Institute of Medicine July 16, 2009 Reducing Costs and Improving Outcomes: Strategies That Work and How to Get There Glenn Steele Jr., MD, PhD President and CEO Geisinger Health System
Geisinger Health System Last updated 07/09/09 Geisinger ProvenHealth Navigator Sites Contracted ProvenHealth Navigator Sites Geisinger Medical Groups Geisinger Specialty Clinics Geisinger Inpatient Facilities Ambulatory Care Facilities Geisinger Health System Hub and Spoke Market Area Geisinger Health Plan Service Area Careworks Convenient Healthcare Non-Geisinger Physicians With EHR
Geisinger Health System An Integrated Health Service Organization Provider Facilities Geisinger Med. Ctr. (+ Janet Weis Children s Hospital) Geisinger Wyoming Valley Med. Ctr. w/ Heart Hosp. & Henry Cancer Ctr. Geisinger South Wilkes-Barre Hosp. Marworth Drug & Alcohol Treatment Center 2 ambulatory surgery centers >40K admissions, ~700 licensed in-pt beds Physician Practice Group Multispecialty group ~750 physicians 38 comm. practice sites >1.6 million outpatient visits 281 residents and fellows Managed Care Companies ~228,000 members Diversified products >18,000 contracted physicians 36,000 Medicare Advantage 90 Non-Geisinger hospitals 43 PA counties
Electronic Health Record (EHR) Decision to implement Epic : 1995 > $120M invested (hardware, software, manpower, training) Running costs: ~4.4% of annual revenue of > $2.3B Fully-integrated EHR 38 community practice sites; GMC in-patient; GWV nursing documentation; GWV and GSWB Emergency Department live on EPIC Northeast hospitals go live with CPOE, medication administration and clinical documentation: Feb 2009 > 3 million patient records ~124,000 active users of MyGeisinger; new goal = 200,000 ~2,300 non-geisinger users ~421 non-geisinger practices (GeisingerConnect) Real-time registries track clinical metrics by dept/physician PACS and web-based image distribution
The Vision Innovation Geisinger Quality Market Expansion Securing the Legacy *Predicated on maintaining healthy operations
Hedging GHS provision of care 30% GHP payor 70% Non-GHP payors GHS insurance companies 50% via Geisinger Clinic
Targets for Geisinger Innovation Unjustified variation Fragmentation of care-giving Perverse payment incentives Units of work Outcome irrelevant Patient as passive recipient of care
Innovation Initiatives* ProvenCare for acute episodic care (the warranty ) ProvenCare Chronic Disease Optimization ProvenHealth Navigator (Advanced Medical Home) Transitions of Care *Achievable only through innovation
ProvenCare for Acute Episodic Care (the Warranty )
ProvenCare for Acute Episodic Care ProvenCare Identify high-volume DRGs Determine best practice techniques Deliver evidence-based care GHP pays global fee No additional payment for complications
ProvenCare CABG: Reliability ProvenCare CABG % patients receiving all ProvenCare components 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% *Feb Q1 2006 Q2 Q3 Q4 Q1 2007 Q2 Q3 Q4 Q1 2008 Q2 Q3 *Single month of data Quarter
Quality/Value - Clinical Outcomes (18 months) Before With % Improvement/ ProvenCare ProvenCare (Reduction) (n=132) (n=181) In-hospital mortality 1.5 % 0 % Patients with any complication (STS) 38 % 30 % 21 % Patients with >1 complication 7.6 % 5.5 % 28 % Atrial fibrillation 23 % 19 % 17 % Neurologic complication 1.5 % 0.6 % 60 % Any pulmonary complication 7 % 4 % 43 % Blood products used 23 % 18 % 22 % Re-operation for bleeding 3.8 % 1.7 % 55 % Deep sternal wound infection 0.8 % 0.6 % 25 % Readmission within 30 days 6.9 % 3.8 % 44 % Value - Financial Outcomes Average total LOS fell 0.5 days (6.2 vs. 5.7) Hospital net revenue grew 7.8% Contribution margin of index hospitalization grew 16.9% 30-day readmission rate fell 44%
ProvenCare CABG Angioplasty Angioplasty + AMI Hip replacement Cataract EPO Perinatal Bariatric surgery Low back
ProvenCare -Chronic Disease Optimization
ProvenCare -Chronic Disease Portfolio Diabetes Congestive Heart Failure Coronary Artery Disease Hypertension Prevention Bundle
Diabete s "B un dle" GHS Qual itytargets CPSL Measures Performance Criteria Standard FY07 HgbA1Cmeasurement Every6 months 10% X HgbA1Ccontrol < 7 7 to9 >9 < 7.0 X LDLmeasurement Year ly 10% X LDLcontrol < 100 <130 >=130 <100 X Blood presurecontrol < 130/80 < 140/90 >=140/90<130/80 X Retinalexam Year ly 10% Urine (protein)exam Year ly 10% X Footexam Year ly 10% Inf luenza immunizat ion Year ly 10% X Pneumococcal immunizat ion Once* 10% X Smoking status Non-smoker 10% X UseofACE/ARB formicroalbuminuria/dmnephropathy Yes 10% UseofACE/ARB forhypertension Yes 10% Patientswhoreceive/achieveALL ofthe above Yearly 100% X Diabetes "Bundle" Measures GHS Quality Targets Performance Criteria Standard HgbA1C measurement Every 6 months 100% X HgbA1C control < 7 7 to 9 >9 < 7.0 X LDL measurement >100 Yearly to 100% X LDL control < 100 <130 >=130 < 100 X Blood pressure control < 130/80 < 140/90 >=140/90 < 130/80 X Retinal exam Yearly 100% Urine (protein) exam Yearly 100% X Foot exam Yearly 100% Influenza immunization Yearly 100% X Pneumococcal immunization Once* 100% X Smoking status Non-smoker 100% X Use of ACE/ARB for microalbuminuria/dm nephropathy Yes 100% Use of ACE/ARB for hypertension Yes 100% CPSL FY07 Patients who receive/achieve ALL of the above Yearly 100% X
Diabetes Profile Report Primary Care Bundle (>23,000 patients) 7,000 7 met 8 met 9 (all met) 6,000 5,000 4,000 3,000 Total diabetes patients 3/09 (11%) 12/08 (12%) 9/08 (12%) 6/08 (12%) 3/08 (11%) 2,000 12/07 (10%) 9/07 (9%) 1,000 9/06 (4%) 6/07 (8%) 3/07 (7%) 0 Total Pts - 0 Measures Met Total Pts - 1 Measure Met Total Pts - 2 Measures Met Total Pts - 3 Measures Met Total Pts - 4 Measures Met Total Pts - 5 Measures Met Total Pts - 6 Measures Met Total Pts - 7 Measures Met Total Pts - 8 Measures Met Total Pts - All Measures Met 12/06 (7%)
Coronary Artery Disease Profile Report Primary Care Bundle Summary 35% 7 met 8 met 9 (all) met 30% 25% 20% 15% % of total CAD patients 3/31/09 (19%) 12/31/08 (19%) 6/30/08 (20%) 4/30/08 (19%) 3/31/08 (19%) 12/31/07 (17%) 9/30/07 (16%) 10% 5% 9/30/06 (8%) 0% % Pts - 0 Measures Met % Pts - 1 Measure Met % Pts - 2 Measures Met % Pts - 3 Measures Met % Pts - 4 Measures Met % Pts - 5 Measures Met % Pts - 6 Measures Met % Pts - 7 Measures Met % Pts - 8 Measures Met % Pts - All Measures Met
ProvenHealth Navigator (Advanced Medical Home)
ProvenHealth Navigator (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)
Patient-Centric Focus Patient engagement Physician endorsement and oversight of care continuum Individualized care plans (e.g., diabetic report card, MyGeisinger) Automated assessment and triage Complete, accurate, searchable data Complete, accurate, current registries Coordinated care (between patient/family/nurse/physicians)
Phase - 1 Total Medical Cost Decreased 4% for Entire Population; ROI = 250%
Readmission Rate Empl Phase 2 Sites Medicare Control Population 17.80% 16.80% 15.80% 14.80% 13.80% 12.80% 11.80% Jan-Apr 2007 Jan-Apr 2008 Readmission Rate Jan-Apr 2007 Jan-Apr 2008 Change Trend Employed Phase 2 17.0% 12.0% -5.0% -29.4% Medicare Control Population 16.8% 17.6% 0.8% 4.8%
ProvenHealth Navigator (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
Transitions of Care
Transitions of Care Began January 2008 as joint quality/efficiency initiative that complements ProvenHealth Navigator (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
Preliminary First Quarter Results GWV Medicine Service 30 Day Readmission Rate GMC Medicine Service 30 Day Readmission Rate 18.0% 16.0% 14.0% 16.0% 13.3% 17% Reduction 18.0% 16.0% 14.0% 13.7% 12.0% 12.0% 10.7% 22% Reduction 10.0% 10.0% 8.0% 8.0% 6.0% 6.0% 4.0% 4.0% 2.0% 2.0% 0.0% Q1 Q1 0.0% Q1 Q1 FY2008 FY2009 FY2008 FY2009
Fundamental Innovation at Geisinger How and Why? 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 Geisinger How and Why? 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
\ All of the above permissive but not enough Clinical leadership Pride of purpose Professionalism Overarching
Caveats Scalable? Applicable to non-ids? Applicable in absence of real-time EHR? Applicable in fee-for-service settings? Pending wider use in marketplace