DoD-VA

1. Merging the Military Health System (MHS) and the Veterans Health Administration (VHA) into a Single Governance Structure The views expressed in this academic research presentation are those of the author and do not necessarily reflect the official policy or position of the U.S. Government, the Department of Veterans Affairs, the Department of Defense, or any of its agencies. Colonel William B. Grimes, MHA, FACHE Senior Service College Fellow

2. Merging the Military Health System (MHS) and the Veterans Health Administration (VHA) into a Single Governance Structure The views expressed in this academic research presentation are those of the author and do not necessarily reflect the official policy or position of the U.S. Government, the Department of Veterans Affairs, the Department of Defense, or any of its agencies. Briefing to The Honorable James B. Peake Secretary of Veterans Affairs

3. Be Persistent! “ Heretics Are Not All Bad!” Paul K. Carlton, Jr., MD, FACS Lt. Gen, USAF, Ret

5. None of Us Want to Face What Lies Ahead of Us It’s Never as Bad as it Seems

7. Intro - Argument Parameters Healthcare Command Medical Education and Training Command Force Health Protection Command TRICARE Contracts DoD Medical Treatment Facilities and Clinics Marine Corps Medical Component Unified Medical Command Joint Regional Offices Army Medical Component Navy Medical Component Deployable Capabilities Joint Regional Commands Army Medical Forces Operational Medical Command Air Force Medical Forces Air Force Medical Component Secretary of Defense Modernization Command Under Secretary of Defense for Personnel and Readiness Assistant Secretary of Defense (Health Affairs) Navy Medical Forces Marine Corps Medical Forces Although this proposed MHS structure was not implemented, it does validate the concept that the “benefits mission” (circled in red above) can be separated from the readiness mission of the MHS. For the purposes of this briefing, any proposed single DoD/VA governance structure involves merging only the benefits mission of the Military Healthcare System (MHS) with the Veterans Health Administration (VHA). In an April 2006 response to Presidential Budget Decision (PBD) 753, the Under Secretary of Defense (Personnel and Readiness) proposed a MHS structure with a “Unified Medical Command” and a separate “Healthcare Command.”

11. DoD Healthcare Costs ($Billions - 2005 constant dollars) Source: www.defenselink.mil/news/Feb2006/d20060206slides.pdf TRICARE for Life

12. VA Healthcare Costs Source: http://www.whitehouse.gov/omb/budget/fy2008/veterans.html Other VA Benefit Programs

13. Redundant Systems Similar requirements = unique opportunity to explore a “seamless” approach to the delivery of health care Source: Dr. Jones & Dr. Tibbits Briefing for 18/19 Mar 08 Trip Battlefield Domiciliary VA DoD Healthcare Venues VA DoD Healthcare Specialties Acute Care Hospitals & Medical Centers Most Healthcare Specialties A Few Specialties e.g., Pediatrics A Few Specialties e.g., Geriatrics

15. Joint Committees SECRETARY DEPARTMENT OF VETERANS AFFAIRS (VA) SECRETARY DEPARTMENT OF DEFENSE (DoD) VA/DoD JOINT EXECUTIVE COUNCIL (JEC) Joint Strategic Planning Committee (JSPC) Construction Planning Committee (CPC) VA/DoD BENEFITS EXECUTIVE COUNCIL (BEC) VA/DoD HEALTH EXECUTIVE COUNCIL (HEC) Contingency Response Working Group Deployment Health Working Group Benefits Delivery at Discharge Working Group Graduate Medical Education Working Group Information Management Information Technology Working Group Joint Facility Utilization and Resource Sharing Working Group Acquisition & Medical Materiel Management Working Group Patient Safety Working Group Pharmacy Working Group Information Sharing Information Technology Working Group Benefits & Services Working Group Medical Records Working Group Coordinated Transition Working Group* Continuing Education & Training Working Group Mental Health Working Group Evidence-Based Clinical Practice Guidelines Working Group Financial Management Working Group Joint Health Care Facility Operations Steering Group (JFSG) Communications Working Group Are there too many DoD/VA Working Groups and Executive Councils to remain effective? Is this strategic?

16. Senior Oversight Committee Overarching Integrated Product Team (OIPT) Full-time staff and VA Detail Incoming from other commissions Press Releases Congress & Media Senior Oversight Committee (SOC) Co-Chairs: DEPSECDEF and DEPSECVA 1 2 3 5 6 7 8 4 DoD/ VA Data Sharing Traumatic Brain Injury / PTSD Case Management Facilities Clean Sheet Legislation & Public Affairs Personnel/ Pay Support Disability System Lines of Action (LOAs) Again, more teams, groups, and action offices…when will there be enough?

18. Agreements by Unique Large number of agreements but what is the real value added?

19. Agreements by Service Examples of Service Branch Category “noise” potentially inflating the true value added

20. Agreements by VISN 85 Agreements with NY Army NG

21. Reimbursement Large variation between Fee and CMAC early in the sharing program

22. Provider VA is the “provider” of the service in over 70% of the agreements…understandable because the VA is bigger…

23. New Agreements by Year The number of new agreements may not be a good indicator of the level of effort…

25. Manage Beneficiary Care TRICARE Manage Beneficiary Care TRICARE Deploy a Healthy Force 9 Manage Beneficiary Care TRICARE Deploy a Healthy Force Deploy Medical Support The MHS Mission Patient Care, Sustain Skills and Training Promote & Protect Health of the Force Deploy to Support the Combatant Commanders to and

26. The “New” MHS Mission - Focused on the Deployable Mission Manage Beneficiary Care TRICARE Manage Beneficiary Care TRICARE Deploy a Healthy Force Manage Beneficiary Care TRICARE Deploy a Healthy Force Deploy Medical Support ...can we remove the benefits mission (i.e. TRICARE) from DoD’s responsibility without negatively affecting readiness?

28. Close to Single Governance North Chicago VAMC – Great Lakes Naval Health Clinic Clear chain of command? This “hybrid” shows the limitations and restrictions of current DoD/VA collaboration public law.

32. COA 1: Combine under DoD Leadership Federal Military Healthcare Command Medical Education and Training Command Force Health Protection Command TRICARE/HERO Contracts DoD Medical Treatment Facilities and Clinics Marine Corps Medical Component Unified Medical Command Joint Regional Offices Army Medical Component Navy Medical Component Deployable Capabilities Joint Regional Commands Army Medical Forces Operational Medical Command Air Force Medical Forces Air Force Medical Component Secretary of Defense Modernization Command Under Secretary of Defense for Personnel and Readiness Assistant Secretary of Defense (Health Affairs) Navy Medical Forces Marine Corps Medical Forces VA Medical Treatment Facilities and Clinics Existing DoD and VA facilities will be combined where possible and grouped geographically using the existing TRO structure Is running such a large healthcare system a core mission for DoD?

33. Federal Military Healthcare Administration Medical Education and Training Command Force Health Protection Command TRICARE/HERO Contracts DoD Medical Treatment Facilities and Clinics Marine Corps Medical Component Unified Medical Command Joint Regional Offices Army Medical Component Navy Medical Component Deployable Capabilities Joint Regional Commands Army Medical Forces Operational Medical Command Air Force Medical Forces Air Force Medical Component Modernization Command Under Secretary of Defense for Personnel and Readiness Assistant Secretary of Defense (Health Affairs) Navy Medical Forces Marine Corps Medical Forces VA Medical Treatment Facilities and Clinics Under Secretary for Heath, Veterans Health Administration Secretary of Veterans Affairs Deputy Secretary Existing DoD and VA facilities will be combined where possible and grouped geographically using the existing VISN structure Secretary of Defense COA 2: Combine under VA Leadership Recommended Running a healthcare system is the core mission for VHA

34. COA 2 Includes a “Don’t Sell the Farm” Clause Large Medical Facilities run by the VHA but with a heavy military presence. These facilities would serve as military casualty reception Centers of Excellence.

35. COA 3: Combine under Health and Human Services (HHS) Leadership Assistant Secretary for Health, HHS National Coordinator for Health Information Technology Director, Office of Global Health Affairs TRICARE/HERO Contracts DoD Medical Treatment Facilities and Clinics Director, Indian Health Service (HIS) Joint Regional Offices Assistant Secretary for Preparedness and Response Director, Agency for Healthcare Research and Quality Commissioner, Food and Drug Administration (FDA) Director, National Institutes of Health (NIH) Assistant Secretary for Resources & Technology Secretary of Health and Human Services Director Centers for Disease Control and Prevention (CDC) Deputy Secretary Chief of Staff Administrator, Centers for Medicare & Medicaid USPHS Personnel Director, Federal Military Healthcare System VA Medical Treatment Facilities and Clinics Existing DoD, VA, and HHS facilities and personnel will be combined where possible and geographically grouped using the existing HHS system of ten regional offices. Most Innovative This option creates the most “synergy” among federal healthcare entities.

36. COA 3 - Synergy Imagine how the ability to respond to national emergencies and the ability to gather medical surveillance data will be improved if all these Federal medical facilities were electronically connected using the same IM/IT system. Even if it is just DoD and VA healthcare facilities in the same system…could be the basis for a national healthcare system