicine PA&E Pilot Developers: • LCDR Randy Bills • LCDR Matt Bouma
Mr. Robert Willis
BUMED, code M81 (PA&E) 202-762-3542 robert.willis3@med.navy.mil
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