CHIME: Geisinger Shows That Better Care Costs Less
By Neil Versel, contributing writer
Geisinger Health System, based in Danville, PA, has been held up as an example of the future of healthcare – an integrated provider and payer organization in which financial incentives are aligned with clinical goals, decisions are made with data in hand and everyone is held accountable for those decisions.
The “sweet spot” for Geisinger, according to President and CEO Dr. Glenn D. Steele Jr., is innovation in population health to reduce the total cost of care, enabled by data-driven care redesign that features systems of care, payment bundling and attention to care transitions.
Geisinger has invested upwards of $200 million on IT, with a tightly integrated Epic Systems EHR as the centerpiece. The electronic health record (EHR) ties together seven hospitals, 46 physician practice sites, four surgical centers, and 17 walk-in and urgent care clinics. About 268,000 people, or 41 percent of Geisinger's total active patient base, use the health system's patient portal, Steele explained at the College of Healthcare Information Management Executives (CHIME) Fall CIO Forum in San Antonio last week.
About half of Geisinger's revenue today is from risk-based contracts, with the rest from traditional fee-for-service payments. The goal is to get to a system where coverage is affordable for all, payment is based on value instead of volume, care is coordinated and there is a culture of continuous innovation and improvement, all with accountability for the care actually delivered, Steele said.
Steele listed quality and innovation as Geisinger's top strategic priorities. The strategy goes back to the seminal 2003 Rand Corp. article in the New England Journal of Medicine, that concluded that patients received only about 55 percent of recommended care for various conditions as well as prevention. “It was pretty much an epiphany for me,” Steele said.
This, he said, means there is much waste and little value.
“There is a relationship [between cost and quality], and it's inverse,” Steele said, citing the work of Dr. Arnold Milstein at Mercer as well as data from Geisinger's own experiences between 2006 and 2010. This is the complete opposite of the prevailing belief more than 20 years ago, during the 1993-94 debate of the ill-fated Clinton administration health reform plan.
In transforming Geisinger, the organization created a brand called ProvenCare, which offers a warranty of sorts for acute, episodic care, investment in chronic disease management and an “advanced” medical home known as ProvenHealth Navigator, Steele said. Geisinger also focused on care transitions – a key point of error and duplication – and adopted “PRIDE” as its motto, for “proven innovation drive for excellence.”
“We baked all of this into our electronic health record,” Steele said. Geisinger also now is on the third version of its data warehouse, Steele added.
With ProvenHealth Navigator for elderly patients, Geisinger Health Plan actually pays for a homecare nurse for the 150-200 highest-utilization and neediest patients at community practices. “What you're talking about is concierge care for the sickest, not concierge care for the richest,” Steele said.
All told, the advanced medical home in place at 42 Geisinger and 49 non-Geisinger practices, plus 17 nursing homes, cut the medical expense trend by 7.1 percent, and Geisinger achieved a return on investment in 1.7 years when including prescription drug coverage, Steele said.
Steele said the reengineering of chronic disease management was impossible without data, analytics and the ability to understand individual practice patters to help minimize variations. With all of those elements in place, the results have been impressive.
Inpatient admissions for ProvenHealth Navigator enrollees fell by 27.5 percent and readmissions by 34 percent in the space of one year, while 72 percent of patients said case managers improved the quality of the experience.
In diabetes management, bundled payments and analytics helped Geisinger prevent 305 heart attacks, 140 strokes and 166 cases of retinopathy over a three-year period, according to a paper Steele co-authored in the American Journal of Managed Care this year.
During his CHIME keynote, Steele shared additional data about patient safety.
Among 715 patient receiving coronary artery bypass grafts, 97 percent had all 40 elements of best practices for that procedure delivered, he said. There were just 37 missed elements in 24 patients, corresponding to a minuscule 0.13 percent error rate among the 28,600 opportunities to make a mistake, according to Geisinger data.
Total inpatient profit improved by $1,946 per patient for the health system, and the health plan paid out at least 28 percent less per patients for CABG at Geisinger hospitals than at other providers.
A second version of the CABG guidelines now incorporates 120 best practices.
In the last couple of years, Geisinger has successfully sold a single price with a guarantee to Wal-Mart Stores. The world's largest retailer started a “Centers of Excellence” program with six major health systems to provide heart, spine and transplant surgeries to employees at a fixed cost.
“We're giving the family $1,000 in walking-around money to come to Danville, and we're still making a 15-16 percent margin on them,” Steele said.
Still, the Geisinger CEO is not content. “I would love to have the healthcare delivery community to come together to decide [what constitutes good outcomes], then work with tech vendors to make it happen,” he said. Steele likened health IT to a “tailored suit” rather than one off the rack. Fit matters.