meprs what it’s good for …*
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MEPRSWhat it’s good for …*
29 July 2010
8:00 – 8:50 a.m.
*And the impact of your data on various programs and metrics
2
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
3
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
4
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
5
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
6
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
7
Costs on SIDRs & SADRs
8
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
9
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)
10
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 CostsBased On: FY06 FY07 FY08 FY09 FY10 FY11
After Summer 2010 Retrofit
FY07 FY08 FY09 FY09 FY09
FY06
FY06
Current FY07 FY08 FY08 FY08 N/A
Application Year
Before Summer 2009 Retrofit
FY07 FY07 FY07 N/A N/AFY06
11
Expenses with No Workload
12
Negative Expenses
13
Unallocated Ancillary/Support?
$0
$2,000,000
$4,000,000
$6,000,000
$8,000,000
$10,000,000
$12,000,000
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
FY07-FY09 Monthly Total Expenses by MEPRS-1(Selected MTF)
B C D E F
14
Erroneous Expenses? (Note: data were extracted June 2010)
15
Rx Percentage of Ambulatory $
Lumpiness: Pharmacy expenses recorded when drugs purchased rather than when dispensed?
16
Dispensing Costs for Direct Care PDTS
Records
17
18
Why the Difference?
19
High-Level MHS Metrics
20
MHS Dashboard
*** Denotes Strategic ImperativeImproving Declining Stable X Under development
Casualty Care and Humanitarian Assistance
G Reduced Combat Losses
Case Fatality Ratio (OIF/OEF Combat Casualty)
G
Observed/Expected Survival Rate (Battle Wounds)
G
Mortality Rate Following Massive Transfusions
G
Battle-Injured Medical Complications Rate G
Age of Blood in Theater G
YEffective Medical Transition
and Warrior Care
MEBs Completed Within 30 Days *** R
DES Cases Returned to MTF G
MEB Experience Rating *** G
VA Transition Process R
GImproved Rehabilitation & Reintegration to
Force
Amputee Functional Re-Integration Rate G
TBI Screening and Referral X X
Potential Alcohol Problems and Referral 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 andProtected Force
Y Reduced Medical Non-Combat Loss
Force Immunization Rate Y
Orthopedic Injuries Rate in Theater
R
Orthopedic Injuries Rate in Garrison (Non-Deployed)
G
Influenza-Like Illness Rate in Theater
R
Influenza-Like Illness Rate in Garrison (Non-Deployed)
G
Psychological Health: In-Theater Evacuations/ Encounters
R
R Improved Mission Readiness
Individual Medical Readiness ***
R
Percentage Unknown Medical Readiness Status
R
Increased Resilience & Optimized Human Performance
Psychological Distress Screens, Referral and Engagement ***
X X
Effectiveness of Care for Complex Medical / Social Problems ***
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 G
Alcohol Screening/Assessment Rate G
FAP Substantiated Child/Spouse Abuse Rate G
Influenza Immunization Rate R
Pandemic/Seasonal Influenza Vaccine Coverage Rate ***
X X
Mental Health Demand-Family of Service Members X X
Percent of Patients Advised to Stop Smoking ***
X X
Active Duty Suicide Rate (Probable/Confirmed) R
G Health Care Quality
Enrollee Preventive Health Quality Index (HEDIS) ***
G
Overall Hospital Quality Index (ORYX) *** G
CONUS Ventilator Associated Pneumonia Rate X X
Health Care Personnel Flu Vaccination Rate X X
Hospitalization 30-Day Disease Mortality Rate G
Y Access to Care
Getting Needed Care Rate *** R
Getting Timely Care Rate *** R X
Percent of Visits Where MTF Enrollees See Their PCM ***
Y
Booking Success Rates for Primary Care Appointing Y
Primary Care Third Available Routine Appointment Y
Y Beneficiary Satisfaction
Satisfaction with Provider Communication Y
Satisfaction with Health Care *** Y
Satisfaction with Health Plan G
Education, Research and Performance Improvement
GCapable MHS Work Force and Medical
Force
Mental Health Provider Staffing X X
Staff Satisfaction *** X X
Competitive & Direct Hire Activity (Medical Professionals)
G
Advancement of Global Public Health
Under Development X X
Contributions to Medical Science
Product to Practice Success ***
X X
Healing Environments
Under Development X X
RPerformance-Based Management
and Efficient Operations
Annual Cost Per Equivalent Life (PMPM) ***
R
Enrollee Utilization of Emergency Services ***
Y
Provider Productivity R
Impact of Deployments on MTFs ***
X X
Bed Day Utilization (Prime Enrollees) X X
RDeliver Information to People so They
Can Make Better Decisions
AHLTA Reliability R
AHLTA Speed Y
User Assessment of EHR Functionality ***
X X
DMHRSi/EAS-IV Transmissions by Service
R
21
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
22
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)
23
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
24
RVUs per FTE
9.5
11.5
13.5
15.5
17.5
19.5
21.5
23.5FY
06 O
ct Dec
Feb
Apr
Jun
Aug
FY07
Oct De
c
Feb
Apr
Jun
Aug
FY08
Oct De
c
Feb
Apr
Jun
Aug
FY09
Oct De
c
Feb
Apr
Jun
Army Navy Air Force MHS
Good
Civilian Averageis 21.8
25
Ambulatory Available FTEs by MEPRS-2(Selected Major Medical Center)
26
Ambulatory Available FTEs & Visits
27
Medicare-Eligible Retiree Health Care Fund
(MERHCF)
Direct Care Level of Effort (LOE)
28
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
29
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
30
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
31
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
32
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
33
FY09 MERHCF LOEPharmaceutical PEC & SEEC Mismatch
Fiscal Year
Parent DMIS
IDParent Name
DoD PEC
DoD SEEC SEEC Description
Net Month Expense
2009 0033 10th MED GROUP-USAF ACADEMY CO87701 11.10 Civilian Personnel Compensation 387,245$ 2009 0033 10th MED GROUP-USAF ACADEMY CO87701 11.72 Military Personnel Compensation 821,658$
1,208,904$
2009 0045 6th MED GRP-MACDILL87701 11.10 Civilian Personnel Compensation 105,859$ 2009 0045 6th MED GRP-MACDILL87701 11.72 Military Personnel Compensation 421,938$ 2009 0045 6th MED GRP-MACDILL87701 11.74 Borrowed Military Labor 2,093$
529,889$
2009 0055 375th MED GRP-SCOTT87701 11.10 Civilian Personnel Compensation 113,216$ 2009 0055 375th MED GRP-SCOTT87701 11.72 Military Personnel Compensation 816,848$ 2009 0055 375th MED GRP-SCOTT87701 11.74 Borrowed Military Labor 3,752$
933,817$
34
FY07 MERHCF LOEImpact of Incomplete Army MEPRSArmy lost $20.0 million or 3.3% of their FY07-
based MERHCF distribution
Official results submitted 29 April 2008
Updated results computed 13 June 2008
Army Air Force NavyDoD Beneficiaries 609,708,647$ 575,864,963$ 395,999,148$ 1,581,572,758$ Non-DoD Beneficiaries 4,284,678$ 5,003,092$ 8,083,711$ 17,371,482$
613,993,325$ 580,868,055$ 404,082,859$ 1,598,944,239$ Total MERHCF LOE
MERHCF LOE by Providing Military ServiceBeneficiary Service Affiliation
MERHCF LOE Total
Army Air Force NavyDoD Beneficiaries 630,458,316$ 576,294,859$ 396,733,252$ 1,603,486,427$ Non-DoD Beneficiaries 4,493,393$ 5,010,408$ 8,086,186$ 17,589,987$
634,951,708$ 581,305,267$ 404,819,438$ 1,621,076,413$ Total MERHCF LOE
MERHCF LOE by Providing Military ServiceBeneficiary Service Affiliation
MERHCF LOE Total
35
FY09 MERHCF LOEImpact of Incomplete Air Force MEPRS
Army Air Force NavyDoD Beneficiaries 709,865,155$ 597,838,289$ 424,149,590$ 1,731,853,035$ Non-DoD Beneficiaries 5,292,442$ 5,019,682$ 10,310,181$ 20,622,305$
715,157,597$ 602,857,971$ 434,459,771$ 1,752,475,340$ Total MERHCF LOE
MERHCF LOE by Providing Military ServiceBeneficiary Service Affiliation
MERHCF LOE Total
Official results submitted 21 April 2010
Army Air Force NavyDoD Beneficiaries 710,296,374$ 620,998,917$ 424,154,627$ 1,755,449,918$ Non-DoD Beneficiaries 5,294,811$ 5,331,881$ 10,310,379$ 20,937,071$
715,591,185$ 626,330,797$ 434,465,006$ 1,776,386,989$ Total MERHCF LOE
MERHCF LOE by Providing Military ServiceBeneficiary Service Affiliation
MERHCF LOE Total
Updated results computed 24 May 2010
Air Force lost $23.5 million or 3.7% of their FY09-based MERHCF distribution
36
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
Questions?
CONTACT INFORMATION
John A. Coventry, Ph.D.SRA International, Inc.
210-832-5212John_Coventry@sra.com
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