- Radio hour
- About us
LT. GENERAL DOUGLAS ROBB
DIRECTOR, DEFENSE HEALTH AGENCY
Interviewer: Michael Keegan
Michael Keegan: Welcome to The Business of Government Hour. I'm Michael Keegan, you host and Managing Editor of The Business of Government Magazine.
And there is dramatic change occurring in American Healthcare. Across the country, healthcare systems are focused on ways to reduce variation in care, improve patient safety, and more effectively use health information technology to improve clinical decision making and outcomes.
The military health system isn't immune to such changes. In fact, within the military there are additional imperatives for designing an integrated health system, which includes more joint operations as a way to meet its aim of readiness, improving the health and care of its people, and doing this while managing costs. With the creation of the Defense Health Agency, DOD has taken a step in this direction. The Defense Health Agency is a starting point for comprehensive enterprise-wide reform. It is a leading example of how DOD will seek to modernize and integrate its system of care, creating a stronger, better, and more resilient military health system for the future.
How is the Defense Health Agency changing the way DOD delivers health care? What are some of the key challenges faced in restructuring such a complex system? And how is the Defense Health Agency transforming its health information technology portfolio?
We will explore these questions and so much more with our very special guest, Lt. General Douglas Robb, Director of the Defense Health Agency.
General, welcome to the show. It's great to have you.
Lt. General Douglas Robb: Thank you very much for the invitation and a chance to talk about what I consider to be pretty exciting, and that's the rollout, implementation and standup of the Defense Health Agency.
Michael Keegan: I'd like to understand a little bit more about DHA. Why was it created? What's its mission? And where do you see it going?
Lt. General Douglas Robb: We have actually had about 17 studies since 1942 that have looked at, is there a better way to deliver healthcare in the Military Healthcare System. And throughout those years, you know, there was a recommendation, usually something along the lines of a more unified structure or a more centralization of the delivery of services.
For whatever reason, many of those opportunities didn't materialize. But about three years ago we were asked by Deputy Secretary of Defense to take a look once again, hey, is there a better way to deliver healthcare in the Military Health Service, and our task force came up with a recommendation that we create a Defense Health Agency. It took momentum, it took root, and as a result, we stood up on 1 October, 2014, and we're well on our way to becoming fully operation capable on 1 October, 2015.
Michael Keegan: You know, and I agree. I should have asked that initially. So, I'll get the parlance correct. So, to get a sense of the scale of operation, could you tell us how the Defense Health Agency, how it's organized, the overall size of its budget, the number of full-time employees, and in a sense, your geographical footprint?
Lt. General Douglas Robb: Absolutely. We were organized around six directorates, and I am the head or the Director of the Defense Health Agency. And we have 4,000 employees. And we have a geographical footprint – the majority of us are right here in the national capital region, but we also have folks that work for us in San Antonio, Denver, San Diego, Chicago, even Germany and out in Japan. Our budget is about $15 billion per year. And we have, again, an incredible mission to support the Army, Navy, Air Force, and Marine Medical Services to ensure that they are able to deliver quality healthcare to our beneficiaries.
Michael Keegan: Good. So, you've given us a sense of the larger organization, and you mentioned you were the Director, the leader, of the Defense Health Agency. Could you tell us a little bit more about your specific duties and responsibilities? And how do you support the overall mission of the Department of Defense?
Lt. General Douglas Robb: Absolutely. Now, our Agency is what we call a Combat Support Agency, and that's a designation by the Chairman of the Joint Chiefs of Staff. And that's important because, at the end of the day, I am accountable to the Chairman and to the Combatant Commanders to ensure that we support the Army, Navy, Air Force, and Marine Medical Services to support our Combatant Commanders and their forces. So, our motto is medically ready forces, ready medical forces. So, everything we do when we get up in the morning until the time we go home, and I would argue often at night when I'm trying to fall asleep, is, you know, what can we do to, again, ensure that our Chief of Staff of the Army, the Air Force, the Navy, and the Marine Corps have medically ready forces and ready medical forces so they can support the Combatant Commanders and our Chairman of the Joint Chiefs of Staff.
Michael Keegan: So, General Robb, this might be a loaded question given the fact you're leading a standup organization, but what are the top, say, three management challenges you've faced in your position and how have you sought to address those challenges?
Lt. General Douglas Robb: Well, one is building the plane as you fly it. We are, you know, responsible to deliver services while we create the organization that does that. But that's not as hard the dedication of those folks and the initiative of those folks working together as a team, that synergy, I think, is coming out loud and clear.
One of the other issues, as you can imagine, standing up a new organization at a time when we're downsizing post-conflict.
Lt. General Douglas Robb: The normal cycle routine, downsizing from post-conflict. And then also as a nation debate what is the size of our force going to look like post-conflict and what can the nation afford? So, you can imagine that there's not any appetite to grow anything.
Lt. General Douglas Robb: There's not an appetite to grow anything. So, what I think is important now to understand here, and this is a great point and time to bring this up, folks would say, “Hey, you're just creating another layer of organization, you know, another headquarters.” And that's not the case. Every single person that comes into our organization is a net loss from the Army, Navy, or the Air Force, either from their end strength or from their headquarters staff. So, it is basically a zero-sum game here. So, that's also, again, a challenge.
We're also looking at not only are we not going to grow as an entity, as a Military Health System, we are looking for efficiencies that we ought to be able to shrink, especially in the headquarters overhead.
Michael Keegan: So, General, you mentioned that the Defense Health Agency was created October 1 of last year, and I want to understand what – since you've taken over the role of Director, what has surprised you most?
Lt. General Douglas Robb: I would say – and this is not a bad surprise to have, by the way – is that I have been absolutely impressed with the caliber of folks who are working in our organization. Whenever you start out a new organization, you know, you've got the whole change management, you've got the cultural change, you've got the shift, but it's fascinating to see that the folks that are in the organization we call the Defense Health Agency, many of those folks have been thinking along, you know, this way for a long time, you know. To a T I'll have folks coming up to me and say, you know, we should have been doing this ten years ago.
Michael Keegan: Yeah.
Lt. General Douglas Robb: Because they see the opportunity to create what I call the synergistic effect of the joint environment back in the garrison. So, there is no shortage of people who understand where we need to go, and there's no shortage of people out there that are dedicated to make that happen.
Michael Keegan: I want to better understand your leadership style and the key principles that continue to form your efforts. Would you outline some of your key leadership principles and illustrate for us how you have applied them during your career?
Lt. General Douglas Robb: In the military, you know, you're always asked the question which is more important, the mission or the people.
Lt. General Douglas Robb: And I would argue, actually, it's not that hard to make that decision because it's mission first, people always. I'm a firm believer that if you take care of your people, they'll take care of the mission, you know. And if you take care of the mission, the mission will take care of your people. And so, you know, and I always tell my folks, you know, when you have a tough problem in front of you, at the end of the day, you know, you say what is right and what is wrong, but if you focus on the patient, if you focus on the patient then everything else is going to sort out. You know, we can use the patient as, again, in medicine you use that as an analogy, but whatever the problem is, you focus on what the problem is and usually you'll come to the right answer. And I always tell my folks, you know, we need to do the right thing even if it's the harder thing to do.
Michael Keegan: What are the strategic priorities for the Defense Health Agency? We will ask Lt. General Douglas Robb, Director of the Defense Health Agency, when our conversation continues on The Business of Government Hour.
Michael Keegan: Welcome back to The Business of Government Hour. I'm Michael Keegan, your host, and our guest today is Lt. General Douglas Robb, Director of the Defense Health Agency.
The Defense Health Agency is in its infancy, but I would like to get a sense of your key strategic priorities going forward. Would you elaborate on those priorities that are shaping your organization and the way the Military Health System operates and delivers care? And to what extent do these priorities, your priorities, sort of dovetail or informed by Secretary Hagel's priorities?
Lt. General Douglas Robb: Well, as you know, your priorities are your boss' priorities. And so, you know, Dr. Woodson, the Secretary for Health Affairs, again, an incredible leader and a tremendous strategic thinker, has lined out six strategic priorities, or what we call lines of effort, that compliment and are in complete alignment with our Secretary's priorities, Secretary of Defense. And those six priorities are for the Military Health System to modernize, to modernize their management with an enterprise focus. And so, when you think about it, the core of that is in fact why we're here talking, is the Defense Health Agency. So, that's going to be the foundation for the enterprise focus for modernizing our Military Health System management.
Number two is to deliver and to define the requirements for the medical capabilities and the manpower that will be needed in the 21st century. You know, we're coming out of 12-13 years of conflict now. Again, we've had some incredible successes in our ability to have the lowest disease non-battle rate in the history of warfare, and again, the lowest lethality rate in the history of warfare. But, you know, now that we're coming home, take those lessons learned, you know, figure out what the inventory is, and then reset for the 21st century. So, that's going to be another exciting line of effort.
Number three, and this has served us well in this conflict, and that's our strategic partnerships. So, our focus is going to be to continue to invest and to expand our strategic partnerships. You know, we've been working with the private sector, whether it's Research and Development, whether it's Medical Innovation, working with other government agencies, working with academic institutions. One prime example is let's look at Trauma Care Delivery in the theater. Taking their ideas and bringing them together for us to create, which is really the most effective Trauma Care Delivery System in the history of recorded warfare.
Now, the things that we've learned, the things that we have made, what I call game-changers, are now already being pushed out into this main sector. So, it goes both ways. They help us create the next generation of clinical practice guidelines or treatment protocols, and then at the same time, they take and bring that back.
Also, as you can imagine after 12 years of conflict, we need to balance our force-structure. We need to – what is the right mix of our, one, our end strength on the active duty force for our Military Healthcare System, but also, what is the right mix between active duty and the reserve component? As you know, you know, a lot of our, especially our air medical evacuation comes out of our reserve force. A lot of our specialists come out of our reserve force. And so, again, what's the right balance that we need, again, to be agile and be able to respond in the 21st century.
The fifth line of effort is to transform what we call our Tricare Health Program. As you know, that's a healthcare plan that we use to provide healthcare in this network to our beneficiaries. And medicine has evolved. Medicine evolves – well, the healthcare debate today, and I'm sure you have many folks in this very same room that I've been talking about, you know, the healthcare debate, and so we need to be keeping up with that, we need to be keeping up with the best practices. What's the best way to deliver a healthcare benefit to our population that's receiving healthcare in the civilian network?
And then finally, our sixth line of effort is to expand our global health – what we call the Global Health Engagement Strategy. Another one of the basic mantras is, you know, you can't go it alone. And so when we look at regional and stability around the globe, health is one of those tools in the toolbox that you can use to, again, create security in an environment overseas.
That's why you can see that our Military Health System is one of the tools that our Combatant Commanders, and then of course our Embassies, use as opportunities to create, one, ultimately a peaceful but a prosperous and a stable nation wherever our interests lie around the globe.
Michael Keegan: M-hmm. So, General Robb, one of the ways your agency is changing the way the Military Healthcare delivers health and care is by implementing a shared services model, and I'd like to understand what you mean by that. What is meant by that? Why did you adopt such an approach? And could you outline some of the benefits of going in this direction?
Lt. General Douglas Robb: Absolutely. Now, when we stood up the Defense Health Agency on 1 October, 2013 we started out along what I call ten shared services lines of effort, and these were the ones that we chose that were thought by our task force that created the Defense Health Agency and then in our proposals to the Deputy Secretary of Defense is where is there opportunity that the services were more alike than different.
You say you have this enterprise called the Military Healthcare System, but we were running essentially, not totally independent, but we were running three separate parallel healthcare systems that were supported by, again, a single budget plan and single policy, but the execution was kind of left up to the services. So as a result, you know, you have effectively had three separate health information and technology systems running out there; some compatible with the others, some not. You're running three separate contracting outfits. You're absolutely running three separate medical education and training platforms. And in many ways, although it was migrating, three separate research and development entities.
So, it made sense that we bring those folks together and look at ways to be more efficient and more effective. In other words, get rid of redundancy, get rid of duplication, and adopt what we call a Joint First Mantra. Why do we have potentially three different kinds of anesthesia machines, or why we taught three different ways to do this? I saw the Joint Trauma System really bring us together. That was one of the really good, what I call game changers, in this conflict where we agreed on common clinical practice guidelines and algorithms and that's why we were able to, again, I know in my heart why we were able to drive this particular conflict down into the lowest, again, died of wounds or the lowest lethality rate in the history of recorded conflict. But it was the coming together and deciding what works in Joint First. So that's where we're going.
Of our ten shared services that we stood up on 1 October, eight of those are already what we call IOC, or Initial Operating Capability, and the next two will be at IOC by the end of the summer. And then we are fully expecting on 1 October, 2015 to be fully operational capable across the full spectrum to where we are providing that service, that core service, back to the services. And I want to say it again, this is important, the same men and women, the same dedicated professionals that were doing health information and technology, or they were doing logistics inside their service, are the same folks that are now doing that inside the Defense Health Agency, except they're working side-by-side with an Army, a Navy, and an Air Force colleague. It makes sense that what you're going to see is you're going to see the strengths of each one of those services making the entity even stronger.
Michael Keegan: Yeah, so I'd like to actually explore each one of – well, a little bit about these shared services. And the first one you mentioned, which was the Tricare Health Plan, one of your charges is to rein in the rising cost of healthcare. And I'd like to understand better what's going on in this shared service? What are you doing with the next generation of contracts that you can let us know about? And what are some of the key initiatives underway?
Lt. General Douglas Robb: The healthcare and healthcare cost debate is not unique to the military and it affects our nation, and so I think this is going to be a learning experience for both of us as we go down this journey. For us in the military, the healthcare costs – some of the factors that have contributed to our rising costs are several factors. One is the increasing number of benefits. Number two the increasing number of beneficiaries that are allowed to use our system. The increased use by our beneficiaries of our healthcare plan. And then number four, one that we don't have as much control over, and that is of course healthcare inflation.
Michael Keegan: Sure.
Lt. General Douglas Robb: Although, currently right now it's kind of flat-lined, but I don't think there's anybody out there that says it's going to stay there very long, you know. So, we need to really, again, get after this. The Defense Health budget, or the Military Healthcare System, is about 10 percent of the top line of our Department of Defense budget. So, you can see that when we feel that we have an obligation to provide the most effective and the most efficient healthcare that we can, again, at the same time maintaining again high quality healthcare. As you can imagine, our line components are saying, you know, can you help us out here. So, that's, when you think about it, again, what's driven the creation of the Defense Health Agency. And again, the strategic vision of our Deputy Secretary of Defense and of course our Secretary for Health Affairs that this entity called the Defense Health Agency will help contribute to that. Executing those dollars and the delivery of that healthcare in the most effective and efficient way you can and maintaining a high quality output is key. Is key.
And so, one of the major areas is our healthcare plan. And, you know, just in the last year we've done a lot of things that have made a difference. And again, these millions add up.
Michael Keegan: Yes they do.
Lt. General Douglas Robb: You know, the implementation of the Sole Community Hospital Reimbursement, you know, we've got $6 million out of that. What we call our Outpatient Prospective Payment, we've got another $700 million out of that. Management and Administrative Actions, you know, some of the efficiencies that we've gained just with internal organizations, $2 million there. When you talk about standardization – and you know, we won three, as you know, Managed Care Support contracts; north, south, and then west – but what we had, we had three separate Tricare Regional Operator Directors. Well, what we know is we've consolidated that down to what we call one, so that even though there's three separate contracts, but we're working off the same sheet of music. So, if somebody's doing something better out West, you know, then by god we're going to bring that up and then we're going to sort it out, do the business case analysis, business process for engineering, and say, “Hey, can we do this in the East, can we do this in the South?” And so just little simple things like that where we think as an enterprise, we think joint solution first, are really, really making the difference.
Now when we look at the next generation of what we call Tricare Health Plan Program, you know, we are in the process of what I will call information gathering.
Michael Keegan: Sure.
Lt. General Douglas Robb: And so we have had several skull sessions, several strategic off-sites where we talk to, again, our current customers, talking to our current folks in the military. But more importantly, we've had several Blue Ribbon Panels where we have brought leaders in the industry from the civilian sector out there that are running, that are recognized, you know, delivering high quality healthcare plans out there, come talk to us about, you know, what has been their experiences in their journey to, again, a more effective and efficient and high quality organization. And to a T, all of them say the same thing is that what the undermining pin of whatever you decide to do but you need to be a continuous learning organization and you've got to be able to, again, continue to watch the data, and monitor the data, and then analyze it, and then deliver it, and then continuously feed that back. And so, you know, we've learned a lot from these folks. And so the way we do our healthcare contracts now, and the way we do it, you know, five years from now, may be a lot different based on the input we get from, again, from not only from industry but there's a lot of smart people thinking about, you know, there's a better way to do business out there.
Michael Keegan: So, General Robb, the Defense Health Agency manages a robust pharmacy benefit for eligible beneficiaries. Would you tell us more about what you're doing in this shared services area? How are you transforming the way the Defense Health Agency provides the pharmacy benefit to its beneficiaries?
Lt. General Douglas Robb: All right. So, our pharmacy benefit is $7 billion annually.
Michael Keegan: Wow.
Lt. General Douglas Robb: Annually. And again as you said, it supports our beneficiary population worldwide of 9.6 million active duty family members and retirees of the uniformed services and their families. So, and as folks probably know out there, we just recently led a new pharmacy contract, and Express Scripts were the ones that won that contract. And again, this is a large benefit. It's a seven year contract, $62 billion, $62 billion. So, you know, when you're talking that amount of money, you know, how you manage that and what's the best deal you can get through the pharmaceuticals can really make a difference.
So, there are several things that we're looking to do as we move forward now that we have a Defense Health Agency, okay, and we've centralized the management of the pharmacy. Now we're going to have what we call a common budget and a common cost accounting. So, we're going to be able to manage the pharmacy benefit, again, like you would, you know, for any large healthcare organization. So, that's going to make a difference. That's going to make a difference. So, if we standardize the business processes, you know, there's going to absolutely be return on investment there.
We're, for the first time, going to be able to look across the enterprise and then create metrics, or what I call not metrics, create accountability.
Michael Keegan: Sure.
Lt. General Douglas Robb: Create accountability so that we can look at performance. You know, before it was Army is looking at the Army, the Navy is looking at the Navy, Air Force is looking at the Air Force, now, again, our governance structure has changed. You know, now the Army is going to be looking at the Air Force's performance, and the Air Force is going to look at the Navy's performance, and the Navy is going to be looking at the Army and the Air Force's performance, you know, and that's going to be fundamentally different.
Michael Keegan: That's a change.
Lt. General Douglas Robb: That's going to be a change. And it's also going to allow us to share best practices because, you know, you were kind of working him up, you know, if the Air Force figured out how to do something better, or the Army, or the Navy, they kind of – nobody's doing anything wrong, but they just kind of kept it in house just because that's the nature of the beast. But now, you know, it's going to rapidly be able to push best practices up and then we can rapidly push them out.
Michael Keegan: Really. And so you mentioned this earlier, your relationship with the Defense Logistics Agency has really changed, and I want to talk about the next shared services area, which is the Medlog, or how you procure medical logistics and purchase medical supplies. How are you working differently or closely with DLA and what are you doing for the future?
Lt. General Douglas Robb: Right. So, as I mentioned before, Defense Logistics Agency has been just an incredible mentor and partner as we stand up. And they have seen for a long time the incredible opportunity, because remember, they are a supporting organization just like us, you know, and their job is to support our nation's defense. And now that they've got a single point of contact and then we can drive the behavior through accountability and transparency, you know, we are partnering with DLA, and as you can imagine, you know, the purchasing power when you bring – and then their ability to negotiate is, you know, an incredible, what I call capability, that we don't possess. In fact, I've had three meetings already with the Director of the Logistics Agency and, you know, and his whole staff and my whole staff and we're just hammering out ways, again, to more effectively procure, and also looking at opportunities with the VA where we can procure pharmaceuticals and medical supplies, and looking at ways to drive the industry to react to us instead of us reacting to the industry.
So, whether you're talking about – the other thing, again, so this is going to help – so let's go back to other shared services. So, this is a hypothetical example. Let's say there are ten different artificial knees out there, okay? And, of course, you've got ten orthopedic doctors that have trained at ten different, as you can imagine, and they all got their favorite, all right? But what you see is the high performing healthcare organizations out there have done is they'll get those ten physicians and they're going to say, you need to agree on one, two, maybe three, maybe three. And what they found is that once they, again, the folks get, you know, you have to learn and each one is a little different when you put them in, but they found that the actual quality output in the standard of care actually rises when they do – because again, standard driven on which knee they're going to pick. They're going to pick the best ones, and then the standardization driving higher quality outcomes. But that's on the patient care piece of it. But you can imagine now, now I'm going to be buying two or three knees larger bulk, so, again, I'm going to drive and help drive the industry and the cost down for our Military Health Service and for our taxpayer.
Michael Keegan: I had the pleasure of having Admiral Harnitchek on the show. And it's really interesting because he's transforming the way DLA does business just like you're doing for the Defense Health Agency. So, I'd like to switch gears a little bit and talk about the health information technology portfolio and what are you doing in that area besides – we'll get into a little bit about the procuring the electronic health record – but what else are you doing?
Lt. General Douglas Robb: As I said before, you know, just by the nature of the way we're organized, we were running basically three health information and technology systems. Now it made sense that we – if we're going to be a medical enterprise, we ought to be running off, you know, a similar system. And whether you're talking about medical items like, you know, because all these things, as you know, most all medical devices now have some IT component to it, and so the opportunity, as we say, to hang, you know, if you talk to the health information and technology folks is that the challenge is and the cost gets driven up the more stuff you hang on your system. So, you've got a single system. So, each service, you know, is going through the drill of standardizing within. Because remember, at the end of the day, healthcare is all local. Especially when things are evolving so fast that, you know, you'll get folks that are out there that are ahead of the ballgame, but, you know, you were saying these pockets of excellence that were springing up, you know, in the Army, Navy, and Air Force at the various locations, but what happens now is over time it would come back and you were hopefully standardized within your service. And that wasn't necessarily happening either. But now, again, the mantra is Joint first. So, all the services pushed their senior health information – so their CIOs were pushed into the Defense Health Agency. They're still the CIOs for the services, but now they work inside the Defense Health Agency. So, now when we decide what we're going to do next, whether it's an evolving technology or new device, we will collectively work together to, as I say, just pick one, you know.
So, from this point forward, again, and it will be a healthy debate, you know. And again, you know, medical folks have their opinions. But at the end of the day, we'll decide what's the best answer, what's the right solution set, whether it's for, again, for a technological advance or whether it's a clinical or business process. Now, what's going to be a little bit more difficult is how do you rectify what's already out there and standardize that. And that's where our challenges are going to be. But we're going to get really disciplined centrally and then decide what still makes sense to keep that service unique. Because if it supports a service unique mission – absolutely. But if it's a, same thing, a mission set in the Army, Navy, and Air Force, you know, we're going to have to figure out what's the best way and what's the most cost-effective way to standardize that for what we already have out there.
Michael Keegan: Yeah. I had a wonderful conversation with Dave Bowen who is your CIO.
Lt. General Douglas Robb: Absolutely.
Michael Keegan: And Dave had a great strategy, and coming from FAA with the shared services is a great guy to have. I actually want to talk about a specific effort and it's a major effort. It's procuring or implementing a new integrated electronic health record. What can you tell us about what's going on in this area? More particularly, what are some of the biggest challenges, and what's you criteria for success?
Lt. General Douglas Robb: So, it's interesting when you talk about an electronic health record, and I've been part of this journey now – I've been up in Washington for almost four years now. Even in the last five years – so when I go back to when I was a young physician, a medical record was a folder in your hand. Paper. And in it were notes and copies of pharmacy, lab, x-ray, you know, and then your notes, and that's all it was. It was an entity to itself.
Now fast-forward, and then many of our medical institutions out there have adopted an electronic health record, and we of course have ours called Altum, and it's no longer just a documentation of the healthcare delivered, okay? It is also now, because it's now electronic, it collects data. So, when you think about it, it is also data that you can use, all right, either for surveillance, or you can use it to, more importantly, monitor outcomes; data driven, you know, clinical practice guidelines, and then you get to collect the data, feedback loop, performance improvement. So, it's a clinical process now tool.
And you've got the whole concept of, you know, if you pop in a diagnosis or you have this set of symptoms, you know, we have the ability now for what I call clinical input. So, it says have you thought of this? Did you order that? Or what's even more exciting is, what are contradictions? So, you write a script now and you say this, and all of a sudden, because it's electronically stored, it compares databases and now it says, “Hey, this person's also on this, you know, it's a cross-reactivity.” Or as you can see in the future, you know, as again in the whole genomics field, you know, we're finding that there are certain gene sets that make you more predisposed to reactions to either medications or procedures.
So, you know, the opportunities are endless. So, it's no longer just that now. That's just the medical support, all right? So, what we have come to find out in the last – even to the last two or three years, maybe even the last year and a half – is now these are becoming business support tools for a clinical support entity.
And we've been talking to industry leaders, again, you know, folks, their experiences that have converted to what I call a next generation healthcare record, whether it's Kaiser, or it's Vanderbilt Health, you know, Jones Hospital, Wisconsin, Intermountain Health. Several folks out there, you know, to say, hey, you know, procuring it is not easy but procuring whatever the electronic health record, you know, that's a decision that has to be made, okay? The hard part is basically installing it, you know, and that installation process, because you're going to have to run two systems. You're going to have to stand up the new system, of which of course you've got to lead train that by six months or more, training, you know, get everybody ready for it. At the same time, you still have to run your current Legacy system, and then that transition, and then from a macro perspective, which will be our responsibility, will be then how do you basically unplug at the right time the Legacy system when the new system is fully mission capable. As you can imagine, this is going to happen over several years. Several years. Because we're a global enterprise.
Michael Keegan: How is the Defense Health Agency changing the way DOD delivers care? We will ask Lt. General Douglas Robb, Director of the Defense Health Agency, when our conversation continues on The Business of Government Hour.
Michael Keegan: Welcome back to The Business of Government Hour. I'm Michael Keegan, you host, and our guest today is Lt. General Douglas Robb, Director of the Defense Health Agency.
So, General, would you tell us more about how you've sought to reform your governance and decision-making process within the Military Health System? How are you driving better driving improvements and performance?
Lt. General Douglas Robb: Coming together and deciding what that instate that would best serve their service and the enterprise would look like. And what we saw was we were running the proposal, so each one of the shared services, and also what the actual organizational structure for the Defense Health Agency would look like, very, very disciplined business case analysis in business process re-engineering for whatever we would decide we were going to do. Now, at the end of the day, someone's got to sign off and say, looks good to me, you know. Well, what we were doing is we were running this through what we call the Deputy's Group, which is the Deputy Sergeant's Generals, okay?
Army, Navy, and the Air Force personnel folks getting together to decide what's the Joint first solution. I think that's going to be one of the strengths as we move forward on what I call a Joint first, but then the execution of our healthcare system as an enterprise as opposed to just executing it as Army, Navy, and Air Force.
Michael Keegan: So with such a significantly large system as the Military Health System, what are some of the challenges, the cultural challenges, you face in order to foster that jointness? What are some of the things you're facing?
The challenging side is where are the boundaries? Where are the boundaries of autonomy between, you know, what ought to be what I call a central entity and what ought to be service-specific, you know. And those will be the normal growing pains, you know. Where are those boundaries of, you know, where's the supported service versus the execution? But you know what? That governance structure is helping us work through that, you know. I think, again, we are well on our way, and in many ways I've been pleasantly surprised at how fast we've been able to make a difference just in a short eight months.
You know, we had predicted, you know – if you look at cost savings which, at the end of the day, it's about high quality execution healthcare that's efficient, you know. One of the reasons to do what we're doing was, you know, this should be a more cost-effective model. But remember I talked about looking at our shared services? We have a very disciplined business case analysis and business process engineering, and we were able to come up with, and we committed, which we committed, $2.4 billion savings over the next five years. $2.4 billion. And when I say committed, that means they've already taken it. So we will deliver. We will deliver. Our folks...every day I come around...what's your number, how are you doing? We're spot on.
When you look across the Military Health System enterprise, there are six, what we call larger markets, where two or more services deliver healthcare, all right? And in those six markets, about 35 almost 40 percent of our healthcare dollars, direct healthcare dollars, are spent. Now in those six regions, as we call them, six multi-service markets
At the end of the day, the mission of our Military Healthcare System is to have a ready medical force to support the men and women that we ask to go in harm's way. And one of the ways that we see that we can enhance what we call the currency and the competency of our healthcare providers and our healthcare team is founded in our multi-service markets.
Michael Keegan: Yes.
Lt. General Douglas Robb: So when we talked about 40 percent of our healthcare that's delivered, in fact, if you add to those six multi-service markets, you add San Diego and Fort Bragg, you're getting well over 40 percent of healthcare delivered in our direct care system. And so those markets are important to us. So there's a big movement now, and again, to coordinate care, to invest resources in those markets, to recapture folks that are now currently being seen in the network, bring them into our facilities, okay, so that we get those critical cases, we get those tough cases, you know. And there are folks, again, are as skilled as they can be, so when we ask them to be sitting in a tent, again, like I said, on the border of Afghanistan or in the middle of the desert in Sub-Sahara Africa, you know, this is key. This is key. So we believe it is cheaper for us to deliver healthcare inside our facilities. Someone who had asked us a business model drive the readiness model or does the readiness model drive the business model? And the answer is yes.
Michael Keegan: I'd like to shift gears a little bit and talk about the way you're changing how you deliver care. And more particularly, the patient-centered medical home paradigm shift. What is it? What are you doing with it? And what are the benefits associated with it?
Lt. General Douglas Robb: So, the patient medical centered home is kind of a paradigm shift and it's where you build the system around the patient instead of the patient being reactive to the system or to the medical staff. I mean, that's the end-state. So, you look at it from the experience of the patient, and a lot of that has to do with something as simple as continuity, seeing the same provider, you know. In the Military Healthcare System, sometimes that can be difficult, but that doesn't mean you shouldn't try. So, what you've got is you've got – those are your patients, those are your patients, you know, and you manage them. But you also manage them as a team. So, what you see in a lot of these places is they're embedding inside the patient's medical-centered home in these clinics, you know, they've got case managers, you know, they've got folks that are pharmacists, you know, they've got embedded mental health right down there so that you surround that patient by a team that can best manage their care. One, it's higher quality care. But number two, it's more efficient care. And number three, at the end of the day, you know, it ought to be more cost-effective care. So that's exciting.
Now we started this journey a couple of years ago, about 90 percent of our primary care clinics have set up and have transferred to the patient-centered medical home model. And again, they have what we call the NCQA recognition and they're well ahead of schedule of meeting that criteria. In fact, we're doing rather good on, again, the quality of the patient-centered medical homes that we're setting up.
One of the other things that's exciting about that is the opportunity for us to, you know, medicine is changing, you know, with telemedicine and telehealth, but the ability now, you know, your provider may not be available with an appointment but now we're set up to where we have secure messaging where I can give you results back, you know, through secure email. It doesn't necessarily require you to come in. What that does, and then I say, “Hey, you're good to go. See you.” Or, “Hey, you need to come in.” Whereas before you would come in. And then again that's valuable time on that provider's schedule. But now I can put a more acute appointment in there. So, that's something exciting.
One of the other additions to this that's going to be supporting the patient-centered medical home is our nurse advice line.
Michael Keegan: M-hmm. And with all these changes that you're leading, the ultimate mission is to procure a healthy and fit Force. Part of the quadruple aim is readiness, Force readiness. What are you doing in the area of lifestyle, behavior changes, to make it easier for your beneficiaries to live a healthy lifestyle? And more particularly, how are you living that example?
Lt. General Douglas Robb: We have several initiatives out there that I think are really going to be key to us to instill that culture, because if you don't come in the Military with that culture then it's up to us to build that, as I call it, your default. And so, the DOD has launched what we call Operation Live Well, and that's what I call a large set of resources that, depending on where your – whether it's healthy eating, or whether it's increased exercise, or there's a lot of different things out there that support a healthy lifestyle.
And one of those subcomponents to Operation Live Well is what we call the Healthy Base Initiative. So, several of the bases are running pilot programs right now where they're focusing on what are the things that they can do from a base initiative, you know. Something as simple in the dining halls, what I call variety, but whether it's color coding, foods that say green is relatively good for performance, amber not so good, red probably not good at all, you know. So just little simple things like that.
And then one of the other – and you've seen it in the press lately, this is the 50th anniversary of the Surgeon General's Report on the effects of tobacco and tobacco products on the health of our nation. And so that's a challenge in the Military, too. Our statistics on how many folks that smoke in uniform are a lot less than they used to be 20 years ago, 50 years ago, but they're not as low as we want them. And some would argue they're not as low as some of the places in our nation. We've had to focus on that, you know, looking at increasing what we call smoke-free campuses. The Defense Health Agency is a smoke-free campus. So, these are all things that we're looking at to focus on how can we best create an environment where we promote health. Because, at the end of the day, we ask these folks to go on some pretty tough locations and they need to be in shape.
And number two is we care about their health and we care about the individual, as we should. It's only about 30 percent of the population that's even eligible to join the Military because of various reasons. But of that population, there's another 30 percent that, of that population, that can't join the Force because they're overweight. That's one of the reasons we're concerned about families, because the biggest predictor of whether you're going to join the Military is if your parents were prior Military. So, the focus on the family is important, not only for the health but also for our nation.
Michael Keegan: How are innovations in Military medicine transforming civilian healthcare? We will ask Lt. General Douglas Robb, Director of the Defense Health Agency, when our conversation continues on The Business of Government Hour.
Michael Keegan: Welcome back to The Business of Government Hour. I'm Michael Keegan, your host, and our guest today is Lt. General Douglas Robb, Director of the Defense Health Agency.
Lt. General Douglas Robb: So one of the things, I think, that's important, when we go back to the multi-service markets, is – yeah, let me share this with you and see if you think it's worthwhile – and that is, at the end of the day, we have a responsibility for what we call a ready medical force. In other words, our medical capability needs to be current and competent in their ability to deliver healthcare in some rather austere environments. Now, so everything that we do ought to be driven on how we do that. Now, some folks say, and that's why you say, why do you even have a healthcare system? Well, that's why.
Michael Keegan: That's why.
Lt. General Douglas Robb: That's why. So, one of the key components of the multi-service market, that's also where our large graduate medical education programs are, okay? And so the question is, does the business model drive the readiness model or does the readiness model drive the business model? And the answer is yes.
Michael Keegan: On both ends.
Lt. General Douglas Robb: On both ends. Because that's why we need to invest and capture as much care as we can in those multi-service markets because that's where our large graduate medical education programs are, which is also where we're getting the most, again, the most critical care cases, you know, the more advanced cases, you know, the opportunity so that we can deploy and perform again, continue to perform like we are. Because that was the fear was will the readiness model potentially – so the question ought to be, would the readiness model potentially become too cost-prohibitive? So the answer is, no, these are actually working hand-in-hand.
Michael Keegan: One feeds the other.
Lt. General Douglas Robb: Yeah. One feeds the other.
Michael Keegan: We have it, if you want to go ahead. We can...please.
Lt. General Douglas Robb: So, one of the questions that folks ask is how can we afford this readiness model?
Michael Keegan: Sure.
Michael Keegan: In both. Perfect. So, you know, when I was preparing for this interview I came across a line from Dr. Woodson which said that if war is the dark side of human experience, military medicine is the hope and the light. What I want to talk about is some of the medical innovations that you folks have championed over the last 12 years. What has happened? Where are these innovations? And how have they translated into the civilian world?
Lt. General Douglas Robb: When you look at the advances in Military medicine, again, that come out of, like you said, the dark side, which is conflict and wars, the incredible advances that have moved medicine forward are driven by, again, the dedication by our healthcare professionals, you know, it's leave no soldiers, sailors, airmen behind, you know. This conflict in particular has really driven particularly combat casualty care and trauma care delivery to a level that's never been seen anywhere to include our nation back home.
There's a group of folks, again, that were very innovative strategic thinkers. This is one example. That nucleus of folks that was down at San Antonio Military Medical Center, down at Wilford Hall and the Brooke Army Med Center, that proposed what we call the Joint Trauma System. This was back in 2005. And what they did was they took the stove-piped entities out there – one was pre-hospital care, hospital care, and end route care – and brought all those guys together to build a continuum of care that has never before been seen to date.
And so there were several things that came out of that. One was in pre-hospital care and what we call tactical combat casualty care. The recognition, again, each war has its significant injuries, and this one was, you know, the IED. So we were seeing folks that were getting these pretty serious blast injuries which can go both ways; one, you're going to get traumatic brain injury, but you're also going to get trauma in a form of amputations. And what they saw was, you know, you can secure the airway and get them to breathe, but if they bleed out...so that rapid recognition, that's something as simple as a tourniquet, will save a soldier, sailor, airmen, and Marine's life, and that rapid application. And so what we saw was, you know, it's not just a Medicare need, the tourniquet, it was every soldier, sailor, and airman care. In fact, a lot of these tourniquets, and there are stories out there where folks put their own tourniquet on, absolutely. You know, something as simple as that. And then what we saw was this whole, what I call development of damage control surgery and damage control resuscitation by our trauma community. We kind of went into the war ten years ago where we used a lot of saline solutions, and now we've come out of this war, it's what's the right mix of blood products? So we completely turned what we call the resuscitation paradigm upside down, and that has been exciting unto itself.
Now you've got folks, because we've pushed damage control surgery and resuscitation so far forward, again, on a tent, you know, in a remote fort operating base, you've got these young men and women coming out of there, these are what we call ICU level patients. These are patients coming out of a tent on a ventilator with lines and tubes everywhere. So now you've got to move that patient. You've moving an ICU, not just down the hall from the OR to the Intensive Care unit, you're moving them in a helicopter from a fort operating location to, again, a theatre hospital. And then, now you've got to move them 6-7-8,000 miles, you know, back to Germany and back to the United States. So the Air Force was able to create these flying ICUs. So you're taking care of patients, again, that folks say they would be challenged to take care of in a hospital at 35,000 feet, and you're it, and you're it.
And then we could go down the whole line of prosthetics, you know. We've got 40-45 below the knee amputee, you know, folks with prosthetics that have returned to combat, have returned to combat. Prior to this conflict they would have been boarded out.
We've had arm transplants. And again, we talked about our alliances with the civilian sector, but, you know, we have one of our young soldiers that actually had an arm transplant, you know, the artificial skin stuff that we're doing with, again, many of our research colleagues out there. The understanding and the recognition of PTSD and traumatic brain injury, you know, folks would say, are we doing enough, you know. The civilian sector, you know, are we taking the best practices out there? We've helped transform the trauma care. You're going to see that, I think, in the, again, as we coalesce and bring, you know, we're able to bring those folks together to bring the best and the brightest and look at what are the clinical practice guidelines and the algorithms, again, that are clinically driven, you know, that have data outcomes that support. So bringing those communities together, you know. Because we're not where we want to be, but we're a whole lot better than we were even five years ago. So, I'm excited about the opportunity there.
Michael Keegan: Well, General, I would like to get your advice. What advice would you give someone who is thinking about a career in medicine, Military service, or just public service in general?
Lt. General Douglas Robb: Well, let's talk about the Military first. You know, folks ask me, you know, why I stay in. And at the end of the day, it's because I can't think of any population that I would be prouder to take care of, you know. The men and women and their families, and our vets, you know, are a special population. It's a privilege and it's an honor to take care of these men and women. You know, we ask a lot of them and many of these folks have given a lot, you know. And it's the least that I can do to ensure, again, from let's say my perspective today, you know, to ensure that we have a medically ready force, you know, and then a ready medical force to ensure that these folks can perform the best to their ability so that they can come home to their husbands, wives, sons and daughters, mothers and fathers, brothers and sisters, you know, and again, not only what I call alive, but also with a quality of life that they so richly deserve. And I think that's true no matter what branch, whether you're in the public health service, health and human services, you know. We all work towards – you know, we all go into medicine or the healthcare related fields because we want to make a difference. I am privileged and honored to take care of each and every day.
Michael Keegan: Well it was a privilege and an honor to have you in with me today. It was a great conversation. I want to thank you for your time, but more importantly, I'd like to thank you for your dedicated service to the country.
Lt. General Douglas Robb: Thank you.
Michael Keegan: This has been The Business of Government Hour featuring a conversation with Lt. General Douglas Robb, Director of the Defense Health Agency. Be sure to join us next week for another informative, insightful, and in-depth conversation on improving government effectiveness. For The Business of Government Hour, I'm Michael Keegan, and thanks for joining us.