Health Care Delivery
Naval Medicine continually examines our methods of delivering services to ensure that they are the best value for Naval Medicine, the MHS and our beneficiaries. We focus on increasing our efficiencies, but will never compromise clinical quality, access to care, customer satisfaction or staff quality of life to achieve that goal.
This year the Bureau of Medicine and Surgery (BUMED) developed a business planning model that combined standard business planning methodology with an automated business planning tool. This new process requires all activities in Naval Medicine to develop, submit, and monitor a comprehensive annual business plan that is integrated with their existing financial plan. This methodology takes into account the changes in our financing due to the TRICARE for Life program, the prospective payment system and the TRICARE Next Generation contracts. The automated tool takes information from seven different data sources to help local commands and headquarters personnel identify variations in cost and productivity for the same services between MTFs. It also helps identify high cost, low productivity services provided at local MTFs. We are providing specialized training to the senior leaders in our MTFs, to ensure that their business plans optimally represent the size and diversity of services provided at their facilities. Our goal is to reduce the variation in cost and productivity between our MTFs, driving out inefficiencies that will result in increased cost savings, patient satisfaction and quality of medical care rendered.
“Family-Centered Care” is one of the initiatives we have undertaken to provide best value for our beneficiaries. Family-Centered Care initiatives are intended not only to increase patient satisfaction and improve the delivery of care; they are intended to create partnerships between providers, patients, and their families by empowering patient's families to become active in the care plan. In the military, the definition of family must be expanded to include both immediate and extended family members as well as friends and the social support network of both single service members and spouses of deployed service members. Single service members create virtual 'families' through a social network within and outside their units. Family-centered care must incorporate this non-traditional type of family support in the delivery of care. By partnering with patients and their families, we can retain them in the direct health care system. This will enable Naval Medicine to provide families with the tools to develop and maintain healthy habits throughout their lives.
Our first Family-Centered Care initiative includes significant improvements to perinatal services in order to integrate our young Sailors and Marines into our health care system during the time in which they are starting their families. Our MTFs have implemented numerous initiatives to provide increased quality of service for expectant women and their families. These initiatives include: increased continuity with providers through prenatal visits with small care teams or individual providers; encouraging our providers to work with patients to create a birth plan for their deliveries; providing private post-partum rooms where possible; providing 24/7 breastfeeding support; DEERS enrollment by the bedside; and establishing a system to provide seamless transfer of care between MTFs during permanent change of station moves for expectant women. These initiatives have been successful in encouraging our patients to choose to deliver their babies in our MTFs despite the fact that they now have the choice to seek perinatal care in the civilian community.
In FY 2003, Naval Medicine embarked on a global Case Management Program (CMP) in Navy MTFs. This program provided contract registered nurses and social workers to assist in the coordination of care for patients with complex illnesses or serious injuries. These professionals work with all disciplines within a medical treatment facility and within the TRICARE network to ensure that patients have a seamless transition in healthcare services, receive the proper referral to needed services and reduce the incidence of duplicate or unnecessary services. This program reduced health care costs, increased patient satisfaction and ensured high quality care for our beneficiaries.
Naval Medicine initiated a third Radiology Residency Program at the Naval Medical Center in Portsmouth, VA. This proactively addressed staffing issues in the most critically understaffed and expensive medical specialty in the Navy, immediately improving access to imaging services in the short-term while providing long-term specialty availability.
We have also invested in Pharmacy Automation Equipment at selected treatment facilities. This program leverages technology by using bar code scanners and computers to continuously track and monitor medication administered to our inpatients. This equipment greatly improves the safety of our patients by reducing the probability of unintended medication errors.
We continue to fund new pilot projects designed to increase our effectiveness in providing healthcare services. With our new business planning tool, we will be able to quickly identify those projects that successfully increase productivity and share those improvements in all of the MTFs throughout Naval Medicine. It is our intent to continuously improve our patient care delivery systems to ensure the best health care for our beneficiaries.
Patient safety is a top priority for Naval Medicine. Every MTF has a minimum of one full time staff member dedicated to coordinating command-wide patient safety initiatives. All of our MTFs participate in the MEDMARX system for medication error reporting that groups medication error events and near misses into five process nodes, allowing MTF staff to evaluate process changes that will increase the safety of medication administration. Naval Medicine also uses a standardized root cause analysis methodology that is used by both local MTF and headquarters staff to track and analyze trends in patient care systems that affect patient safety. All of our MTFs are required to submit monthly patient safety scores and receive a monthly Safety Assessment Score. These scores are used to assess overall MTF performance and are monitored closely.
We maintain our high standards through rigorous reviews. Our medical treatment facilities are reviewed by leading accreditation agencies including the Joint Commission of the Accreditation of Healthcare Organizations (JCAHO), Accreditation Council for Graduate Medical Education; the College of American Pathologists and the American Association of Blood Banks.
Naval Medicine has implemented through the JCAHO a major paradigm shift in the accreditation process of our MTFs: "Shared Vision-New Pathways". Shared Visions-New Pathways shifts the focus from survey preparation to continuous improvement of operational systems that directly impact the quality and safety of patient care. It is intended to force standards based process integration across all functional lines by using actual patient experience as a lever.
DOD/VA Resource Sharing and Coordination: Status on Implementation of Presidential Task Force Recommendation
Naval Medicine continues to support ongoing efforts implementing the Presidential Task Force recommendations to pursue sharing collaboration with the Department of Veterans Affairs specifically to optimize the use of federal health care resources. I believe our progress is one of our success stories. Site-specific sharing initiatives, including in the key geographical areas as directed by the FY2002 and FY2003 Defense Authorization Acts, are occurring and continue to be developed. Naval Medicine currently has 54 medical agreements, 34 Reserve agreements, 24 Military Medical Support Office agreements, and 13 non-medical agreements with the Department of Veterans Affairs. Naval Medicine has also partnered with the Department of Veterans Affairs on five medical facilities construction projects. These are:
1. Naval Hospital Pensacola FL. This joint venture outpatient facility will be built on Navy property, and the VA will fund the project, and provide Naval Medicine with 32,000 square feet. This will be a replacement facility for Naval Medicine’s aging Corry Station Clinic. Navy and VA have agreed on a site and negotiations continue on the amount of land to be allocated for construction and how services will be integrated to best serve both DoD beneficiaries and Veterans
2. Naval Hospital Great Lakes, IL. A FY2007 construction start has been proposed to build a separate Navy/VA Ambulatory Care Clinic on the grounds of the North Chicago Veterans Affairs Medical Center. Full integration planning has begun, with facility and site analysis to follow. The North Chicago VAMC is now providing emergency and inpatient services to Navy beneficiaries. Additionally, the North Chicago Veterans Affairs Medical Center will be available to the Navy for specified services with the Department of Veterans Affairs funding modifications of its surgical suites and urgent care facilities.
3. Naval Hospital Beaufort, SC. A tentative FY2011 construction start has been planned for a replacement hospital. The Department of Veterans Affairs currently operates a small clinic within the existing hospital, and is expected to be a partner in developing the replacement facility.
4. Naval Ambulatory Care Clinic Charleston, SC. A FY2005 construction start has been planned for a replacement clinic aboard Naval Weapons Station (NWS) Charleston. Navy has offered the Department of Veterans Affairs the options of an adjacent site onboard NWS or the take-over of the existing NWS clinic. The Department of Veterans Affairs is studying these options with a final decision to be made in the future
5. U.S. Naval Hospital Guam. A FY2008 construction start is planned for replacement of the current hospital. The Navy has offered the Department of Veterans Affairs a site for nearby freestanding community-based outpatient clinic. It’s proposed that the Department of Veterans Affairs will fund the clinic, roads and parking, and will continue to utilize Navy ancillary/specialty care.
Other examples of partnerships that show the depth and variety of our collaboration include the development of uniform clinical practice guidelines for tobacco use and diabetes last year, and development of hypertension and low back pain guidelines scheduled for 2004. Asthma guidelines are projected for revision in 2005.
In the works is a VA/DoD agreement that would permit the use of North Chicago VA Medical Center spaces to establish a center to manufacture blood products in exchange for the use of these blood products. This agreement would alleviate the necessity for Naval Medicine construction costs for a new center at Naval Hospital Great Lakes. An agreement between the Bureau of Medicine and Surgery and the Department of Veterans Affairs headquarters to share each other’s “lessons learned” databases is presently being developed.
Aggressive investigation of other mutually advantageous resource sharing possibilities is on-going at all Naval Medicine facilities with the focus of providing of our beneficiary populations – military and veterans, the outstanding healthcare they deserve.
Defense Health Budget for FY2004
One of Naval Medicine’s greatest accomplishments is meeting the healthcare needs of all its beneficiaries – active duty, retiree, family members and eligible survivors. Nation-wide, healthcare costs are now increasing at the fastest rate in the last decade. Healthcare inflation continues to exceed inflation in other sectors of the economy. Utilization of healthcare services continues to increase as technology advances results in effective new – albeit sometimes costly - treatments and longer life spans.
In addition, as the news of TRICARE’s quality and effectiveness spreads, and as the costs of other insurance programs rises, more retirees under 65 are dropping other health insurance and relying on TRICARE. From the trends of the past few fiscal years, it’s estimated that in FY 2004 there will be a 5.2 percent increase in this population.
DoD has ongoing programs that help control health care cost increases, such as building cost control incentives to managed care support contracts and competitively awarding these contracts for best value, and ensuring the pharmaceuticals delivered in our Military Treatment Facilities and through the TRICARE Mail Order Pharmacy Program are procured through using discounted federal government pricing. DoD and Naval Medicine management programs have also been utilized to ensure that healthcare provided to beneficiaries is reviewed for clinical necessity and appropriateness.
Naval Medicine has worked hard to get the best value from every dollar Congress has provided, but your assistance is needed to restore the flexibility to manage funds across activity groups. Fencing sector funds prevents transfer of funds from MTFs to the private sector, but also prevents transfer of private sector funds to the MTFs. This fencing prevents funding MTFs to increase their productivity without the burden of prior approval reprogramming, which can take anywhere from three to six months. The T-NEX contract, with its incentive to move care into MTFs, makes having this flexibility all the more vital. Two-way flexibility between the private sector care and direct care accounts is necessary for revised financing to function successfully. The Navy appreciates the congressional intent to protect direct care funding, but we recommend that the FY 2005 Defense Appropriations Act language remove the separate appropriation for Private Sector Care to allow the flexibility to move funds to wherever care is delivered without a Prior Approval reprogramming.
Transition to The Next Generation of TRICARE Contracts
TRICARE Next Generation has provided sweeping improvements in its provision of TRICARE Benefits under contracting initiated this fiscal year. While there will be no significant benefit changes, it simplifies the old contracts, and provides performance incentives and guarantees. It also distinguishes health plan management, which includes such activities as financing, claims, payment rates, marketing, and benefit design, from healthcare delivery. Some major elements of the old TRICARE contracts have been sifted out into separate contracts to allow companies with particular competencies in these contract areas provide even better service and quality healthcare.
The most obvious change is the transition from 12 regions to three, and enhancing leadership in each region by putting a Flag, General Officer or SES as director. This is a significant step in transforming TRICARE. These Regional directors have a key role in enhancing participation of providers in TRICARE and in implementing the plan to improve TRICARE Standard for those who choose to use it, and will also be responsible for integration of military treatment facilities with civilian networks, ensuring support to local commanders and overseeing performance in the region. Rear Admiral James A. Johnson, Medical Corps, is on board in the TRICARE West Region.
Medical commanders within these regions will also have an enlarged role and additional responsibilities under the new contracts, with the focus on accountability. Commanders will take on responsibilities formerly managed by the TRICARE contractor, including patient appointing, utilization management, use of civilian providers in military hospitals, and other local services.
The transition to the new TRICARE contracts in TRICARE West is going well, and all the services are working closely with TMA to make the transition phase as seamless as possible for our patients.
Closure of U.S. Naval Hospital Roosevelt Roads, Puerto Rico
On February 12, 2004, U.S. Naval Hospital Roosevelt Roads, Puerto Rico officially closed its doors to patient care, ending more than 47 years of healthcare service to Department of Defense beneficiaries. The last time a Naval Hospital closed was almost nine years ago when Naval Hospital Long Beach closed as a result of the Base Realignment and Closure.
E-Health
Naval Medicine continues to be on the forefront of technology with the development of Naval Medicine Online (NMO). This website allows one tool for all of Naval Medicine to obtain and access information from anywhere around the world. This technology will be the key to knowledge sharing throughout Naval Medicine as an enterprise, allowing the right information to be obtained by the right people at the right time—whenever and wherever it is needed.
NMO contains knowledge tools including File Cabinet that allows individuals to share documents and other electronic files; protected chat rooms that will allow users to have secure communications with patients or other Naval Medicine personnel and news services that provide information of relevance to the Naval Medical community.
A key new function of NMO is the developer whiteboard. This tool allows Naval Medicine to leverage the brainpower of our workforce by placing software code in a secure area and allowing members of Naval Medicine to modify the code, making improvements useful to Naval Medicine. NMO also has online video teleconference capabilities and allows Naval Medicine personnel access to the Department of Veterans Affairs lessons learned database.
The Navy Marine Corps Intranet (NMCI) is a long-term initiative between the Department of the Navy (DoN) and the private sector to deliver a single integrated and coherent department-wide network for Navy and Marine Corps shore commands. Under NMCI, EDS and their partners will provide comprehensive, end-to-end information services for data, video and voice communications for DoN military and civilian personnel and deliver global connectivity to make our workforce more efficient, more productive, and better able to support the critical war fighting missions of the Navy and Marine Corps.
Naval Medicine is committed to transitioning to NMCI infrastructure and services where feasible. The Naval Medicine – NMCI shared vision is to create a single Navy and Marine Corps Enterprise-wide Network that provides seamless access to and exchange of comprehensive healthcare information throughout Naval Medicine and the Military Health System Community of Interest.
The Naval Medicine – NMCI transition strategy incorporates four parallel endeavors. They are:
1. Transition of BUMED Headquarters into NMCI (~800 Seats)
2. Transition of non-clinical Naval Medical Department Commands into NMCI (~5,900 Seats)
3. Completion of a Composite Health Care System Computer-based Patient Record (CHCS II) NMCI Interoperability Beta Test at Naval Medical Center, Portsmouth, VA (72 Seats). The Military Health System’s (MHS) largest, and most critical, network-centric information system, CHCS II forms the core of DOD’s computer-based patient record initiative, and as such, is and will be broadly integrated across the enterprise at the center of the MHS healthcare delivery mission. The Beta Test will document infrastructure and network performance characteristics to include: Interoperability, Accessibility, Continuity of Business Operations, Quality of Service, Information Assurance, and Clinical Provider Productivity.
4. Transition of all clinical Navy Medical Department Commands into NMCI (~38,300 seats).
Naval Medicine is partnering with Electronic Data Systems (EDS), Science Applications International Corporation (SAIC), and Booz-Allen & Hamilton (BAH) to complete the financial analysis of our transition endeavors. We expect positive economies in transitioning to NMCI, which include robust information security, email server consolidation, network operations center consolidation, and uniform seat management services across the Naval Medicine Enterprise.
Medical Research
Naval Medicine also has a proud history of medical research successes from our laboratories both here in the United States as well as those located overseas. Our research achievements have been published in professional journals, received patents and have been sought by industry as partnering opportunities.
The quality and dedication of the Naval Medicine’s biomedical research and development community was exemplified this year as Navy researchers were selected to receive prestigious awards for their work. CAPT Daniel Carucci, MC, USN, received the American Medical Association’s Award for Excellence in Medical Research for his work on cutting edge DNA vaccines. His work could lead to the development of other DNA-based vaccines to battle a host of infectious diseases such as dengue, tuberculosis, and biological warfare threats. Considering the treat of biological terrorism, DNA vaccine-based technologies have been at the forefront of “agile” and non-traditional vaccine development efforts and have been termed “revolutionary”. Instead of delivering the foreign material, DNA vaccines deliver the genetic code for that material directly to host cells. The host cells then take up the DNA and using host cellular machinery produce the foreign material. The host immune system then produces an immune response directed against that foreign material.
In the last year, Navy human clinical trials involving well over 300 volunteers have demonstrated that DNA vaccines are safe, well tolerated and are capable of generating humoral and cellular immune responses. DNA vaccines have been shown to protect rodents, rabbits, chickens, cattle and monkeys against a variety of pathogens including viruses, bacteria, parasites and toxins (tetanus toxin). Moreover, recent studies have demonstrated that the potential of DNA vaccines can be further enhanced by improved vaccine formulations and delivery strategies such as non-DNA boosts (recombinant viruses, replicons, or exposure to the targeted pathogen itself). A multi-agency Agile Vaccine Task Force (AVTF) comprised of government (DoD, FDA, NIH), academic and industry representatives is being established to expedite research of the Navy Agile Vaccine.
Naval Medicine is developing new strategies for the treatment radiation illness. Adult Stem Cell Research is making great strides in addressing the medical needs of patients with radiation illness. The Anthrax attack on the Congress and others reminded us of the threat of weapons of mass destruction, to include ionizing radiation. Radiation exposure results in immune system suppression and bone marrow loss. Currently, a bone marrow transplant is the only life saving procedure available. Unfortunately, harvesting bone marrow is an expensive and limited process, requiring an available pool of donors. In the past year, Naval Medicine researchers have developed and published a reproducible method to generate bone marrow stem cells in vitro after exposure to high dose radiation, such that these stem cells could be transplanted back into the individual, thereby providing life-saving bone marrow and immune system recovery.
In this same line of research, Naval Medicine is developing new strategies for the treatment of combat injuries. We are developing new therapies to “educate” the immune system to accept a transplanted organ -- even mismatched organs. This field of research has demonstrated that new immune therapies can be applied to “programming stem cells” and growing bone marrow stem cells in the laboratory. Therapies under development have obvious multiple use potential for combat casualties and for cancer and genetic disease.
Other achievements during this last year include further development of hand-held assays to identify biological warfare agents. During the 2001 anthrax attacks, Navy scientists analyzed over 15,000 samples for the presence of biological warfare (BW) agents. These hand-held detection devices were used in late 2001 to clear Senate, House and Supreme Court Office Buildings and contributed significantly to maintaining the functions of our government. The hand-held assays that are used by the DoD were developed at Naval Medical Research Center (NMRC). Currently NMRC produces hand-held assays for the detection of 20 different biological warfare agents. These assays are supplied to the US Secret Service, FBI, Navy Environmental Preventive Medicine Units, US Marine Corp, as well as various other clients.
Naval Medicine’s overseas research laboratories are studying diseases at the very forefront of where our troops could be deployed during future contingencies. These laboratories are staffed with researchers who are developing new diagnostic tests, evaluating prevention and treatment strategies, and monitoring disease threats. One of the many successes from our three overseas labs is the use of new technology, which includes a Medical Data Surveillance System (MDSS). The goal of the MDSS is to provide enhanced medical threat detection through advanced analysis of routinely collected outpatient data in deployed situations. MDSS is part of the Joint Medical Operations-Telemedicine Advanced Concept Technology Demonstration (JMOT-ACTD) program. Interfacing with the shipboard SAMS database system, MDSS employs signal detection and reconstruction methods to provide early detection of changes, trends, shifts, outliers, and bursts in syndrome and disease groups (via ICD-9 parsing) thereby signaling an event and allowing for early medical/tactical intervention. MDSS also interfaces with CHCS and is operational at the Army’s 121st Evacuation Hospital in South Korea, and is being deployed at the hospital and clinics at Camp Pendleton. Currently, MDSS may have an opportunity to collaborate with other industry and service-related efforts for the purpose of developing homeland defense-capable systems. Homeland defense initiatives are currently being coordinated through the Defense Threat Reduction Agency.
Noise-Induced Hearing Loss (NIHL) is one of the most common military disabilities with over 353,116 new cases reported in 2003 despite aggressive hearing conservation programs in the military. Military related NIHL is very costly. When disability costs for tinnitus and aircraft accidents related to communication problems are included, costs for military related hearing loss may exceed $1 billion annually. Additionally, NIHL may degrade warfighter performance, mission accomplishment, and survivability. Today’s hearing conservation programs are based on fit and frequency dependent personal hearing protection devices (HPDs), engineering solutions, and noise avoidance; which are helpful but do not provide adequate protection around today’s noisier weapons systems. Accordingly the Navy has taken the lead in research to elucidate the mechanisms underlying NIHL. The results have lead to the development of a safe oral nutritional supplement that has proven in laboratory settings to enhance resistance and healing to inner ear damage from noise. The efficacy of these nutritional supplements to prevent and treat NIHL is being studied in two joint military-civilian clinical trials lead by the Naval Medical Center, San Diego. If these trials succeed, we believe that a proven and effective treatment and prevention strategy, when combined with hearing conservation measures, could be dramatically reduced. A conservative estimate based on the robustness of the biological response in preclinical data suggests that a 50% reduction in hearing related injury is possible.
Naval Medicine and Sea Power 21
Naval Medicine is totally committed to the Chief of Naval Operations’ transformational vision for projecting decisive joint capabilities from the sea – Sea Power 21. Examples of transformation abound throughout Naval Medicine where hard work identifying efficiencies and cutting costs have resulted in opportunities to support recapitalization. These include the ongoing efforts to reduce variation in costs across our MTFs as well as among clinics within MTFs. Optimization efforts focusing on maximizing the fixed capabilities of our facilities to the greatest extent possible are active, ongoing, and will continue into the future. Transformation is not limited to shore facilities and includes remaking our fleet assets such as the reconfiguration of forward medical assets from cold war era fleet hospitals to the smaller, more agile and more flexible platforms and units describer earlier in my statement.
We are right sizing our active military force to the best mix of active, and civilian or contract personnel to bring the right capability to bear at the right time, and in alignment with the CNO’s vision. We have reconfigured and integrated our Naval Reserve components to shape missions along with the active component, creating one force, assuring the very best use of the skills and talent our Reserve medical personnel bring to the mission. Further, Naval Medicine is committed to the growth and development of our people through investments in leadership that are directly in support of Sea Warrior by ensuring the right skills are in the right place at the right time.
Naval Medicine will continue to seek aggressively opportunities to pursue efficiencies that improve our primary mission of Force Health Protection and do our part to return resources for recapitalization of the Navy. We are affecting positive change throughout Naval Medicine, embracing and implementing the CNO’s vision for the Navy, and I am confident that we are on the correct course for the challenges ahead.
Conclusion
Naval Medicine has been successful in accomplishing its mission over the years, and with your support, the military benefit has become one of the most respected healthcare programs in the world. We know from Navy’s quality of life surveys that among all enlisted personnel and female officers, the number one reason these service members stay Navy is the exceptional healthcare benefit.
You have allowed us to provide our service members, retirees and family members a benefit that is worthy of their service, and clearly articulates the thanks of a grateful nation for their selfless service. With your support, we have opportunities for continued success, both in the business of providing healthcare, and the mission to supporting deployed forces and protecting our citizens throughout the United States.
In just a few short months, I will leave this office, and will retire after serving more than 32 years in the United States Navy. I wish to thank this committee for its support to Naval Medicine, and to me during my time as the Navy’s Surgeon General. It has been a privilege to serve.
