Understanding BUMEDs Performance Based Budget PBB A Clinical Quality Perspective

1
Understanding BUMEDs Performance Based Budget
(PBB) A Clinical Quality Perspective

• CDR Annette M. Von Thun
• Head, Evidence-Based Programs (BUMED M3)
• May 6, 2008

Thanks to LCDR Bouma Robert Willis (BUMED M8)
2
Outline Objectives

• Review the basic principles of the PBB
• Discuss the relative contributions of the
  Evidence-Based Health Care (EBHC) and Public
  Health components
• Discuss where the EBHC data originates is
  displayed
• PHN
• PHN Dashboard
• Review PBB Resources/Reports

3
PBB Context Escalating Medical Costs
Increase over FY2000 43.8B
14.3B
2.6B
4.5B
(M)
7.6B
14.9B
FY2000 Baseline 17.4B

• Increased benefits mandated by Congress
• Includes TFL Benefit
• Real costs to the beneficiaries are decreasing
• 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

4
PBB Timeline

• 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
  Services funding based on workload measures
  (RVUs, RWPs and Mental Health Bed Days).
• 2006 Expansion of PPS to use performance-based
  planning, financing and management for ALL
  Defense Health Plan (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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PBB Purpose

• Pay for Performance model to ensure quality and
  appropriate utilization of resources
• Properly aligns authority, accountability and
  financial responsibility.
• Provides the appropriate tools and information to
  enable leaders to achieve business plan
  performance goals.
• Will result in programmatic adjustments to future
  annual budgets
• Provides financial incentive for achieving
  uniform level of excellence with respect to
  quality measures across Navy Medicine.
• Will allow Navy Medicine to re-allocate resources
  to those commands who are excelling in the
  provision of healthcare.

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Composition of PBB
NAVY Quality Driven Metrics
Adjustments
PPS Workload
Bed Fill Rates
Public Health
IMR
EBHC
Deployment
PPS
Navy Performance Based Budget
Staffing Mitigation
5
10
45
5





5

• Calculates each individual quality metric at the
  Parent MTF Level.
• Provides a weighted score based on 4 categories
  that corresponds to financial recompense
• Applies to CONUS Facilities Only

Note PBB calculates each individual metric at
the Parent Level. Adjustments are based upon the
Planned OM budget across All BAGS and each
metric may adjust up/down a maximum percentage
based from the planned budget.
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Composition of PBB
NAVY Quality Driven Metrics
Adjustments
PPS Workload
Bed Fill Rates
Public Health
IMR
EBHC
Deployment
PPS
Navy Performance Based Budget
Staffing Mitigation
5
10
45
5





5

• Prospective Payment System (PPS) is based upon
  productivity (compared with base year)
• Outpatient Care (RVUs)
• Inpatient Care (RWPs)
• Mental Health Bed Days
• Is driven substantially by HA/TMA

8
Composition of PBB
NAVY Quality Driven Metrics
Adjustments
PPS Workload
Bed Fill Rates
Public Health
IMR
EBHC
Deployment
PPS
Navy Performance Based Budget
Staffing Mitigation
5
10
45
5





5

• An MTFs funding can be impacted up to 25 as a
  consequence of the PBB quality metrics.
• Each metric may adjust up/down a maximum
  percentage based from the planned budget
• Measure Max Adjustment
• EBHC ( 10)
• IMR ( 5)
• Inpatient Bed Fill ( 5)
• Public Health ( 5)

9
Composition of PBB
NAVY Quality Driven Metrics
Adjustments
PPS Workload
Bed Fill Rates
Public Health
IMR
EBHC
Deployment
PPS
Navy Performance Based Budget
Staffing Mitigation
5
10
45
5





5

• Deployments taken into consideration

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Composition of PBB
NAVY Quality Driven Metrics
Adjustments
PPS Workload
Bed Fill Rates
Public Health
IMR
EBHC
Deployment
PPS
30 other
Navy Performance Based Budget
Staffing Mitigation

5
10
45
5





5

45 25 ???

• 30 of budget categorized as OTHER
• Portion of budget unaffected by PPS PBB

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PBB Significance

• Leadership, Comptroller and Care-giving
  Communities are jointly and keenly interested in
  the performance of these metrics, linking
  resources, performance and quality outcomes.

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• Performance-Based Budget

Public Health
BedCap
IMR
EBHC
Deployment
PPS
30 other
Navy Performance Based Budget
Staffing Mitigation

45
5
10
5





5

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• PBB IMR Metric

Public Health
BedCap
IMR
EBHC
Deployment
PPS
30 other
Navy Performance Based Budget
Staffing Mitigation

45
5
10
5





5

• Individual Medical Readiness
• Focused on Indeterminate
• BSO 18 Personnel Only
• FY09 May focus on additional categories (eg.
  Fully Medically Ready).

14

• PBB IMR Metric

Public Health
BedCap
IMR
EBHC
Deployment
PPS
30 other
Navy Performance Based Budget
Staffing Mitigation

45
5
10
5





5

• Individual Medical Readiness

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• PBB Bed Capacity

Public Health
BedCap
IMR
EBHC
Deployment
PPS
30 other
Navy Performance Based Budget
Staffing Mitigation

45
5
10
5





5

• Inpatient Bed Fill Rate
• 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
  consumes resources inefficiently.

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• PBB Bed Capacity

Public Health
BedCap
IMR
EBHC
Deployment
PPS
30 other
Navy Performance Based Budget
Staffing Mitigation

45
5
10
5





5

• Inpatient Bed Fill Rate

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• PBB Public Health

Public Health
BedCap
IMR
EBHC
Deployment
PPS
30 other
Navy Performance Based Budget
Staffing Mitigation

45
5
10
5





5

• Public Health
• Originally proposed to compensate based upon
  execution of Health Promotion budget.
• Measure was being shadowed.
• Didnt encourage or promote healthy behaviors or
  population health.

Being Revised
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• PBB Public Health

Public Health
BedCap
IMR
EBHC
Deployment
PPS
30 other
Navy Performance Based Budget
Staffing Mitigation

45
5
10
5





5

• Public Health
• Revising to reflect more objective outcomes
• 3 programs methodology pending
• Tobacco Cessation (all MTF beneficiaries)
• Physical Readiness Program (BSO-18 only)
• Healthy Weight/Ship Shape/Obesity (BSO-18 only)

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• PBB Public Health (draft)

Public Health
BedCap
IMR
EBHC
Deployment
PPS
30 other
Navy Performance Based Budget
Staffing Mitigation

45
5
10
5





5

• Public Health Tobacco Cessation
• Assess The of individuals screened for
  nicotine/tobacco dependence
• Document The of individuals diagnosed with
  nicotine/tobacco dependence
• Act The of nicotine/tobacco users who were
  provided counseling

• These metrics will be applicable to all
  beneficiaries.
• Will use specified ICD-9, CPT, and HCPCS codes.
• Historical FY 2007 data to be used to establish
  baseline.

20

• PBB Public Health (draft)

Public Health
BedCap
IMR
EBHC
Deployment
PPS
30 other
Navy Performance Based Budget
Staffing Mitigation

45
5
10
5





5

• Public Health Physical Readiness
• PRIMS reporting of service members
  unaccounted for in PRIMS as compared to the
  number of active duty on board.
• Repeat PFA Failures The of individuals who
  have failed either portion of the PFA (BCA or
  PFT) at the Command for 2 or more consecutive
  times.

• These metrics are for BSO-18 only.
• PRIMS data would be used to calculate biannually
  for Spring and Fall PFA.
• Historical FY 2007 data to be used to establish
  baseline.

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• PBB Public Health (draft)

Public Health
BedCap
IMR
EBHC
Deployment
PPS
30 other
Navy Performance Based Budget
Staffing Mitigation

45
5
10
5





5

• Public Health Healthy Weight
• ShipShape Completion The of service members
  who completed/enrolled in the ShipShape course.
• ShipShape Success The of individuals who are
  within BCA standards within 6 months after
  completing ShipShape (shadowed).
• ShipShape Failure The of BCA failures vs.
  enrolled in ShipShape (shadowed).

These metrics will be based on BSO-18 only PRIMS
data and will be biannual to coincide with PFA
cycles.
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• PBB EBHC measures

Public Health
BedCap
IMR
EBHC
Deployment
PPS
30 other
Navy Performance Based Budget
Staffing Mitigation

45
5
10
5





5

• Evidence-Based Health Care
• Based on performance of 5 HEDIS measures as
  compared to the 75th-90th percentiles
• Data pulled from Population Health Navigator
  (PHN) and averaged for the last 3 months
• Cervical colon cancer measures previously
  shadowed will be incorporated soon

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• PBB EBHC measures

Public Health
BedCap
IMR
EBHC
Deployment
PPS
30 other
Navy Performance Based Budget
Staffing Mitigation

45
5
10
5





5

Evidence-Based Health Care
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EBHC Impact

• 10 of budget now influenced by EBHC measures
  BIG
• Commanders now interested in Clinical Quality
  Disease Mgmt Programs TREMENDOUS opportunity
• Opportunity to GAIN or LOSE 10

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EBHC Measures PHN

• Where EBHC data comes from
• Where else you can find this data

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PHN Background

• USAF tool created in 2000
• Official name MHS Population Health Portal
• Adapted for Tri-Service use Fall 2003
• Incorporated into BUMED Business Plan FY04
• Navy name Population Health Navigator

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PHN compiles data from . . .
DEERS
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CHCS
PHN
M2
PDTS
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PHN feeds data to . . .
PHN Dashboard
PBB
Tri-Service Bus. Plan
TMA
PHN
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Population Health Navigator

• Strengths
• Provides both corporate level (HEDIS) metrics
  and drills to patient/provider/clinic level
• Provides data on patient care regardless of where
  care provided
• throughout entire MHS
• inpatient outpatient care
• network MTF care
• Can be displayed in Excel for easy use of data.
• FREE and readily available

• Limitations
• Updated monthly, 4-6wk lag time.
• Greater delay in posting of network care.
• Does not include non-enrolled beneficiaries
• Only predefined modules, not able to query

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PHN Dashboard

• Compares to other clinics/MTFs
• Contrast own clinic/MTF over time
• Displays denominators, values, and benchmarks
• Navy averages
• HEDIS 50th percentile
• HEDIS 90th percentile

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Dashboard Details

• No accounts/ passwords required
• CAC-enabled
• Updated monthly once PHN refreshed
• Also available via PHC and NMO webpages
• https//dataquality.med.navy.mil/reconcile/popheal
  th

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Parent DMIS names appear here
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Child DMISs name and Parent DMIS average here
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PBB Reports/Resources

• https//nmo.med.navy.mil/pbb/
• http//navymedicine.med.navy.mil/pbb/

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http//navymedicine.med.navy.mil/pbb/
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PBB EBHC Adjustments
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Performance-Based Budget
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Performance-Based Budget
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Performance-Based Budget
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Performance-Based Budget
Data posted Feb 08
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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.
Green Above 90th Percentile Yellow Between 90th
and 75th Percentile Red Below 75th Percentile
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Future Directions

• Performance-Based Budget
• Addition of 2 EBHC measures
• Incorporate EBHC measures into PPS?
• ORYX measures? (doubtful)
• Disease Mgmt Policy
• New (HEDIS/non-HEDIS) measures
• Tobacco cessation
• Population Health Navigator
• Daily data refresh?
• CDM data input
• Graphing capability?
• Active enrollment?
• PHN Dashboard
• Display all 7 measures, update benchmarks
  ETA???

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Web Site POC

• https//NMO.med.navy.mil/PBB

• PBB Concept
• Mr. Marshall, Comptroller, Navy Medicine
• PAE Pilot Developers
• LCDR Randy Bills
• LCDR Matt Bouma
• BUMED PBB POC
• Mr. Robert Willis
• BUMED, code M81 (PAE)
• 202-762-3542
• robert.willis3_at_med.navy.mil