Session #3
How Geisinger Uses Analytics to Improve Care
Glenn Steele, Jr., MD, PhD
President & CEO
Geisinger Health System
Healthcare Analytics Summit 2014
Salt Lake City, Utah
September 24, 2014
Glenn Steele, Jr., MD, PhD
President & CEO
Geisinger Health System
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Where We Are Now (Nationally)
• Unjustified variation in quality, access, and cost of care
• Unwarranted and fragmented care-giving
• An addiction to perverse payment incentives
– Piece rate Medicare/Medicaid payment model
 Driving up units of work
 Driving up cost
 Diminishing value and quality
• Transition to new payment incentives (predicated on
fundamentally new care delivery models)
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Where Do We Want to Be?
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Affordable coverage for all
Payment for value
Coordinated care
Continuous improvement/innovation
National health goals, leadership, accountability
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Geisinger Health System
An Integrated Health Service Organization
Managed
Care Companies
Provider
Facilities
 Geisinger Medical Center and its
Shamokin Hospital Campus
 Geisinger Wyoming Valley
Medical and its South WilkesBarre Campus
 Geisinger Community Medical
Center. Scranton, PA
 Geisinger-Bloomsburg Hospital
 Geisinger-Lewistown Hospital
 Marworth Alcohol & Chemical
Dependency Treatment Center
 2 Nursing Homes
 >87K admissions/OBS & SORUs
 1,761 licensed inpatient beds
Physician
Practice Group
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Multispecialty group
~1050 physician FTEs
~670 advanced practitioners
85 primary & specialty clinic
sites (52 community practice)
2 outpatient surgery centers
~2.5 million outpatient visits
~400 resident & fellow FTEs
~270 medical students
 ~468,000 members
(including ~80,000
Medicare Advantage
members and 124,000
Medicaid members)
 Diversified products
 ~37,000 contracted
providers/facilities
 43 PA counties
 Offered on public & private
exchanges
 Members in 5 states
Moody’s Aa2/Stable
Standard & Poor’s, AA/Stable
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Transforming Healthcare with Technology
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> $190 M invested (hardware, software, manpower, training)
Running costs: ~4.6% of annual revenue of > $3.6 Billion
Fully-integrated EHR: 52 community practice sites; 5 hospitals; 4 EDs; 4 Surgical Centers; 14
CareWorks retail-based and worksite clinics, walk-in clinics and after hours clinics
– Acute and chronic care management
– Optimized transitions of care
Networked Patient Portal - ~234,000 active users (40% of ongoing patients)
– Patient self-service (self-scheduling, patient-entered data)
– Home monitoring integrated with Medical Home
“Outreach Health IT” – 6,461 users in 812 non-Geisinger practices
– Remote support for regional ICUs
– Telestroke services to regional EDs
Active Regional Health-Information Exchange (KeyHIE)
– 19 hospitals, 100+ practices, 634,000 patients consented, publish 600,000+ documents
monthly, participants access 900+ patients monthly
e-health (eICU®) Programs
Keystone Beacon Community
– HIT-enabled, Community-wide care coordination in 5 rural counties
CDIS (Clinical Decision Intelligence System
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GHP: Data since 2006 and forward of 40 million Health Plan Medical Claims for about 1 million
members. The Health Plan has about 120 analytical users accessing the EDW
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6
Geisinger Health System Coverage Area
7
The Geisinger “Sweet Spot”
Geisinger
Clinical
Enterprise
Population Health
Innovation
Geisinger
Health Plan
to reduce total
cost of care
Data Driven Care Redesign
• Systems of Care
• Bundles
• Transitions of Care
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Strategic Priorities
Quality and Innovation
• Patient Centered Focus
– Patient activation (empowerment)
– Culture of quality, safety and health
• Value Re-Engineering
Market Leadership
• Extending the GHS Brand
• Scaling and Generalizing Innovation
The Geisinger Family
• Personal and professional well being
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THE GEISINGER VALUE
RE-ENGINEERING “TOUCHSTONES”
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State of the Evidence…
Volume 348(26) 26 June 2003
pp 2635-2645
The Quality of Health Care Delivered To Adults In the United States
McGlynn, Elizabeth A.: Asch, Steven M.: Adams, John: Jeesey, Joan: Hicks, Jennifer:
DeCristofaro, Alison: Kerr, Eve A.
BACKGROUND
We have little systematic information about the extent to which standard processes involved in healthcare—a
key element of quality—are delivered in the United States.
METHODS
We telephoned a random sample of adults living in 12 metropolitan areas in the United States and…received
written consent to copy their medical records…to evaluate performance on 439 indicators of quality of care
for 30 acute and chronic conditions as well as preventative care…
RESULTS
Participants received 54.9 percent of recommended care.
CONCLUSIONS
The deficits we have identified in adherence to recommended processes for basic care pose serious threats
to the health of the American public. Strategies to reduce these deficits are warranted.
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Cost/Quality “Correlation”
MD Quality Index
(outcomes or % adherence to EBM)
Lower
Higher
50th %ile
Low Efficiency
High Quality
High Efficiency
High Quality
(Dream Suppliers)
50th %ile
Low Efficiency
Low Quality
(Nightmare
Suppliers)
Lower Efficiency/
Higher Cost
High Efficiency
Low Quality
Higher Efficiency/
Lower Cost
MD Longitudinal Cost Efficiency Index
(total cost per case mix-adjusted treatment episode)
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Adapted
from Regence Blue Shield;NotArnie
Milstein, MD - Mercer
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Cost = Quality
2006-2010
GHS Innovations
Cost/Quality ≠ R
2003
Cost or Quality
1993-1994
Hillary-Care ‘Debate’
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Geisinger Transformation Initiatives
• ProvenCare® for Acute Episodic Care
(the “Warranty”)
• ProvenCare® Chronic Disease
• ProvenHealth Navigator® (Advanced Medical
Home)
• Transitions of Care
• PRIDE (Proven Innovation Drive for Excellence)
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ProvenCare® for Acute Episodic Care
ProvenCare®
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Identify high-volume DRGs
Determine best practice techniques
Deliver evidence-based care
GHP pays global fee
No additional payment for complications
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Current as of 4/9/13
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ProvenCare® CABG
Clinical Outcomes: Pre vs. Post ProvenCare® protocols
Before
ProvenCare®
After
ProvenCare®
N = 132
N = 715
In-hospital mortality
1.5 %
0.5%
67 %
Patients with any complication
(STS)
38 %
34%
11 %
Atrial fibrillation
24 %
20%
17 %
Permanent stroke
1.5 %
1.3%
13 %
Prolonged ventilation
5.3 %
4.9%
8%
Re-intubation
2.3 %
1.0%
57 %
Intra-op blood products used
24 %
12 %
50 %
Re-operation for bleeding
3.8 %
2.4%
37 %
Deep sternal wound infection
0.8 %
0.18%
78 %
Post-op mean LOS
5.2 d
5.0d
4%
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%
Improvement
ProvenCare® CABG:
Reliability & Financial Outcomes
Reliability:
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40 best practice elements x 715 patients = 28,600 opportunities
37 missed best practice elements in 24 patients
37 / 28,080 = 0.13% elements missed
(715-24) / 715 = 96.6% of all patients had ALL elements delivered
Financial Outcomes – Hospital:
• Contribution margin increased 17.6%
• Total inpatient profit per case improved $1946
Financial Outcomes – Health Plan:
®
• Paid out 4.8% less per case for CAB with ProvenCare than it
would have without
• Paid out 28 to 36% less for CAB with GHS than with other
providers
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ProvenCare® CAB V2.0
 42 ACC / AHA 2011 Class I and IIIh guidelines
 25 additional Geisinger consensus-based
guidelines
 67 Total guidelines adopted and translated into
120 best practices
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ProvenCare® Acute Episodic Bundles
Thoracic
Lung
Perinatal
CAB
and PCI
• Clinical Best Practices
• Workflow Process
Redesign
Bariatric
Surgery
• Convener for CMMI
Bundling Initiative
(17 organizations)
Heart Failure
• Corporate Destination
Medicine Option
Lumbar
Spine
Knee
Arthroscopy
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COPD
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Hip: Fragility
Fracture or
Arthroscopy
20
Company’s New “Centers of Excellence” Program is First-of-its Kind
Partnering with Six of the Nation’s Foremost Health Care Systems to
Provide Better Care
We devoted extensive time developing Centers of Excellence in order to
improve the quality of care our associates’ receive. We have identified six
renowned health systems that meet the highest quality standards for
heart, spine and transplant surgery. Through these organizations, our
associates will have no out-of-pocket expenses and a greater peace of mind
knowing they are receiving exceptional care from a facility that
specializes in the procedure they require. This is the first time a retailer
has offered a comprehensive, nationwide program for heart, spine and
transplant surgery.”
~ Sally Welborn, senior vice president of global benefits at Walmart
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Poll Question #1
The most important lever to drive default best
practice is:
a)
b)
c)
d)
e)
Real-time data feedback
A change in provider “sociology”
Different payment incentives
Two of the above
All of the above
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ProvenCare® CHRONIC DISEASE
Portfolio of ProvenCare®
Chronic Disease Programs
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Diabetes
Congestive Heart Failure
Coronary Artery Disease
Hypertension
COPD
Prevention Bundle
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Value Driven Care for 28,355 Patients with Diabetes
3/06
3/07
6/14
Diabetes Bundle Percentage
2.4%
7.2%
14.4%
% Influenza Vaccination
57%
73%
74%
% Pneumococcal Vaccination
59%
83%
79%
% Microalbumin Result
58%
87%
78%
% HgbA1c at Goal
33%
37%
47%
% LDL at Goal
50%
52%
60%
% BP < 140/80
39%
44%
66%
74%
84%
85%
% Documented Non-Smokers
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Transforming the Management of Diabetes
3 Year Results in 25,000 DM Patients
305 MI’s
Prevented
140 Strokes
Prevented
NNT
to prevent 1
MI
NNT
to prevent 1
Stroke
82 patients
170 patients
Primary Care Diabetes Bundle Management: Three-Year Outcomes for Microvascular
and Macrovascular Events (in press) FBloom; TGraf; WStewart; GSteele, et. al. (in press)
166 Cases of
Retinopathy
Prevented
NNT
to prevent 1
Retinopathy
152 patients
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Improving CAD Care for 17,965 Patients
9/06
3/07
6/14
8%
11%
26%
% LDL <100 or <70 if High Risk
38%
37%
63%
% ACE/ARB in LVSD,DM, HTN
65%
66%
78%
% BMI measured
79%
86%
99%
% BP < 140/90
74%
74%
80%
% Antiplatelet Therapy
89%
91%
95%
% Beta Blocker use S/P MI
97%
97%
97%
% Documented Non-Smokers
86%
86%
86%
% Pneumococcal Vaccination
80%
80%
79%
% Influenza Vaccination
60%
74%
76%
CAD Bundle Percentage
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Improving Preventive Care for 251,385 Patients
11/07
11/12
6/14
Adult Preventive Bundle
9.2%
33%
19%
Breast Cancer Screening (q 2 yrs 50-74) (discuss q 2 yrs 40-49)
46%
64%
72%
Cervical Cancer Screening (q 3 yr Age 21-29) (q 5 yr Age 30-64)
64%
68%
74%
Colon Cancer Screening (Colonoscopy q 10 yrs Age 50-74 or FOBT
yearly)
44%
67%
65%
Prostate Cancer Discussion (Age 50-74)
72%
76%
55%
Lipid Screening (Every 5 yr M > 35, F > 45)
75%
88%
86%
Diabetes Screening (Every 3 yr > 45)
85%
91%
90%
Obesity Screening (BMI in Epic)
77%
98%
98%
Documented Non-Smokers
75%
79%
79%
Tetanus Diphtheria Immunization (every 10 yr)
35%
75%
76%
Pneumococcal Immunization (Once Age >65)
84%
86%
83%
Influenza Immunization (Yearly Age >18)
**Change in age from Age>50 to Age>18 February 2013
47%
59%
46%
Chlamydia Screening (Yearly Age 18-25)
22%
35%
40%
Osteoporosis Screening (every 7 yr Age >65)
52%
70%
76%
Alcohol Intake Assessment
84%
95%
97%
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Zoster
Vaccine
>60)2014
**New Measure February
2013
Copyright
Geisinger(Age
Health System
39%
ProvenHealth Navigator®
Innovations in Management of Elderly
• “SNFist” model in targeted
nursing homes
• Focused on transitions of care
and length of stay
• Redesigned care model
• Smartly utilizing information
technologies
• Reduced
– Admits/1000
– Readmissions/1000
– ER Visits/1000
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ProvenHealth Navigator® Results
 Advanced Medical Home deployed in 42 Geisinger and
49 non-Geisinger sites
 Patients say case managers improved quality: 72%
Admissions
(27.5%)
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Readmits
(34.0%)
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Real Time Population Management
ProvenHealth Navigator® Reduces Cost Trend
0%
95% Confidence Interval
-2%
-4%
-6%
Median Estimate
-8%
-10%
Median Estimate
• ROI
all years
95%for
Confidence
Interval
2007-2010, with Rx
coverage = 1.7
Q3 2009
Q1 2009
Q3 2008
Q1 2008
Q3 2007
Q1 2007
Q3 2006
Q1 2006
Q3 2005
95% Confidence Interval
Q1 2005
-12%
• Medical expense
trend reduced by
7.1%,
p<.01 Interval
95%
Confidence
Cumulative percent difference in spending (Pre-Rx Allowed PMPM $) attributable to PHN in
the first 21 PHN clinics for calendar years 2005-2009. Dotted lines represent 95%
confidence interval. P = < 0.003
Source: Reducing Long-Term Cost by Transforming Primary
Care: Evidence From Geisinger's Medical Home Model
(Am J Manag Care. 2012;18(3):149-155)
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Partial and Incremental PCMH Practice Transformation:
Implications for Quality and Costs
Michael L. Paustian, Jeffrey A. Alexander, Darline K. El Reda,
Chris G. Wise, Lee A. Green, and Michael D. Fetters
Conclusions. Estimated effects of the PCMH model on quality and
cost of care appear to improve with the degree of PCMH
implementation achieved and with incremental
improvements in implementation.
PCMHs in Michigan saved $26.37 PMPM comparing those with full
implementation of model vs. no implementation, 7.7% savings. Also
improved adult quality and adult preventive care. Very consistent with
Geisinger results.
© Health Research and Educational Trust
DOI: 10.1111/1475-6773.12085
RESEARCHARTICLE
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Poll Question #2
Integrated care for a population of patients
has been accomplished:
a) Only in vertically integrated payerprovider systems
b) With CMS via ACO’s
c) By partnering with commercial payers
d) In none of the above
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TRANSFORMING HEALTHCARE
WITH TECHNOLOGY
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Reengineering Primary & Specialty Care
• ProvenHealth Navigator®
– Advanced Medical Home covers 91sites, serving 151,00 GHP lives
and 45,000+ FFS Medicare lives
– SNFist model expands to 17 nursing homes
– Outcomes: reduced readmissions and improved care coordination,
similar cost curve bending at GHS and University of Michigan
• PCP & specialists coordinated patient management
– CKD/ESRD high risk management and psychiatric care management
– Neurology/Dermatology/Endocrine/Cardiology/Autism
• Convenient Care redesign of primary
care/emergency medicine
– 12 urgent care/after hours care sites
(and growing rapidly)
– Coordinated low cost alternative to ED
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Patient Activation: “Open Notes” –
A Transparency and Patient Engagement Pilot
• Expanded in 2013 to 1,100+ Geisinger providers &170,000 patients
• Launched in 2010, a 12-month trial of 105 PCPs inviting 19,000
patients to review notes through secure electronic portals
(BI Deaconess, Geisinger, Harborview)
• Geisinger participation: 24 PCPs, 8,700 patients
• Results from first year:
– Over 80% of patients opened their notes
– Majority of patients reported feeling more in control, better
prepared for visits and more likely to take medications as
prescribed
– 99% of patients and more than
80% of physicians wanted to continue
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Innovations in Personalized Medicine
• Bio-banking expanding with unique partnerships to advance
genomic medicine (strategic partnership with Regeneron
commencing)
• Clinical data warehouse grows
• Data analytics deployed to identify care gaps, permitting
clinical intervention
• Focused population health research initiatives
– Obesity
– Autism and developmental medicine
• Institute for Advanced Application created
to advance clinical innovation and
reengineering of care
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Scaling and Generalizing – Experiments
(Geisinger Health System / Geisinger Insurance Operations / xG Health)
GHS:
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Wilkes-Barre
Scranton
Shamokin
Lewistown
Bloomsburg
Harrisburg
Atlantic City
GIO:
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Medicaid MCO
HIX*
New Jersey
Delaware
Maine
West Virginia
• 41 Clients
*Health Insurance Exchange
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From Fee-for-Service
to
Total Cost of Care
(
Residual “Piece Rate”)
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Enabling Behavior Change:
 Providers
 Patients
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Poll Question #3
Payment for health care services in your system
is:
a) Exclusively Fee-for-Service
b) Mainly Fee-For-Service but some population
risk (upside only)
c) Mainly Fee-For-Service but some population
risk (upside & downside)
d) Fee-For-Service now but you’re worried about
a move to population risk in the near future
e) Unsure or not applicable
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