MEPRS
What it’s good for …*
29 July 2010
8:00 – 8:50 a.m.
*And the impact of your data on various
programs and metrics
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
2
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
3
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
4
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
5
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
6
Costs on SIDRs &
SADRs
7
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
8
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)
9
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 Costs
Based On:
Before Summer 2009
Retrofit
Application Year
FY08
FY09
FY06
FY07
FY10
FY11
FY06
FY07
FY07
FY07
N/A
N/A
Current
FY06
FY07
FY08
FY08
FY08
N/A
After Summer 2010
Retrofit
FY06
FY07
FY08
FY09
FY09
FY09
10
Expenses with No Workload
11
Negative Expenses
12
Unallocated Ancillary/Support?
FY07-FY09 Monthly Total Expenses by MEPRS-1
(Selected MTF)
$12,000,000
$10,000,000
$8,000,000
$6,000,000
$4,000,000
$2,000,000
$0
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
B
C
D
2009
E
F
13
Erroneous Expenses?
(Note: data were extracted June 2010)
14
Rx Percentage of Ambulatory $
Lumpiness: Pharmacy expenses
recorded when drugs purchased
rather than when dispensed?
15
Dispensing Costs for
Direct Care PDTS
Records
16
17
Why the Difference?
18
High-Level MHS Metrics
19
MHS Dashboard
Casualty Care and
Humanitarian Assistance
G
Y
Reduced Combat Losses
Case Fatality Ratio (OIF/OEF Combat
Casualty)
Observed/Expected Survival Rate (Battle
Wounds)
Y
G
Force Immunization Rate
G

G

Battle-Injured Medical Complications Rate
G

Age of Blood in Theater
G

Effective 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

G
Improved 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
Reduced Medical Non-Combat Loss

Mortality Rate Following Massive
Transfusions
Y
Healthy and Resilient Individuals,
Families and Communities
Healthy, Fit and
Protected Force
X
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
X


Increased Resilience & Optimized
Human Performance
Psychological Distress Screens,
Referral and Engagement ***
Effectiveness of Care for
Complex Medical / Social
Problems ***
X
X
Healthy Communities/Healthy Behaviors
X
X
X
X
Improving
Declining
Capable MHS Work Force and Medical
Force
Y

Active Duty Lost Work Days Rate
Y

Mental Health Provider Staffing
X
X
G

Staff Satisfaction ***
X
X
Competitive & Direct Hire Activity
(Medical Professionals)
G

MHS Body Mass Index Rate
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
Advancement of Global Public Health
Under Development
G

Overall Hospital Quality Index (ORYX) ***
G

CONUS Ventilator Associated Pneumonia Rate
X
X
Health Care Personnel Flu Vaccination Rate
X
Hospitalization 30-Day Disease Mortality Rate
Product to Practice
Success ***
G
X
Under Development
X
X
R
Performance-Based Management
and Efficient Operations
R

Enrollee Utilization of Emergency
Services ***
Y
X


Provider Productivity
R

Impact of Deployments on MTFs
***
X
X
Bed Day Utilization (Prime Enrollees)
X
X
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

Beneficiary Satisfaction
Satisfaction with Provider Communication
Y

Satisfaction with Health Care ***
Y

Satisfaction with Health Plan
G

Under development
X
Annual Cost Per Equivalent Life
(PMPM) ***
Access to Care
X
X
Healing Environments
Enrollee Preventive Health Quality Index (HEDIS)
***
Stable
X
Contributions to Medical Science
Health Care Quality
Y
*** Denotes Strategic Imperative
G
MHS Cigarette Use Rate
Y
Strategic Deterrence for Warfare
Under Development

Education, Research and
Performance Improvement
R
Deliver 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

20
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
21
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)
22
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
23
Army
Navy
Air Force
MHS
24
Jun
Apr
Feb
Dec
FY09 Oct
Aug
Jun
Apr
Feb
Dec
FY08 Oct
Aug
Jun
Apr
Feb
11.5
Dec
13.5
FY07 Oct
Aug
Jun
Apr
Feb
Dec
Good
9.5
FY06 Oct
RVUs per FTE
23.5
21.5
19.5
17.5
15.5
Civilian
Average
is 21.8
Ambulatory Available FTEs by MEPRS-2
(Selected Major Medical Center)
25
Ambulatory Available FTEs & Visits
26
Medicare-Eligible Retiree
Health Care Fund
(MERHCF)
Direct Care Level of Effort (LOE)
27
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
28
about population characteristics
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
29
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
30
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) NonAccrual 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
31
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
32
FY09 MERHCF LOE
Pharmaceutical PEC & SEEC Mismatch
Parent
Fiscal DMIS
Year
ID
Parent
Name
DoD
PEC
DoD
SEEC
Net Month
Expense
SEEC Description
2009 0033
2009 0033
10th MED GROUP-USAF
87701
ACADEMY
11.10 Civilian
CO Personnel Compensation
10th MED GROUP-USAF
87701
ACADEMY
11.72 Military
CO Personnel Compensation
$
$
$
387,245
821,658
1,208,904
2009 0045
2009 0045
2009 0045
6th MED GRP-MACDILL
87701
11.10
6th MED GRP-MACDILL
87701
11.72
6th MED GRP-MACDILL
87701
11.74
Civilian Personnel Compensation
Military Personnel Compensation
Borrowed Military Labor
$
$
$
$
105,859
421,938
2,093
529,889
2009 0055
2009 0055
2009 0055
375th MED GRP-SCOTT
87701
11.10
375th MED GRP-SCOTT
87701
11.72
375th MED GRP-SCOTT
87701
11.74
Civilian Personnel Compensation
Military Personnel Compensation
Borrowed Military Labor
$
$
$
$
113,216
816,848
3,752
933,817
33
FY07 MERHCF LOE
Impact of Incomplete Army MEPRS
Army lost $20.0 million or 3.3% of their FY07based MERHCF distribution
Official results submitted 29 April 2008
MERHCF LOE by Providing Military Service
Beneficiary Service
Affiliation
Army
Air Force
Navy
DoD Beneficiaries
$ 609,708,647 $ 575,864,963 $ 395,999,148
Non-DoD Beneficiaries
$ 4,284,678 $ 5,003,092 $ 8,083,711
Total MERHCF LOE $ 613,993,325 $ 580,868,055 $ 404,082,859
MERHCF LOE
Total
$ 1,581,572,758
$
17,371,482
$ 1,598,944,239
Updated results computed 13 June 2008
Beneficiary Service
Affiliation
DoD Beneficiaries
$
Non-DoD Beneficiaries $
Total MERHCF LOE $
MERHCF LOE by Providing Military Service
MERHCF LOE
Army
Air Force
Navy
Total
630,458,316 $
576,294,859 $
396,733,252 $ 1,603,486,427
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
34
FY09 MERHCF LOE
Impact of Incomplete Air Force MEPRS
Air Force lost $23.5 million or 3.7% of their FY09based MERHCF distribution
Official results submitted 21 April 2010
MERHCF LOE by Providing Military Service
Beneficiary Service
Affiliation
Army
Air Force
Navy
DoD Beneficiaries
$ 709,865,155 $ 597,838,289 $ 424,149,590
Non-DoD Beneficiaries
$ 5,292,442 $ 5,019,682 $ 10,310,181
Total MERHCF LOE $ 715,157,597 $ 602,857,971 $ 434,459,771
MERHCF LOE
Total
$ 1,731,853,035
$
20,622,305
$ 1,752,475,340
Updated results computed 24 May 2010
MERHCF LOE by Providing Military Service
Beneficiary Service
Affiliation
Army
Air Force
Navy
DoD Beneficiaries
$ 710,296,374 $ 620,998,917 $ 424,154,627
Non-DoD Beneficiaries
$ 5,294,811 $ 5,331,881 $ 10,310,379
Total MERHCF LOE $ 715,591,185 $ 626,330,797 $ 434,465,006
MERHCF LOE
Total
$ 1,755,449,918
$
20,937,071
$ 1,776,386,989
35
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
36
Questions?
CONTACT INFORMATION
John A. Coventry, Ph.D.
SRA International, Inc.
210-832-5212
John_Coventry@sra.com