QUiC Clinics in the Central Texas Market: Value-Based Primary Care in Military Medicine.

INTRODUCTION: For the past 16 years, Military Health System primary care providers have been incentivized to pursue work in a fee-for-service (FFS) model. The system values documentation of productivity to earn as many relative value units as possible. The result is densely packed clinic schedules that often lack the space or flexibility to accommodate patients when sick. Leakage ensues. Furthermore, prevention and patient experience are not directly incentivized. METHODS: The Central Texas Market's Accountable Care Organization reformed incentives in its #5 FFS-designed community-based medical homes to value outcomes over productivity. The resulting quality, urgent, internet, and phone care (QUiC) clinics are value-based and, therefore, better structured to achieve the Quad aim (better care, better health/readiness, and low cost). Forsaking deeply ingrained FFS practices, QUiC clinics funnel all routine (information-sharing) appointments into efficient internet or phone appointments. With the time freed by managing common needs in short bursts, QUiC clinics see sick patients with no notice (urgent care). They also focus on prevention and patient experience. We measured the effectiveness of the QUiC clinics in the value-based metrics of (1) patient experience, (2) Healthcare Effectiveness Data and Information Set measures of quality and prevention. (3) access-to-care, (4) leakage, and (5) enrollment. RESULTS: Over a 19 month period, the five community-based medical homes improved significantly in all areas. Specifically, measures of patient satisfaction improved from the mid-80s percent satisfied to the mid-90s percent satisfied. Healthcare Effectiveness Data and Information Set measures increased from average compared to national benchmarks (<50th percentile to 75th percentile) to the 90th percentile in four of five measures of quality and the 75th percentile in the remaining measure. Access to care for routine appointments decreased from 15.4 days to the third next available appointment to 2.8 days. Leakage decreased from 12.2% to 9.6%. These successes were attained without cost or significant reductions in patient enrollments. In changing workflows, the market became the #1 user of virtual video visits in the DOD. CONCLUSIONS: This performance improvement project proved the concept that a military market can vastly improve value-based primary care outcomes at no cost and within multiple community-based clinics.

Finding Opportunities for Health-Care System Advancement in the COVID-19 Crisis.

The coronavirus disease 2019 (COVID-19) pandemic forced American medical systems to adapt to high patient loads of respiratory disease. Its disruption of normal routines also brought opportunities for broader reform. The purpose of this article is to describe how the Carl R. Darnall Army Medical Center (CRDAMC), a medium-sized Army hospital, capitalized on opportunities to advance its strategic aims during the pandemic. Specifically, the hospital sequentially adopted virtual video visits, surged on preventative screenings, and made-over its image to appeal to patients seeking urgent care. These campaigns supported COVID-19 efforts and larger strategic goals simultaneously, and they will endure for years to come. Predictably, CRDAMC encountered obstacles in the course of its transformation. These obstacles and their follow-on lessons are provided to assist future medical leaders seeking quantum change in the opportunities made available by health crises.

Testicular Cancer: Diagnosis and Treatment.

Testicular cancer is the most common solid tumor among males 15 to 34 years of age, with an estimated 8,850 new cases and 410 deaths during 2017 in the United States. With effective treatment, the overall five-year survival rate is 97%. Risk factors for testicular cancer include undescended testis (cryptorchidism), personal or family history of testicular cancer, age, ethnicity, and infertility. The U.S. Preventive Services Task Force recommends against routine screening in asymptomatic men. Men with symptoms should receive a complete history and physical examination. Scrotal ultrasonography is the preferred initial imaging study. If a solid intratesticular mass is discovered, orchiectomy is both diagnostic and therapeutic. Staging through chest radiography, chemistry panel, liver function tests, and tumor markers guides treatment. Active surveillance, chemotherapy, retroperitoneal lymph node dissection, and radiation therapy are treatment options following orchiectomy. For patients desiring future fertility, sperm banking should be discussed early in the course of treatment. Family physicians often play a role in the care of cancer survivors and should be familiar with monitoring for recurrence and future complications, including secondary malignant neoplasms, cardiovascular risk, and infertility and subfertility.