Bipartisan Policy Center
Glenn D. Steele Jr., MD, PhD
President and CEO
Geisinger Health System
April 24, 2008
Geisinger Health System
Business Strategy & Development
02/08
Geisinger Health System
Business Strategy & Development
02/08
Geisinger Health System
Business Strategy & Development
02/08
Geisinger Health Plan
• ~ 211,000 members
– HMO, PPO, diversified products
– 35,000 Medicare Advantage
• >16,000 empanelled physicians*
• 75 non-Geisinger hospitals
• 41 PA counties
* Includes Geisinger physicians of ~700
Electronic Health Record (EHR)
•
•
•
•
Decision to implement Epic®: 1995
> $80M invested (hardware, software, manpower, training)
Running costs: ~ 4.2% of annual revenue of $2.0B
Fully-integrated EHR - 40 community practice sites; GMC inpatient; GWV nursing documentation; GWV and GSWB
Emergency Department live on EPIC®
– GSWB nursing documentation to go live: April 2008
• > 3 million patient records
– ~ 98,000 active users of MyGeisinger; goal = 100,000
– > 1,300 non-Geisinger users; confidential access (referring
physicians)
– Real-time registries track clinical metrics by dept/physician
– PACS and web-based image distribution
Targets for the Geisinger Transformation
• Unjustified variation
• Fragmentation of care-giving
• Perverse payment incentives
– Units of work
– Outcome irrelevant
• Patient as passive recipient of care; not an active
participant
Managing to Success
Transformation Initiatives*
•
•
•
•
Geisinger Medical Home
Chronic Disease Care Optimization
Transitions of Care
ProvenCareSM for acute episodic care (the “warranty”)
*Achievable only through innovation
Managing to Success
Geisinger 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)
Admission Metrics
GHP MC
Medicare
Baseline
Pre-Program
Jan – Oct. 2006
First Year of
Pilot
Jan-Oct. 2007
Percent
Reduction
311/1,000
311/1,000
0%
365/1,000
291/1,000
-20%
269/1,000
232/1,000
-13.8%
Lewistown
Lewisburg
Readmission Metrics
Baseline: PreProgram
2005 Q4 – 2006 Q3
Readmission Rate
First Year: Pilot
2006 Q4 – 2007 Q3
Readmission Rate
%
Reduction
GHP Managed Care
(MC) Medicare
16.6%
16.5%
0%
GHP MC Medicare
GHS Sites
17.0%
16.6%
-2.3%
All Medical Home
Sites
19.5%
15.9%
-18.5%
Lewistown (2,120 pts)
20.3%
17.8%
-12.3%
Lewisburg
(645 pts)
15.2%
7.9%
-48.0%
Diabetes "Bundle"
GHS Quality Targets
Measures
Performance Criteria
Standard
CPSL
FY07
Every 6 months
100%
X
< 7.0
X
HgbA1C measurement
HgbA1C control
<7
LDL measurement
7 to 9
>9
Yearlyto
>100
< 100
<130
>=130
< 130/80 < 140/90 >=140/90
100%
X
< 100
< 130/80
X
X
Yearly
100%
Yearly
100%
Yearly
100%
Influenza immunization
Yearly
100%
X
Pneumococcal immunization
Once*
100%
X
Non-smoker
100%
X
Use of ACE/ARB for microalbuminuria/DM nephropathy
Yes
100%
Use of ACE/ARB for hypertension
Yes
100%
Yearly
100%
LDL control
Blood pressure control
Retinal exam
Urine (protein) exam
Diabetes "Bundle"
X
GHS Quality Targets
Measures
Performance Criteria
Standard
CPSL
FY07
Every 6 months
100%
X
HgbA1C measurement
HgbA1C control
LDL measurement
Foot exam
Smoking status
Patients who receive/achieve ALL of the above
LDL control
Blood pressure control
Retinal exam
Urine (protein) exam
Foot exam
Influenza immunization
Pneumococcal immunization
Smoking status
<7
7 to 9
>9
< 7.0
Yearlyto
100%
>100
< 100
<130
>=130
< 100
< 130/80 < 140/90 >=140/90 < 130/80
Yearly
100%
Yearly
100%
Yearly
Yearly
Once*
Non-smoker
X
X
X
Yes
100%
Yes
100%
Yearly
100%
Patients who receive/achieve ALL of the above
X
X
X
X
X
100%
100%
100%
100%
Use of ACE/ARB for microalbuminuria/DM nephropathy
Use of ACE/ARB for hypertension
X
X
Diabetes Profile Report
Primary Care Bundle Summary
> 20,000 patients
35%
7 met
8 met
All met
% of total diabetes patients
30%
12/31/07
25%
12/31/07
22%
25%
20%
9/30/06
23%
15%
9/30/06
15%
12/31/07
10%
10%
5%
9/30/06
4%
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 % Pts 8 Measures Met All Measures Met
Chronic Disease Portfolio
•
•
•
•
•
Diabetes
Congestive Heart Failure
Coronary Artery Disease
Hypertension
Prevention Bundle
ProvenCareSM for Acute Episodic Care
(the “Warranty”)
Pay-for-Performance
Acute Episodic Care
ProvenCareSM
•
•
•
•
•
Identify high-volume DRGs
Determine best practice techniques
Deliver evidence-based care
GHP pays global fee
No additional payment for complications
ProvenCare
SM
CABG: Reliability
ProvenCareSM CABG
100%
care
90%
80%
P=0.01
P=0.01
70%
60%
50%
40%
30%
20%
10%
0%
Fe
b06
A
pr
-0
6
Ju
n06
A
ug
-0
6
O
ct
-0
6
D
ec
-0
6
Fe
b07
A
pr
-0
7
Ju
n07
A
ug
-0
7
O
ct
-0
7
D
ec
-0
7
% of
patients who
% of patients
received
all
who received
components
all
of
of components
care
Quality
Clinical Outcomes - (18. mos)
Before
With
ProvenCareSM ProvenCareSM
(n=132)
(n=181)
In-hospital mortality
Patients with any complication (STS)
Patients with >1 complication
Atrial fibrillation
Neurologic complication
Any pulmonary complication
Blood products used
Re-operation for bleeding
Deep sternal wound infection
Readmission within 30 days
1.5 %
38 %
7.6 %
23 %
1.5 %
7%
23 %
3.8 %
0.8 %
6.9 %
0%
30 %
5.5 %
19 %
0.6 %
4%
18 %
1.7 %
0.6 %
3.8 %
% Improvement/
(Reduction)
21 %
28 %
17 %
60 %
43 %
22 %
55 %
25 %
44 %
Value
Financial Outcomes - (18 months)
•
•
•
•
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%
ProvenCareSM Portfolio
• ProvenCare:
– CABG
– Angioplasty
– Angioplasty + AMI
– Hip replacement
– Knee
– Cataract
– EPO
– Perinatal
– Bariatric surgery
Policy Implications
• Pay for acceptable outcomes only (Medicare)
– Achievable by:
• IDS
• Virtual IDS