Heal • Teach • Discover • Serve HealthCare Management Association November 10, 2009 The Geisinger Experience Transforming Healthcare Glenn Steele Jr., MD, PhD President and CEO Geisinger Health System
Aug 22, 2015
Heal • Teach • Discover • Serve
HealthCare Management Association November 10, 2009
The Geisinger Experience Transforming Healthcare
Glenn Steele Jr., MD, PhDPresident and CEO
Geisinger Health System
Geisinger Health System
Careworks Convenient Healthcare
Non-Geisinger Physicians With EHR
Last updated 07/09/09
Geisinger ProvenHealth Navigator SitesContracted ProvenHealth Navigator SitesGeisinger Medical GroupsGeisinger Specialty Clinics
Geisinger Inpatient FacilitiesAmbulatory Care Facilities Geisinger Health System Hub and Spoke Market AreaGeisinger Health Plan Service Area
Heal • Teach • Discover • Serve
Geisinger Health System
ProviderFacilities
Physician Practice Group
Managed CareCompanies
An Integrated Health Service Organization
• Multispecialty group• ~750 physicians• ~60 primary and specialty clinic sites (38 community practice sites)• >1.6 million outpatient visits• 281 residents and fellows
• Geisinger Medical Center with Janet Weis Children’s Hospital• Geisinger Northeast (2 campuses) - Geisinger Wyoming Valley Medical
Center with Heart Hospital, HenryCancer Center, Level II Trauma Center
- Geisinger South Wilkes-Barre Ambulatory Surgery, Adult &
PediatricUrgent Care, Pain Medicine, SleepMedicine
• Marworth Alcohol & Chemical Dependency Treatment Center• Ambulatory surgery centers• >40K admissions• ~700 licensed in-patient beds
• ~226,000 members (incl. 36,000 Medicare Adv.)• Diversified products• >18,000 contracted physicians• 90 Non-Geisinger hospitals• 43 out of 67 PA counties
Heal • Teach • Discover • Serve
• > $120M invested (hardware, software, manpower, training)• Running costs: ~4.4% of annual revenue of > $2.3B• Fully-integrated EHR: 38 community practice sites; 2 hospitals; 3
EDs– Acute and chronic care management
– Optimized transitions of care
• Networked PHR - 133,000 active users (27% of ongoing patients)– Patient self-service (self-scheduling, kiosks)
– Home monitoring integrated with Medical Home
• “Outreach EHR” - 2,300 non-Geisinger physician users– Regional image distribution
• Regional Health-Information Exchange (KeyHIE)– 11 hospitals, 90+ practices, 2.5 M patients
Electronic Health Record (EHR)
Heal • Teach • Discover • Serve
• Geisinger Quality
• Innovation
• Market Expansion
• Securing the Legacy
*Predicated on maintaining healthy operations
The Vision
Heal • Teach • Discover • Serve
“Hedging”
• GHS provision of care– 30% GHP payor– 70% Non-GHP payors
• GHS insurance companies– 50% via Geisinger Clinic
Heal • Teach • Discover • Serve
Targets for Geisinger Innovation
• Unjustified variation
• Fragmentation of care-giving
• Perverse payment incentives– Units of work
– Outcome irrelevant
• Patient as passive recipient of care
Heal • Teach • Discover • Serve
Innovation Initiatives
• ProvenCare® for Acute Episodic Care (the “Warranty”)
• ProvenCare® Chronic Disease
• ProvenHealth NavigatorSM (Advanced Medical Home)
• Transitions of Care
Heal • Teach • Discover • Serve
The Geisinger Advantage
• Our physicians and professional staff• Our market• Vision and leadership• Operational and professional integration• Enterprise-wide clinical decision support (via the EHR)• Accountability, transparency, incentives – all aligned• Our insurance/provider “sweet spot”
Heal • Teach • Discover • Serve
ProvenCare® for Acute Episodic Care (the “Warranty”)
Heal • Teach • Discover • Serve
Pay-for-PerformanceAcute Episodic Care
ProvenCare®
• Identify high-volume DRGs
• Determine best practice techniques
• Deliver evidence-based care
• GHP pays global fee
• No additional payment for complications
Heal • Teach • Discover • Serve
Quality/Value - Clinical Outcomes Before ProvenCare® ProvenCare® % Improvement
(n=132) (n=321)
In-hospital mortality 1.5 % 0.3 % 80 %Patients with any complication (STS) 38 % 33 % 13 %Patients with >1 complication 8.4 % 5.9 % 30 %Atrial fibrillation 24 % 21 % 13 %Neurologic complication 1.5 % 0.9 % 40 %Any pulmonary complication 7 % 5 % 29 %Re-intubation 2.3 % 0.9 % 61 %Blood products used 24 % 22 % 8 %Re-operation for bleeding 3.8 % 2.8 % 26 %Deep sternal wound infection 0.8 % 0.3 % 63 %Readmission within 30 days 6.9 % 5.6 % 20 %
Heal • Teach • Discover • Serve
ProvenCare® CABG
Fiscal Year 2009 Milestones / Issues• Completed literature review and began to
evaluate addition of urgent cases and valves
• Financial lookback complete and payment model adjusted
Fiscal Year 2010 TimelineQ1-Update Outcomes DataQ2-Add Urgent Cases ?Q3-Review LiteratureQ4-Reassess Process Measures
ProvenCare CABG
0%10%20%30%40%50%60%70%80%90%
100%
% patients receiving all ProvenCare components
Heal • Teach • Discover • Serve
ProvenCare® CABG: Financial Outcomes
Hospital:• Net revenue increased 3.8%• Direct costs decreased 5.1%• Contribution margin increased 11.3%• Total inpatient profit per case improved $2560
Health Plan:• Cost 4.8% less per case for GHS CAB with ProvenCare®
than it would have without• Cost 28 to 36% less for CAB with GHS than other
providers
Heal • Teach • Discover • Serve
Not Just SurgeryVirtual Care Models: Epo Management
Epo CKD (n=184)* Control (n=74)**
Median days to goal = 49 days Median days to goal = 62.5 days
% Time below goal = 25%
% Time in goal = 49%
% Time above goal = 26%
% Time below goal = 39.7%
% Time in goal = 43.9%
% Time above goal = 16.4%
Avg Epo Units/week = 4667*** Avg Epo Units/week = 12,000
Home/Clinic = 90%/10% Home/Clinic = 39.2%/60.8%
Expanded Dose Utilization = 44% Expanded Dose Utilization = 16%
Avg Hgb at start = 9.6 mg/dl Avg Hgb at start = 10.0 mg/dl
Avg T-Sat at start = 18% Avg T-Sat at start = 18%
***Savings $5,719/pt/year @$0.015/unit of Epo (p<.001)
*VITALine Q4FY2009 results on file, Hgb range 11-12 since 2007
**Bucaloiu et. al, Managed Care Interface, June 2007. Hgb target range 11-13 at this time
Heal • Teach • Discover • Serve
ProvenCare® Portfolio
ProvenCare®:
– CABG– PCI (Percutaneous Coronary Interventions
Angioplasty/Angioplasty + AMI)
– Hip replacement– Cataract– EPO– Perinatal– Bariatric surgery– Low back– Lung cancer
Heal • Teach • Discover • Serve
ProvenHealth NavigatorSM
(Advanced Medical Home)
Heal • Teach • Discover • Serve
ProvenHealth NavigatorSM
(Advanced Medical Home)
• Partnership between primary care physicians and GHP that provides 360-degree, 24/7 continuum of care
• “Embedded” nurses• Assured easy phone access• Follow-up calls post-discharge and post-ED visit• Telephonic monitoring/case management• Group visits/educational services• Personalized tools (e.g., chronic disease report cards)
Heal • Teach • Discover • Serve
Phase - 1 Total Medical Cost Decreased 4% for Entire Population; ROI = 250%
Heal • Teach • Discover • Serve
Readmission Rate
11.80%
12.80%
13.80%
14.80%
15.80%
16.80%
17.80%
Jan-Apr 2007 Jan-Apr 2008
Empl P hase 2 Sites Medicare Control P opulation
Jan-Apr 2007 Jan-Apr 2008 Change TrendEmployed Phase 2 17.0% 12.0% -5.0% -29.4%
Medicare Control Population 16.8% 17.6% 0.8% 4.8%
Readmission Rate
Diabetes: MyGeisinger/Report Card
Last 2-3 values displayed
LDL values and goals
Last BP readings
7/15/2007
Heal • Teach • Discover • Serve
ProvenHealth NavigatorSM (Advanced Medical Home)
• Currently serves 35,000 Medicare recipients and 15,000 commercial patients
• Results from best primary care sites:
• 25% patients’ admissions
• 23% days/1000
• 53% readmissions following discharge
• Significant benefit to patients and families, avoiding multiple hospital admissions
Heal • Teach • Discover • Serve
Transitions of Care
Heal • Teach • Discover • Serve
Transitions of Care
• Began January 2008 as joint quality/efficiency initiative that complements ProvenHealth NavigatorSM (Advanced Medical Home)
• Inpatient and outpatient interventions– Eliminate unnecessary admissions– Reduce readmissions
• Free up capacity for more acutely-ill patients
• Focused on heart failure, medical/surgical inpatient wards, and Emergency Department)
• Program expansion is planned, including addressing LOS
• Modeling and predictive instruments used
Heal • Teach • Discover • Serve
GWV Medicine Service30 Day Readmission Rate
16.0%
13.3%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
FY2008 FY2009
GMC Medicine Service30 Day Readmission Rate
10.7%
13.7%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
FY2008 FY2009
22%
Reduction
Q1 Q1
17%
Reduction
Q1 Q1
Preliminary First Quarter Results
Heal • Teach • Discover • Serve
Anatomy• Continuum of Care (provider “all-in”)
• Hub and spoke provider design
• Aligned incentives
• Insurance/provider joint goals
Market• Demography
• Brand
• Market share (insurance and provider)
• Electronic enabler across 43 counties
Fundamental Innovation at GeisingerHow and Why?
Heal • Teach • Discover • Serve
Financial Health• Balance sheet
• Operating margin
• “Hedging” strategy
• Planned risk taking
Sociology• IHS culture
• Clinical leadership (insurance and provider)
• Patient centric design
• The “common good” goal
Fundamental Innovation at GeisingerHow and Why?
Heal • Teach • Discover • Serve
All of the above
“permissive” but not enough
Clinical leadership
Pride of purpose
ProfessionalismOverarching
Heal • Teach • Discover • Serve
Caveats
• Scalable?
• Applicable to non-IDS?
• Applicable in absence of real-time EHR?
• Applicable in fee-for-service settings?
• Pending wider use in marketplace
Heal • Teach • Discover • Serve
““Reengineering Care”Reengineering Care”Necessary and compelling; no matter Necessary and compelling; no matter
what happens in Washington!what happens in Washington!