MEPRS What it’s good for …*

29 July 2010 8:00 – 8:50 a.m.

*And the impact of your data on various programs and metrics

Objectives • Identify major programs, applications and metrics utilizing cost, workload, or manpower data from MEPRS

*

• For selected programs, describe how MEPRS data are used • Discuss examples where “questionable” MEPRS data have an impact on the selected programs, possibly affecting MHS decisions

*NOTE

: Presentation is from the viewpoint of those who use centrally available data rather than data from local systems 2

Selected Applications

• Inpatient Third Party Collection (TPC) Rates – Adjusted Standardized Amounts (ASAs) for billing third parties – MTF expense data pooled with peers to create standardized rates • US Family Health Plan (USFHP) Capitation Rates – Former USTF/Designated Provider hospitals – Approximately 108,000 enrollees – Direct Care portion of rates based on expense and workload data from CONUS MTFs • Practice Management Revenue Model (PMRM) – Army PMRM used in productivity evaluation – “Purple PMRM” with Tri-Service data available from TMA – FTE data from MEPRS input to comparative metrics involving PPS earnings estimates 3

Selected Applications (continued)

•

Costs on MDR/M2 Encounter Records

– MEPRS expense data basis for unit costs: • Standard Inpatient Data Records (SIDRs) • Standard Ambulatory Data Records (SADRs) • Pharmacy Data Transaction Service (PTDS) dispensing costs • Lab/Rad – Resulting encounter record costs used in numerous analyses and metrics • Metrics –

Per Member Per Month (PMPM) costs

• Metric reported to the USD(P&R) level • Adjusted MEPRS expenses allocated to enrollment categories based on encounter records workload 4

Selected Applications (continued)

• • Metrics (continued) –

Provider Productivity (RVUs per FTE)

• Metric reported to the USD(P&R) level • FTE data from MEPRS • Prospective Payment System (PPS) – Ratios of PPS earnings to MEPRS cost used to adjust for programmatic increases or decreases – Starting to use Radiology workload data from MEPRS

Medicare Eligible Retiree Health Care Fund (MERHCF)

– Annual direct care Level of Effort (LOE) and reconciliation – Rates for future distributions 5

Data Issues Affecting These Applications

• Expenses with no workload • Negative expenses • Unallocated ancillary/support expenses • Erroneous expense data (magnitude; appropriateness; FCC identification) • “Lumpiness” of expense data across time • Data missing when applications are “due” • Lack of association between FTEs and workload • Differences in Services’ accounting and/or reporting 6

Costs on SIDRs & SADRs

7

Challenge/Goal

• Direct care encounter records — Standard Inpatient Data Records (SIDRs) and Standard Ambulatory Data Records (SADRs) are not billing/claims data, but contain patient-level clinical (limited) and workload data • MEPRS captures expense data from financial systems and reports or allocates to clinical and non-clinical functional cost centers (FCCs; e.g., MEPRS-3 treatment clinic service) • GOAL: Allocate appropriate costs of patient care, support and overhead activities to patient-level encounter records for various reporting and analysis purposes 8

Principles of Allocation

• “Interrupt” (undo) the EAS-IV stepdown process so that various components of expenses may be identified and allocated separately • Use the most logical (intuitive, literature-based, or tested) basis for unit cost development and for allocating each expense component to individual encounters (SIDRs or SADRs) • After allocation, test to ensure all expenses have been accounted for • Perform various analyses to check reasonableness of results (e.g., coefficients of variation for SIDR costs within DRGs) 9

Base Year Data Issues May Affect Encounter Records in Three FYs

• Unit costs are developed from the most recent complete year of MEPRS and encounter data • Inflation rates are applied to take the unit costs forward for application in future years • During annual SIDR/SADR retrofit process, record costs are updated so that, in as many years as possible, they are based on that same year’s costs and workload data

SIDR/SADR Costs Based On:

Before Summer 2009 Retrofit

FY06

FY06

FY07

FY07

Application Year FY08 FY09

FY07 FY07

FY10

N/A

FY11

N/A

Current After Summer 2010 Retrofit FY06 FY06 FY07 FY07 FY08 FY08

FY08

FY09

FY08 FY09 N/A FY09

10

Expenses with No Workload

11

Negative Expenses

12

$12,000,000

Unallocated Ancillary/Support?

FY07-FY09 Monthly Total Expenses by MEPRS-1 (Selected MTF)

$10,000,000 $8,000,000 $6,000,000 $4,000,000 $2,000,000 $0 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 2007 2008 2009 13 B C D E F

Erroneous Expenses?

(Note: data were extracted June 2010)

14

Rx Percentage of Ambulatory $

Lumpiness: Pharmacy expenses recorded when drugs purchased rather than when dispensed?

15

Dispensing Costs for Direct Care PDTS Records

16

17

Why the Difference?

18

High-Level MHS Metrics

19

MHS Dashboard

Casualty Care and Humanitarian Assistance G Reduced Combat Losses

Case Fatality Ratio (OIF/OEF Combat Casualty) Observed/Expected Survival Rate (Battle Wounds) Mortality Rate Following Massive Transfusions Battle-Injured Medical Complications Rate G G G    Age of Blood in Theater G G  

Y Effective Medical Transition and Warrior Care MEBs Completed Within 30 Days ***

DES Cases Returned to MTF

MEB Experience Rating ***

R G G VA Transition Process R

G Improved Rehabilitation & Reintegration to Force

Amputee Functional Re-Integration Rate G      TBI Screening and Referral Potential Alcohol Problems and Referral X X X X

Increased Interoperability with Allies, Other Government Agencies and NGOs

Under Development X X

Reconstitution of Host Nation Medical Capability

Under Development X X

Strategic Deterrence for Warfare

Under Development X X

Healthy, Fit and Protected Force Y Reduced Medical Non-Combat Loss

Force Immunization Rate Orthopedic Injuries Rate in Theater Orthopedic Injuries Rate in Garrison (Non-Deployed) Influenza-Like Illness Rate in Theater Influenza-Like Illness Rate in Garrison (Non-Deployed) Psychological Health: In-Theater Evacuations/ Encounters Y R G R G R      

R Improved Mission Readiness Individual Medical Readiness ***

Percentage Unknown Medical Readiness Status R R  

Increased Resilience & Optimized Human Performance Psychological Distress Screens, Referral and Engagement *** Effectiveness of Care for Complex Medical / Social Problems ***

X X X X

Healthy and Resilient Individuals, Families and Communities Y Healthy Communities/Healthy Behaviors

MHS Cigarette Use Rate Y Active Duty Lost Work Days Rate Y MHS Body Mass Index Rate Alcohol Screening/Assessment Rate FAP Substantiated Child/Spouse Abuse Rate Influenza Immunization Rate

Pandemic/Seasonal Influenza Vaccine Coverage Rate ***

X G G G R X Mental Health Demand-Family of Service Members

Percent of Patients Advised to Stop Smoking ***

Active Duty Suicide Rate (Probable/Confirmed)

G Health Care Quality Enrollee Preventive Health Quality Index (HEDIS) *** Overall Hospital Quality Index (ORYX) ***

CONUS Ventilator Associated Pneumonia Rate Health Care Personnel Flu Vaccination Rate Hospitalization 30-Day Disease Mortality Rate

Y Access to Care Getting Needed Care Rate *** Getting Timely Care Rate *** Percent of Visits Where MTF Enrollees See Their PCM ***

Booking Success Rates for Primary Care Appointing X R G R R Y G X X G Y Y Primary Care Third Available Routine Appointment

Y Beneficiary Satisfaction

Satisfaction with Provider Communication

Satisfaction with Health Care ***

Satisfaction with Health Plan Y Y G X X       X X   X          X

Education, Research and Performance Improvement G Capable MHS Work Force and Medical Force

Mental Health Provider Staffing

Staff Satisfaction ***

Competitive & Direct Hire Activity (Medical Professionals) X X G X X 

Advancement of Global Public Health

Under Development Under Development X X

Contributions to Medical Science Product to Practice Success *** Healing Environments

X X X X

R Performance-Based Management and Efficient Operations Annual Cost Per Equivalent Life (PMPM) ***

R 

Enrollee Utilization of Emergency Services *** Provider Productivity Impact of Deployments on MTFs ***

Y R X   X Bed Day Utilization (Prime Enrollees) X X

R Deliver Information to People so They Can Make Better Decisions

AHLTA Reliability AHLTA Speed R Y  

User Assessment of EHR Functionality ***

X X DMHRSi/EAS-IV Transmissions by Service R 

*** Denotes Strategic Imperative

Improving Declining Stable

X

Under development 20

• •

Per Member Per Month (PMPM)

What are we measuring? The average percent change in Defense Health Program annual cost per equivalent life compared to average civilian sector health insurance premium changes Why is it important? Metric looks at how well the MHS manages the care for individuals who have chosen to enroll in an HMO-type benefit (Prime). It is designed to capture aspects of three major management issues: 1. How efficiently the Military Treatment Facilities (MTFs) provide care 2. How effectively the MTFs manage enrollee demand 3. How well the MTFs determine which care should be provided inside the facility versus purchased from a managed care support contractor 21

PMPM: Impact of Missing MEPRS

• Key metric periodically reported to the USD (P&R) • Source of direct care costs and FTEs is MEPRS • In one update a large Medical Center was missing Contractor labor; in the same Service, multiple months of MEPRS data were missing at the cutoff date for metric reporting • Overall PMPM with estimates for missing data were below the goal (

green

); when data were complete, TMA had to report back to the USD that the Service had failed to meet the goal (

red

) 22

RVUs per Primary Care Provider Per Day

• What are we measuring? Metric computes the Work RVUs for all the visits of a provider for a specified period attributed to a specific clinical site divided by the available FTEs of that provider in that clinic computed on a per day basis • Why is it important? It reflects the availability of a specific provider for patient care and the volume/intensity of the associated work. National standards for Primary Care allow for comparison – If providers are below average, process improvement initiatives may be undertaken for increasing productivity – Practices of providers above average may lead to best practice dissemination • Metric assumes a direct correlation between available FTEs and workload reported in a given cost center 23

RVUs per FTE

23.5

21.5

19.5

17.5

15.5

13.5

11.5

9.5

Civilian Average is 21.8

Army Navy Air Force MHS 24

Ambulatory Available FTEs by MEPRS-2 (

Selected Major Medical Center) 25

Ambulatory Available FTEs & Visits

26

Medicare-Eligible Retiree Health Care Fund (MERHCF)

Direct Care Level of Effort (LOE)

27

MERHCF Defined

• Established by Congress (2001 NDAA) to provide mandatory funding for a military retiree health care entitlement • Covers certain Medicare-eligible DoD beneficiaries (military retirees, retiree family members and survivors not simply “over-65s”) • Pays for

MTF care

, purchased care and pharmacy • Recognizes DoD’s accrued and future liability for cost of retiree/survivor health care for military service members and their family members based on actuarial analyses and assumptions about population characteristics 28

Overview – MTF LOE

• Purpose: To estimate annual DoD expenses for Military Treatment Facility (MTF) care of

Medicare-eligible

DoD and other uniformed services retirees, dependents of retirees and survivors • Results support reconciliation of annual Accrual Fund charges and projection of future MERHCF direct care budget allocations and reimbursement rates • Level of Effort (LOE) procedures comply with DODI 6070.2

Department of Defense Medicare Eligible Retiree Health Care Fund Operations

29

LOE Methodology • Expense data are taken from the MEPRS EAS-IV Repository • Workload data are extracted from patient encounter records in the Military Health System (MHS) Data Repository (MDR)

– Inpatient: Standard Inpatient Data Records (SIDR) – Ambulatory: Standard Ambulatory Data Records (SADR) – Pharmacy: Pharmacy Data Transaction Service (PDTS) Records 30

Direct Care Expense Allocation

• MEPRS expenses are allocated to beneficiary categories on the following bases: – Inpatient – Relative Weighted Products (RWP, DRG based) from SIDRs – Ambulatory – Ambulatory Patient Group (APG) weighted work units from SADRs – Pharmacy – Prescription counts (for admin costs) and ingredient costs (for pharmaceuticals) in PDTS • LOE beneficiary categories used are: – (1) Active Duty, (2) Active Duty Family Member, (3) Non Accrual Fund Retiree, (4) Non-Accrual Fund Retiree Family Mbr/Srv, (5) Accrual Fund Retiree, (6) Accrual Fund Retiree Family Mbr/Srv and, (7) All Other MTF patients 31

Identifying Pharmacy – by Program Element Code (PEC)

• 0807701 Pharmaceuticals in Defense Medical Centers, Station Hospitals and Medical Clinics – CONUS – Includes pharmaceuticals specifically identified and measurable to provision of Pharmacy Services in DoD owned and operated CONUS facilities – Excludes manpower authorizations, support equipment and other cost directly associated with the production and operation of DoD owned and operated facilities – This Program Element is designed to specifically collect Pharmaceuticals. It will include all prescription supply items used in the direct patient care by hospitals, dental clinics, veterinary clinics and other clinics such as Occupational Health Clinics… • 0807901 Pharmaceuticals in Defense Medical Centers, Station Hospitals and Medical Clinics – OCONUS 32

FY09 MERHCF LOE Pharmaceutical PEC & SEEC Mismatch

Fiscal Year Parent DMIS ID Parent Name DoD PEC DoD SEEC SEEC Description Net Month Expense

2009 2009 0033 0033 2009 2009 2009 0045 0045 0045 2009 2009 2009 0055 0055 0055 $ 387,245 $ 821,658 $ 1,208,904 11.10

11.72

11.74

Civilian Personnel Compensation Military Personnel Compensation Borrowed Military Labor $ 105,859 $ 421,938 $ 2,093 $ 529,889 11.10

11.72

11.74

Civilian Personnel Compensation Military Personnel Compensation Borrowed Military Labor $ 113,216 $ 816,848 $ 3,752 $ 933,817 33

FY07 MERHCF LOE Impact of Incomplete Army MEPRS

Army lost $20.0 million or 3.3% of their FY07 based MERHCF distribution

Official results submitted 29 April 2008

Beneficiary Service Affiliation DoD Beneficiaries Non-DoD Beneficiaries Total MERHCF LOE MERHCF LOE by Providing Military Service Army $ 4,284,678 Air Force $ 5,003,092 $ Navy 8,083,711 MERHCF LOE Total $ 1,581,572,758 $ 17,371,482 $ 1,598,944,239

Updated results computed 13 June 2008

Beneficiary Service Affiliation DoD Beneficiaries Non-DoD Beneficiaries Total MERHCF LOE MERHCF LOE by Providing Military Service Army Air Force Navy $ 630,458,316 $ 4,493,393 $ 634,951,708 $ 576,294,859 $ 5,010,408 $ 581,305,267 $ 396,733,252 $ 8,086,186 $ 404,819,438 MERHCF LOE Total $ 1,603,486,427 $ 17,589,987 $ 1,621,076,413

34

FY09 MERHCF LOE Impact of Incomplete Air Force MEPRS

Air Force lost $23.5 million or 3.7% of their FY09 based MERHCF distribution

Official results submitted 21 April 2010

Beneficiary Service Affiliation DoD Beneficiaries Non-DoD Beneficiaries Total MERHCF LOE MERHCF LOE by Providing Military Service Army $ 709,865,155 Air Force Navy $ 5,292,442 $ 715,157,597 $ 5,019,682 $ 10,310,181 MERHCF LOE Total $ 1,731,853,035 $ 20,622,305 $ 1,752,475,340

Updated results computed 24 May 2010

Beneficiary Service Affiliation DoD Beneficiaries Non-DoD Beneficiaries Total MERHCF LOE MERHCF LOE by Providing Military Service Army Air Force Navy $ 424,154,627 $ 5,294,811 $ 5,331,881 $ 10,310,379 $ 434,465,006 MERHCF LOE Total $ 1,755,449,918 $ 20,937,071 $ 1,776,386,989

35

Concluding Thoughts

• MEPRS data are used in many programs, applications and metrics • Uncorrected data problems can affect the outcome of studies, analyses, metrics, and resulting decisions • Detection/correction of various MEPRS data problems centrally takes time and is difficult to accomplish systematically • Local detection/correction of data problems is most effective • Several tools are available to assist in identification of data problems 36

Questions?

CONTACT INFORMATION

John A. Coventry, Ph.D.

SRA International, Inc.

210-832-5212 [email protected]