glenn steele, md, phd, president and ceo, geisinger - hcma

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


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



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


• > $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)


• Geisinger Quality

• Innovation

• Market Expansion

• Securing the Legacy

*Predicated on maintaining healthy operations

The Vision


“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

• ProvenHealth NavigatorSM (Advanced Medical Home)

• Transitions of Care


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”


ProvenCare® for Acute Episodic Care (the “Warranty”)


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


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 %


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


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


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


ProvenCare® Portfolio

ProvenCare®:

– CABG– PCI (Percutaneous Coronary Interventions

Angioplasty/Angioplasty + AMI)

– Hip replacement– Cataract– EPO– Perinatal– Bariatric surgery– Low back– Lung cancer


ProvenHealth NavigatorSM

(Advanced Medical Home)


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)


Phase - 1 Total Medical Cost Decreased 4% for Entire Population; ROI = 250%


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


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


Transitions of Care


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


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


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?


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?


All of the above

“permissive” but not enough

Clinical leadership

Pride of purpose

ProfessionalismOverarching


Caveats

• Scalable?

• Applicable to non-IDS?

• Applicable in absence of real-time EHR?

• Applicable in fee-for-service settings?

• Pending wider use in marketplace


““Reengineering Care”Reengineering Care”Necessary and compelling; no matter Necessary and compelling; no matter

what happens in Washington!what happens in Washington!

glenn steele, md, phd, president and ceo, geisinger - hcma

Documents

geisinger clinic

geisinger experience

geisinger advantage

nongeisinger hospitals

ceo geisinger health

acute episodic care

passive recipient of

integrated ehr