Air Force Consultant Report
Air Force Consultant’s Report
Antoin “Marcus” Alexander, MD, FAAFP
AFMOA, San Antonio, TX
I hope that everyone is finding time to enjoy the summer with families and friends. Our folks work hard, and it is important to take the time to recharge. The summer brings with it the last quarter of FY17. I think much of the tone for FY17 was set by the National Defense Authorization Act for FY17. If you have not had a chance to glance over it, I would recommend a quick look at the summary by googling “NDAA 2017 summary.” This gives a good idea of the perceptions of the Senate Armed Services Committee, and specifically the perceptions and goals of the Military Compensation and Retirement Modernization Commission for the Military Health System. These perceptions and goals are important to keep in mind as we think of the positive changes the AFMS has made in 2017 and the challenges we still have to figure out.
What are key statements in the 2017 NDAA for us all to be aware of?
While it is important to understand the MHS specific statements, there are some noteworthy generalities. The national defense budget is $602 billion, with nearly $23 billion in unfunded requirements of which $7 billion were considered readiness-related. Thus, even things that we think make perfect sense and are valid requirements that drive funding or resourcing are competing with $23 billion worth of similar requirements that won’t have funding. There are money and manpower limitations that are real and that we have to keep in mind as members of the system that we are trying to improve.
The NDAA specifically targeted comprehensive reform of the military health system as a means for sustaining the quality of life of the men and women of the total force and their families. This proposed reform targeted improving operational medical force readiness, improve access to care, and expand beneficiaries’ choices of health plans while providing higher quality care and a better experience of care. The NDAA stated that there is a lack of additional capacity to enroll patients in bottle-necked primary care clinics, but beneficiaries continue to be required to receive care at military hospitals. The NDAA also states that data shows that military healthcare providers have much lower productivity than their comparable civilian counterparts (productivity goal of 40% Medical Group Management Association median), which severely limits beneficiaries’ access to care. This statement about MGMA targets is clearly not applicable to primary care given that AFMH targets are enrollment based; however, the general implication is that DoD physicians don’t produce enough clinical care. Additionally, the NDAA states that the total cost to provide healthcare in military treatment facilities is greater than the cost in the private sector. This did not state if the requirement costs of ready medics and a medically ready force was included in the comparison.
The NDA A specifically recommended several provisions: eliminate the requirement for pre- authorization for specialty care referrals, improve pediatric care and related services, incentivize participation in disease management programs, require a standardized appointment process, require contracts for turn-key primary care/urgent care clinics at MTFs, establish performance accountability for military healthcare leaders, right-size the footprint of the MHS to meet operational medical force requirements, and authorize conversion of military healthcare provider positions to civilian or contract positions. Our AFMS leadership has prepared to offer objective cost verses benefit data and feasibility regarding the application of these provisions and reform targets.
What things has the AFMS done thus far?
Many things have been done to improve the quality and safety of care delivered by the AFMS. Some measures directly impact outcomes, and others are positive steps towards desired outcomes. Some examples follow below.
The AFMH branch completed time motion studies at three MTFs to objectively quantify provider workload by three categories: time spent caring for scheduled patients, time spent caring for patients without an appointment, and time spent doing no clinical work. In total the providers averaged 57 hours per week. This data will be key in shaping current and future workload and manpower models. AFMOA is currently working with A1 manpower as they conduct site visits to relook at family health clinic workload and manning models.
A pilot was started by placing 20 non enrolled AFMH contract providers at 11 MTFs to mitigate short term (less than 6 month) vacancies. This was then included to establish 23 non enrolled civilian provider positions in the FY 18 POM that started to fill in January 2017. Additionally, 19 non enrolled positions were requested in the FY 19 POM. Thus a commitment has been made to explore accounting for a continuous percentage of unavailable providers via prepositioned non enrolled providers.
AFMOA has engaged in a pilot to centrally facilitate hiring of locum tenems contract providers for thirty- five positions that were identified to have significant summer underlap regarding outbound and inbound providers. While timing this year will not allow contractors to be in place exactly as the underlap occurs, If successfully put in place for August through November, the providers will help MTFs recover from the underlap this year and establish a process to potentially utilize summer 2018 June through August.
The AFMS established an AFMH deliberate planning team composed of 50 field representatives of all AFMH components plus AFMOA/ AFMSA/HAF representatives. Over six months the team met to consider organizational systems thinking based changes to improve AFMH. The team will present the AF SG with specific activities and milestones in areas such as workload, staff availability, standard work, access, education and training, and strategic communication.
Arthur Kellerman, Dean of the USU School of Medicine, published an article in Health Affairs Blog that highlighted facts such as DoD FY17 budget for military health of $48.8 billion provides care for 9.8 million beneficiaries, verses Kaiser Permanente FY16 budget of $64.6 billion provided care for 11.3 million. By this data, we are actually cheaper per beneficiary and support combat missions in addition to beneficiary care. Dr. Kellerman also goes on to propose solutions such as making greater use of enlisted providers in garrison and utilizing their skills to their full capacity as we do down range in order to expand access to care, standardizing key workflows, and ensuring provider clinical proficiency. The Comprehensive Medical Readiness Program was established to focus on clinical currency for readiness. Requirements for all family physicians to perform a minimum of 100 pediatric clinical encounters under the age of 14 every two years was a start to ensuring that our FPs are prepared to be the only downrange pediatrician and also maintain scope of practice of FPs. Additionally, all FPs in UTCs were required to perform 140 patient days every two years (2 weeks of inpatient per year with an average censes of 5 patients per day) in an inpatient setting to maintain readiness skills and scope of practice.
Virtual appointments were added to take credit for the workload identified in the time motion study that was done for patients that did not have an appointment and to improve quality and satisfaction for both the patient and the provider team. This quantification will also allow continued right sizing of provider workload in the near future.
A ramp up guide was released that quantified time, training, and experience for AFMH providers to be functioning at full capacity. This guide will help prevent provider burn out, improve the quality and safety of care provided, and provide objective means to right size true provider capacity across the AFMS in the future.
Genesis was rolled out at Fairchild in addition to a transition to MED- COI infrastructure to increase the speed of the system. The MHS has planned to roll this system and infrastructure out AFMS wide over the next five years. This roll out is faster and more aggressive than the majority of the civilian organizations that roll out Cerner’s EHR.
Workload for PHAs was calculated and included in considerations for FY19 and FY20 manpower programming in the POM as well as mitigation strategies until potential POM authorizations would be available.
Physician representatives joined recruiters on visits to civilian medical schools, residencies, and the AAFP National Conference of Family Medicine Residents and Students generating hundreds of interested candidates and potentially significantly bolstering Family Medicine recruitment. Additionally the medical corps office has vigorously engaged with HPSP students and held several primary care dial-ins facilitated by program directors and consultants in order to bolster primary care recruitment.
While there may be disagreement with some of the NDAA assertions or solutions, there is complete agreement that reform of the military health system is required to improve not only the quality of care delivered, but also to improve patient satisfaction and staff satisfaction. There have been many strides taken in the right direction. In addition to continued systematic improvement, we as family physicians must continue to embrace ownership of our empaneled patients, function as efficiently as possible, and utilize all the members of our team to their full scope.
As always I thank you for your hard work and the amazing care you provide.
WE ARE … FAMILY MEDICINE