Performance Based Adjustment Model (PBAM)

1. Performance Based Adjustment Model (PBAM) PBAM Basics Management Division Resource Management U.S. Army Medical Command March 2012 UNCLASSIFIED

2. Agenda • Background • Data and Sources • Reports • Methods • Access

3. Background • PBAM is a financial and budgeting model designed to assist the Army MEDCOM in putting it’s strategic vision into action by linking budgets with outputs and outcomes • Periodic adjustments to current and future year budgets based on performance in key strategic areas • Promotes healthcare capacity and access to care • Payments are based on changes in workload generated • Enhances quality clinical outcomes and patient satisfaction • Payments based on how well we take care of our patients • Promotes efficiency and data quality • Bonuses and penalties based on how resources and information are managed

4. Background • Beginnings • Evolution

5. Background • Beginnings • Development began in 2005 • Development team consisted of administrative and clinical staff – officially chartered PBAM Workgroup • “Shadow” year in 2006 • No Financial adjustments made but data available for review by MTFs • Full implementation in 2007 with financial adjustments • Evolution • PBAM has undergone many updates and refinements with more expected as the model matures. Intent is to move from retrospective model to “TRUE” prospective model by funding to Business Plans.

6. Background First Year Evolution of PBAM

7. Data and Sources • Data Sources • Data Cycle

8. Data Sources • Workload and Efficiency • M2: RVUs, APCs, RWPs, and Mental Health Bed days • EASIV: Provider availability data (FTEs) • Quality • Evidence Based Practice :MHS Population Health Portal • HEDIS and Action List • Patient Satisfaction (2 Sources) • Army Provider Level Satisfaction Survey (APLSS) • TRICARE Inpatient Satisfaction Survey (TRISS) • ORYX: External Contract • Readiness: MODS/MEDPROS • BMI: Clinical Data Repository (CDR) • Administrative • Coding Accuracy: Code Auditing Reporting Application (CARA) • Coding Timeliness: CARA • PCM Continuity: TRICARE Operations Center (TOC) • Network Primary Care: M2

9. Data Cycle • Uses a 12-month rolling data set • Model Year: August through July • Aligns the most complete 12-month data set with the Fiscal Year • First report of FY is based on August data, the final report is July • PBAM baseline set using the July report • The July report is the final report of the FY • Used as part of the budgeting process for the following year • 12-month data set that does not change once established (Aug-Jul) • Follow-on year is compared to this data to make financial adjustments • PBAM Monthly Reports • Reports are titled based on the final month in the data set • Budget modifications are made by a comparison of a the current rolling-12 to the established baseline

10. Reports • Three Primary Reports • Capacity • Quality • Administrative • Two Summary Reports • Financial • Workload

11. Healthcare Capacity Ambulatory Section Provides information and payment amounts for workload metrics Inpatient Section Work Performed in Civilian Facilities & Coding Error Correction Adjustments Summary

12. Quality Evidence Based Practice Action List & HEDIS Provides information and payment amounts for Quality metrics ORYX Patient Satisfaction IPSR BMI PHA Quality Summary

13. Administrative Performance MEPRS Penalty Provides information and payment amounts for administrative processes Coding Accuracy Metrics SIDR/SADR Metrics PCM Continuity MAPR Summary Network Primary Care

14. Workload Summary Summary Ambulatory Performance Summary Provides a summary view of the workload data from the Product Line Summary Inpatient Performance Summary RWPs & MHBDs Inpatient RVU Performance Summary

15. Financial Summary Net Reporting Period Adjustments Provides a roll-up view of financial adjustment information from the three Primary Reports Combined Adjustments Workload Earnings EBP Earnings Other Quality Adjustments Administrative Adjustments

16. PBAM Components • Healthcare Capacity • Quality and Outcomes • Administrative Performance

17. Healthcare Capacity • Financial Adjustments made for 2 factors • Workload • Ambulatory RVUs • RWPs & Mental Health Bed Days • Inpatient RVUs • External Workload • Efficiency • Ambulatory • RVU/Provider/Day • Inpatient • Average Length of Stay

18. Quality and Outcomes Evidence Based Practice Patient Satisfaction Inpatient Professional Services Rounds Body Mass Index (BMI) Periodic Health Assessment (PHA)

19. Quality and Outcomes • Evidence Based Practice • Metrics (9) • Asthma Medications • Breast Cancer Screening • Cervical Cancer Screening • Colorectal Cancer Screening • Diabetes (3): A1c Test, A1c Control, and LDL-C Control • Chlamydia Screening • HEDIS: Well Child Visits • 50th Percentile and 90th Percentile incentives • Percentiles unique to each metric • ORYX • Metrics (2) • Childhood asthma : Home care plan prior to discharge: 90% • Antibiotics given within 1 hour prior to cut time: 98%

20. Quality and Outcomes • Patient Satisfaction • One question for Patient Satisfaction (APLSS) • Q20: Everything considered, how satisfied were you with “MTF X” during this visit? • Three questions for Access to Care (APLSS) – How do you rate: • Q9: Phone service you received in scheduling the appointment for this visit. • Q11: The amount of time from when you made the appointment until you actually saw the healthcare provider. • Q13: Courtesy and helpfulness of the staff during this visit. • One Question for Inpatient Satisfaction (TRISS) • Q21: “Using any number from 0 to 10, where 0 is the worst hospital possible and 10 Is the best hospital possible, what number would you use to rate this hospital during your stay?” • Incentive targets and amounts differ by question

21. Quality and Outcomes • Inpatient Professional Services Rounds (IPSR) • Recognizes and incentivizes documentation of inpatient professional services • Body Mass Index (BMI) • Incentivizes recording the Height and Weight in the Vitals table in AHLTA • Periodic Health Assessment (PHA) • Incentivizes completion of the Active Duty Soldier PHA

22. Administrative Performance MEPRS Transmission SIDR/SADR Code Audit and Reporting Application (CARA) Network Primary Care Primary Care Manager (PCM) Continuity

23. Administrative Performance • MEPRS Transmission Timeliness • MEPR is delinquent 45 days after end of reporting month; DoD standard. • Coding Timeliness Metrics • SIDR Timeliness: 99%, 45 days from Disposition • SADR/CAPER Timeliness: 98%, 30 days from Encounter • SIDR Completion: 100%, 15 months from Disposition • Coding Accuracy Metrics • CPT Accuracy: 93% • E&M Accuracy : 93% • ICD-9 Accuracy : 93% • PCM Continuity • Bonus for each encounter where the patient saw their PCM • Network Primary Care • Penalty for enrollees using private sector care within the MTF’s catchment area for Primary Care and non-emergent conditions in the ER

24. FY12 Model Refinement/Information • Convert to the CAPER as the source for Ambulatory Workload • SADR data not populated as of FY12 • Convert to Provider Aggregate RVUs • Modified CAPER(13) Work and Practice Expense RVUs • Return General Duty Nurse RVUs (Provider Spec 600) • Continue to cap current year losses at 5% of healthcare budget • Continue to apply negative adjustments at final distribution

25. FY12 Changes/Additions • Behavioral Health Service Line Workload • Suspension of BH Service Line workload from PBAM resourcing • Addition of a EBP Metric • HEDIS: Well Child Visits (6 visits with first 15 months of life) • Periodic Health Assessment (PHA) for AD Soldiers • Incentive to facilitate the timely completion of the PHA within 15 months • Patient Satisfaction modifications • Addition of Inpatient Satisfaction from the TRISS • Structure similar to APLSS questions

26. PBAM System & Access • Web based • HTTP Secure access protocol • Reports are published from the web using Microsoft Excel • No special programs required by end-users • CAC access • CAC are required for access • Specific users identified • Uses Active Directory to validate access permission • Eliminates user name and password requirements • All reports available to all users • Allows for peer comparison • Report availability • New reports monthly with all historical reports maintained for review • Published at Medical Command, Regional Command, Parent DMIS, and child DMIS levels

27. Conclusion Army Facilities Continue to Expand Capacity and Deliver More Healthcare FY11 Incentives Begin AN Dashed lines represent projected values based on Business Planning Key – incentivize the “right” metrics Incentives work - need to know second and third order effect Risk is taken at the MACOM level Stability in the model is desired at the user level – only take on enduring incentives – not a “Christmas Tree” Can’t wait for data to be “good” – proper incentives drive accuracy of the data

28. Questions?

29. Backup Slides

30. FY12 PBAM APLSS Pat Sat Methodology Q20 Qs 9, 11, & 13 • Instead of adjusted scores, adjusted targets • APLSS Questions: 9,11,13,and 20 • MTF Specific Targets • 5-Tier Methodology for Q20 • 4-Tier Methodology for Qs 9, 11, &13 • Targets based on percent of AD/ADFM and RET/RETFM returns received • Targets and Rates

31. FY12 PBAM APLSS Pat Sat Methodology Target Methodology for APLSS Questions: 9,11,13,and 20 Determine the MEDCOM % Satisfied for Overall Satisfaction by Combined BenCat (AD/ADFM & RET/RETFM) A E Determine MTF Adjusted Percent Satisfied using MTF % of Returns to adjust the MEDCOM % Satisfied by Combined BenCat (similar to PY normalization of % satisfied) AD/ADFM: A x B = C RET/RETFM: E x F = G MTF Adjusted Sat: C+G = N B F C G N Calculate the Target Adjustment Factor by subtracting the MEDCOM Overall % Satisfied from the MTF Adjusted % Satisfied Establish MTF Targets by adding the MTF Adjustment Factor to the Base Targets for each Achievement Tier

32. Satisfaction – MTF Targets Q9 Q11

33. Satisfaction – MTF Targets Q13 Q20

34. FY12 PBAM TRISS Pat Sat Methodology • Inpatient Satisfaction • TRICARE Inpatient Satisfaction Survey (TRISS) • Question 21 • “Using any number from 0 to 10, where 0 is the worst hospital possible and 10 Is the best hospital possible, what number would you use to rate this hospital during your stay?” • A rating of 9 or 10 is considered satisfied • MTF Specific Targets • Adjusted using five categories • Health Status, Age, Beneficiary Category, Product Line, and Gender • Reported Quarterly • Rates and Base Targets

35. FY12 PBAM TRISS Pat Sat Methodology MEDCOM and MTF % Satisfied determined for Overall Satisfaction without Adjustments 1. 2. MEDCOM Satisfied determined for all components of each category: a) Health Status b) Age c) Ben Cat d) Product Line e) Gender Percent of total returned MTF surveys determined for each component of all categories 3. 4. Determine the Adjusted Satisfaction percentage for each Category. Gender used as an example: MTF Male Survey return percentage (A: 16.54%) multiplied by the MEDCOM Male Satisfied Percent (B: 72.10%). Add MTF Female Survey return Percentage (C: 88.46%) multiplied by the MEDCOM Female Percent Satisfied (D: 58.70%). Equals Demographic Adjusted Satisfaction (A x B) + (C x D) = Z (16.54% x 72.10%) + ( 83.46% x 58.70%) = 60.90% - 5. Calculate the MTF Target Adjustment Factor by subtracting the MEDCOM Overall % Satisfied from the MTF Adjusted % Satisfied 6. Establish MTF Targets by adding the MTF Adjustment Factor to the Base Targets for each Achievement Tier

36. Inpatient Satisfaction – MTF Targets