I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Headquarters U.S. Air Force

Air Force AssociationAFMS Updates

Maj Gen Thomas W. TravisDeputy Surgeon General

9 December 2011

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Purpose and Overview

� Purpose:� Provide overview of recent successes and discuss hot topics

� Overview� Major Transformational Initiatives� Hot Topics

� Human Weapon System� Structure� Benefits

� Accomplishments� Discussion

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Air Force Medic Video

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Major Transformational Initiatives

� EMEDS Health Response Team (HRT)

� Patient Movement and Casualty Care

� Patient Centered Medical Home(PCMH)

� Recapture of Care at Specialty Clinics� Military Education and TrainingCenter (METC)

� USAFSAM Opens at WPAFB

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Hot Topics: Human Weapon System

� Resiliency / Suicide� Change In Messaging� Post-Vention� AF Suicide Rate Decrease from CY10

� Traumatic Brain Injuries/PTSD� Research Initiatives & Investments� Deployment Transition Center

*Increase in AF Mental Health Providers

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Hot Topics: Structure and Benefits

� Governance� Military Health System (MHS) in NCR� Entire MHS and Timelines� Awaiting SECDEF Decision and COA

� AF & DoD Healthcare Efficiencies� TRICARE Fees/TRICARE Prime� No Cost to AD and Their Families

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Why We Need To Address MilitaryHealth Costs

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“Healthcare is eating the Department of Defense alive�”- Secretary Gates, USA Today, 1 Jun 2011

How do we “bend the cost curve” withoutcompromising readiness?

2028 - $109B

2012 - $52B

16% of DoD BA

10% of DoD BA

� Increases in beneficiaries– Increase of 400,000 since 2007– Anticipate 250,000 more TRICARE

Young Adult– Low cost share encourages enrollment

� Expanded benefits– TRICARE For Life, Prescription benefits,

Reserve Benefits, Psychological Health/ Traumatic Brain Injury

� Increased utilization– Existing users are consuming more

care (ER, Orthopedics, BehavioralHealth)

– Low co-pays encourage utilization� Healthcare inflation

– Higher than general inflation rate– Consistent with civilian healthcare

sector

Major Cost Drivers

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We’re Proud of Our Achievements!

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- EMEDS HRT/Theater Med Info Prgm successfully exercised/ready- Deployment Transition Ctr sees 2K combat pts; first-ever USMC pts- Eliminated 1K inspection line items to improve Health Services

Inspection & decrease MTF document prep time > 50%- Deployed first Tactical Critical Care Evacuation Team (TCCET)

- 451 HPSP graduates; highest annual number recorded- 7 Specialty Clinics new programs saw increase in enrollment by 3%;Relative Value Unit up 18%; Relative Weighted Procedures up 15%

- Lead Med Equip COE; AFMS best annual purchasing performance;2658pkgs/$82M and decreased contract award times saving $14M

- 773K patients now enrolled/104 Clinics implemented PCMH- Tri-Service Workflow awarded CSAF Excellence/Best Practice Award- First Service to offer Group Lifestyle Balance diabetes prevention- Implemented e-Health tools to strengthen/facilitate pt partnerships

- Centrally archived 1.1M digital images, largest repository in world- Military Education Training Command (METC) awarded Institute forCredentialing Excellence’s Presidential Commendation for service

- Fielded vacuum spine board for lighter/leaner Air Evac pt movement- Established and Activated San Antonio Military Health System

BEST

VAL

UE

BETT

ER H

EALT

HBE

TTER

CAR

ERE

ADY

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

“TRUSTED CARE ANYWHERE”

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

BACK UP SLIDES

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Focus and Alignment)Through the AFMS Framework

Transform Deployable CapabilityRapid Response to Any Worldwide Contingency

Build Patient-Centered CareContinuity & Prevention to Optimize Health

Invest in Education, Training & ResearchSustain Our Future Capabilities

FitForce

OverlappingMission Areas

Strategies

Strategy � Common Practice � Culture

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

In Pursuit of Lighter &Leaner Medical Response

� EMEDS Health Response Team (HRT)� Lessons learned from humanitarian response� Operational results:

� Immediate Care <20 minutes�Emergency Care <2 hours�OR/ICU <3 hours

� Successfully exercised for contingency

Pursuing Perfection in Medical Response Capability

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Continuous Advances inCasualty Care

Expeditionary Operations Evolving to Save Lives Globally

*AeroSpace Interoperability Council

INTERFLY AGREEMENTApplying Lessons Learned From the C-17

WWII30%

Korea25%

Vietnam24%

PersianGulf24%C

omba

t Mor

talit

y R

ate

Learning From Coalition Partners, WeLeveraged Trauma Registry Data To

Build Innovative Solutions> 80 Patients Moved as of Nov 11

Tactical Critical Care Evacuation Team (TCCET)

OIF/OEF<10%

Re-engineering Global Patient Staging

Creating a “patient staging” continuumModular Aeromedical Staging Capability (MASC)

New CASF Activated at SAMMC

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

AF Medical HomeFamily Health Initiative (FHI)

� FHI creates incentives for successfrom patient perspective� Increased continuity� Decreased ER visits� Better health outcomes (HEDIS)� Patient Satisfaction

� Objectives:� Continuity = Healthier Outcomes� Improve access, quality, service� Encourage Teamwork &

Communication

Creating The Environment To Provide Patient-Centered Care

Family Health Clinics Implemented – 69Pediatric Clinics Implemented – 35Total Population Enrolled –773,887

PATIENTEXPERIENE

QUALITYMEASURES

INFORMATIONMANAGEMENT

&TECHNOLOGY

PATIENTEXPERIENCE

PHYSICIAN-LEADTEAM

AIR FORCEMEDICAL HOME

PROACTIVE PREVENTIVE HEALTH CARE

PATIENT

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Innovation & Insight toRecapture Care

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Specialty Hospitals Focused on Currency and Recapture

Travis AFB, CA Langley AFB, VA Elmendorf AFB, AK Eglin AFB, FL Keesler AFB, MS WPAFB, OHNellis AFB, NV

� Deliver Patient-Centered Care To Our Beneficiaries

� Create Currency Opportunities To Support Readiness

� Allow Medics To Practice Full Scope Of Care

� Tackle Per Capita Cost Through Targeted Investments

Bringing Patients Back to the Military Treatment Facility

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Invest in Education, Training andResearch

� Military Education and Training Center (METC)� Joint Medical Training� Open for Officer Medical Training Courses

� USAFSAM Opening at WPAFB

� CSTARS Course� Maintains Trauma Training

� GME/DME and Nursing Education� Expanded Opportunities� Increased Healthcare Provider Numbers

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The Suicidal Mind

� Suicide is a behavior, not a disease� How we think and communicate about it affects its rate

� Usually characterized by desperation, hopelessness� Rage: anger and frustration - Impulse� Avoidance: legal/financial concerns, guilt� Mental illness: Depression, Bipolar Illness

� Substance use often fuels the fire

� Top risk factors� Relationship problems� Mental health history� Legal/ administrative problems

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Establishing Partnerships toEnhance Capabilities

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Partnerships are Vital Tools to Build & Sustain Medical Services

Physician/Dentist Education (GME/DME)� Stand alone programs� Masters with civilian universities� Integrated/affiliated with Federal partners

Nurse Education (Transition Program)� New sites include: Cincinnati, OH & Scottsdale, AZ

Nurse Enlisted Commissioning Program (NECP)

Research

USAF Dental Hygiene Program

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2004 2005 2006 2007 2008 2009 2010 2011

AD Suicides ARC in Duty Status ARC not in duty status

Civilian Suicides CY AD Rate Total Force Rate

Rat

e/10

0K

Num

ber

* 52 Week Rolling RateResults Analysis

CY10/CY11 #s * Rolling 12 Month RateAD AF Suicides through 25 Nov: 49/39 13.4Total Force Suicides through 25 Nov: 89/84 14.1Improvement Actions/Next Steps- Update AFI 44-154, Suicide and Violence Prevention Education and Training- Suicide Prevention Program Evaluation Grant Proposal

Red Boundary

Metric AF Active Duty and AF Total Force Suicides Status: Yellow

Objective Track suicides over time to identify trends

Metric Owner: AFMSA/SG3OQ Metric POC: Major Michael McCarthy Last Updated On: 25 Nov 11

Green Boundary

Metric Definition: Suicide Rate= (Raw Number of Suicides Over the Last 12 Months/End Strength) x100,000

UNCLASSIFIED // FOUO

CY10 DoD Rate

**

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

New Suicide PreventionInitiatives

Point of Attack

� Frontline Supervisor Training for at-riskAFSCs

� Semiannual Wingman Days

� Security Forces/JAG initiatives

� VCSAF Memos� Face-to-face suicide prevention trng� Unit Consultation Tools

� Comprehensive Post-Suicide Guidelines

� Public Affairs Guidance for Suicide

� Increase AD mental health providers by 25%� Add 70 more to Primary Care

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Process� Strategic Communication Plan

� Shift to strengths-based messaging

� RAND social media study

� Improved weekly dashboard slide

� Fort Hood Follow-on Review

� Response to DHB DoD TF on thePrevention of Suicide by MilitaryMembers

� 2011 Community Assessment� Expanded use of multimedia tools

� CSAF/CMSAF PSAs

“The Air Force’s pioneering suicide prevention program was producing the first empiricalevidence that a comprehensive, public health approach could, in fact, reduce suicide across

a population.” – Volpe Report

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Air Force SuicidePrevention Overview

Suicide Rates (per 100,000/yr) AD Risk Factors/Stressors (%)10 year Pre-Program 13.5 Relationship Problems 54.210 year Post-Program 9.9 History of Any Mental Health

Diagnosis45.8

CY10 Active Duty 16.4CY11 Active Duty (Rolling Rate) 13.4 Legal/Admin Problems 33.9CY11 Q2-Q3 Active Duty 11.5

Seen by Mental Health in PastMonth

18.6CY11 Total Force (Rolling Rate) 14.1CY11 Q2-Q3 Total Force 12.9By AD Career Group (CY 10-11)(per 100,000/yr)

Alcohol in System at Death 17

Security Forces (3P) 33.8 Deployed in the Past Year 12Aircraft Maintenance (2A) 21.8

Financial Problems 10.2Intelligence (1N) 0.0

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Security Forces rate down > 30% from Feb ‘11 peakAs of 25 Nov 11

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Deployed and Non-deployedTBI in the DoD 2010

AF accounted for 11% of TBI (deployed/non-deployed) cases

� Facts:� TBI Incidence in the AF is lower

than other services due tomission differences

� Most TBI in the AF is mild (mTBI)� Most mTBI cases recover quickly

� Goals:� Early diagnosis and treatment� Identify Airman with persistent post-

concussion symptoms� Educate AFMS healthcare teams on

TBI diagnosis, management, andresources

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Enhanced TBI ScreeningCapabilities

� All Warfighters medically evacuated from theater to LandstuhlRegional Medical Center (LRMC) undergo TBI screening regardlessof injury for which they were evacuated

� TBI screening on Post Deployment Health Assessment (PDHA), PostDeployment Health Re-Assessment (PDHRA)

� All clinical medics trained on current concussion managementguidelines in deployed setting

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Clinical Capabilities andMeasures of Success

� Services:� Early and appropriate evaluation,

diagnosis, and treatment following apotentially concussive event

� Clinical algorithms standardize care

� Capabilities:� Theater: 332 EMDG, Balad� Joint Base Elmendorf-Richardson� San Antonio Military Health System

� Measures of Success:� Resolution/control of symptoms� Return to duty� Medical evaluation board statistics

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Active Duty Airmen with PTSD

3 Month Period Prevalence

0.000

1.000

2.000

3.000

4.000

5.000

6.000

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

FQ1 FQ2 FQ3 FQ4 FQ1 FQ2 FQ3 FQ4 FQ1 FQ2 FQ3

FY2009 FY2010 FY2011

Rate of A

D w

/PTSD per 1,000

Num

ber o

f Airm

en

AD with PTSD

AD Rate w/PTSD per 1,000

PTSD diagnosis under 0.5% or 1,300 Airmen; 4-5 times morecommon in Airmen with combat exposure

*2011 FQ3 Data Still Processing

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Air Force PTS Prevention

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� Airman Resiliency Training� Traumatic Stress Response Teams� Leader’s Guide� Deployment Transition Center� Telemental Health

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Improved AF Mental Health

� Increased Mental Health providers FY12-FY16

� All MTFs funded for a Mental Health Provider in Primary Care

� Airmen educated on mental health during Self Aid Buddy Care

� Service member screened 5X face-to-face pre/post deployment

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Provider Type MH CLINIC BHOP SNC Peds Total/IncreasePsychiatrists: +18 0 0 0 153 (+18)Psychologists: +1 +30 0 0 287 (+31)Clinical SWs: +3 +35 +36 +5 275 (+79)Psych Nurse Pract +22 +5 0 0 42 (+27)Psych Nurses: +15 0 0 0 45 (+15)MH Techs: +169 0 0 0 896 (+169)

Building Mental Health Availability for the Total Force

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Beneficiaries Move Between Direct (MTF) andPurchased Care (Downtown Network) Systems

Direct Care(MTF)

Active duty& family

Retirees& family

Military Health System (MHS)

VHABenefits

Medicare

EmployerSponsoredInsurance

Approximately 50% of MHS beneficiaries are enrolled in TRICARE Prime, an HMO like benefit set. The rest are in a FFS environment

PurchasedCare

4.16 million(Includes 950KGuard/Reserve andtheir dependents)

Under 653.42 millionOver 651.9 million

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Civilian Employers Share The Burden OfHealthcare Costs With Employees At A Much

Greater Rate Than DoD

� A Sept. 2010 report from the Kaiser Family Foundation found:� On average, employees nationally paid $899 for single coverage and $3,997 for family

coverage� Annual deductible for single coverage for PPOs - $675, HMOs - $601, and POS - $1,048.

Also on average these workers paid $22 for a primary care visit and $31 for a specialtycare visit.

� Average copayments per prescription drug were $11 for tier one, $28 for tier two, and$49 for tier three

� Only 28% of large employers offered health insurance to retirees

� TRICARE Prime enrollees� Active duty and their families pay no enrollment fees and no out-of-pocket costs for

any type of care as long as care is received from the PCM or with a referral� All other beneficiaries including retirees < 65 pay annual enrollment fees ($230/year for

individuals or $460/year for families), and the cost for care is based on where the careis received, MTF outpatient and inpatient no visit fees and for network providersoutpatient $12 per visit

� Military Treatment Facility (MTF) Pharmacy: $0 copayment for all tiers; TRICAREPharmacy Home Delivery: $3 tier one, $9 tier two, and $22 tier three; and TRICARERetail Network Pharmacy: $3 tier one, $9 tier two, and $22 tier three

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A Number Interventions Have BeenProposed ) Could Impact Readiness

� Increase TRICARE beneficiary cost sharing to incentivize more prudentutilization of health care resources� Single most significant lever, but under control of Congress� What is recruitment impact?

� Create incentives for under 65 retirees to use employer based insurance� Examine use of tax credits; how does this impact employment and recruitment?

� Medical Service Integration– share back office functions such as IT andlogistics; a joint care model through a Unified Medical Command; or through afederal health care system that includes VA

� Establish correct balance between direct and purchased care system so thatown vs buy decisions are optimized and care is coordinated

� Optimize the Graduate Medical Education training platforms so that they mostefficiently serve the readiness needs; own vs buy decisions.

� Identify and mute variation in care delivery by establishing more standardizedand efficient care processes – process improvement� Estimates suggests a potential savings of up to 30%

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Strategies To Enhance Value And Bend The CostCurve In Military Healthcare Can Be Grouped

• Health Benefits and Eligibility– Benefit design and cost sharing < selective co-pay

– Health Savings Account

• Enhanced Medical Service Integration– Spectrum includes: Shared Services; Unified Medical

Command; Federal Health Care System

• Efficiencies Within the Direct Care System– Process improvement, medical home, care coordination, etc– Remove variation from service areas

• Healthcare Network Integration AndManagement• Includes better cost management and care coordination in

Purchased care system• And better integration of direct and purchased care system

Large potential impact,but under Congressional

control

Transformationalchange,

but significant barriersto implementation

Opportunities to applycommercial sector best

practices

Opportunities forimproved care

coordination andmanagement

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Strategies Vary By Span Of ControlAnd Implementation Difficulty

Hardest

Service

DoD

Strategic Sourcing

Health Benefits /Eligibility

Health Savings Accounts

Network Integration

Modify TRICARE Prime Cost Sharing

Relative Difficulty

Influ

ence

/Con

trol

Congress

New Care Models

Variation Analysis

Efficiency Direct Care

Shared ServicesUnified Medical Command

Direct/Purchased Care Balance

Modify GME Strategy

Tax Credit forEmployer Insurance

Wellness Programs

Overhaul Cost Accounting

Risk Based ApproachTo Managing Fraud

Pharmacy Benefits/Copays

Least Hard

Modify TRICARE Standard\Extra Cost Sharing

Performance Based Budgeting

CMS Partnership/TFL

33Even The Simple Things Aren’t So Easy )..