PRAISE FOR
Proven Care
and Glenn Steele and David Feinberg
“In rural Pennsylvania, an extraordinarily innovative model for the future of the U.S. healthcare system has emerged. In ProvenCare, leaders Glenn Steele and David Feinberg give us the compelling inside story of how they built it and what it will take for the rest of us to do so, too.”
—Atul Gawande, MD, MPH
Samuel O. Thier Professor of Surgery, Harvard Medical School;
and New York Times bestselling author of Being Mortal
“Using vivid stories, its visionary leaders Glenn Steele and David Feinberg show us how Geisinger became a national leader in delivering high value care—care so consistently good it is called ‘ProvenCare,’ which comes with a warranty and even refunds if patients are dissatisfied. More important, other healthcare systems can implement the Geisinger formula and achieve the same successful transformation.”
—Ezekiel J. Emanuel, MD, PhD
Vice Provost of Global Initiatives; Chair, Department of Medical Ethics and Health Policy; and Levy University Professor, University of Pennsylvania
“For more than a decade, Geisinger has been showing U.S. healthcare what ‘social capital’ can mean—the improvements that are possible when clinicians work together in real teams, when ‘performance’ is clearly defined, and when insurance and provider functions are integrated. Geisinger’s innovations and effectiveness were led first by Glenn Steele, and more recently by David Feinberg—two of the best CEOs in modern healthcare. ProvenCare represents their playbook, and a road map for other organizations to follow their lead.”
—Thomas H. Lee, MD
Chief Medical Officer, Press Ganey; and author of An Epidemic of Empathy in Healthcare
“Our health system must achieve better care, better health, lower costs, and the best possible patient experience through innovation and spreading proven results. Drs. Steele and Feinberg eloquently describe the Geisinger journey, and the story serves as a guiding light for everyone in our health system who wants to achieve better results. The book should be read by everyone who is focused on health system transformation, improvement, caring for patients, and innovation.”
—Patrick Conway, MD, MSc
Deputy Administrator for Innovation and Quality and Director, Center for Medicare and Medicaid Innovation, CMS*
“A must-read for anyone interested in understanding how changing the way care is provided can unlock value in healthcare. Written by the former and current CEOs of Geisinger, it is a readable explanation of the importance of clinical leadership and integrated health systems in creating value. The discussion and experience with ProvenCare will be especially helpful to clinicians, while the financial outcomes of ProvenCare will capture the attention of system CFOs.”
—Gail Wilensky, PhD
Economist and Senior Fellow, Project HOPE
“An aging population with multiple chronic conditions, coupled with increased consumerism as patients become more involved in their healthcare decision making, means hospitals and health systems are examining their care processes as they grapple with these new challenges. David and Glenn provide a how-to manual on improving access to care and the quality of care, while lowering costs, in their extraordinary new book. Their fresh approach is based on their leadership of one of the country’s leading health systems. A must-read for everyone interested in advancing health in America.”
—Rick Pollack
President and CEO, American Hospital Association
“Great leaders, to paraphrase Napoleon, must define reality and then give hope. ProvenCare accomplishes both of these objectives, and provides a road map for improving healthcare outcomes that is fact-based, and battle-tested. This is fundamentally a story about leading change in the very complex field of healthcare. The results achieved within the Geisinger system are inspirational, compelling, and relevant.”
—L. Kevin Cox
Chairman, Health Transformation Alliance; and CHRO, American Express Company
“ProvenCare explores common myths about healthcare in America, and exposes the fallacy that more care is better, along with the tragedy of how many in our country are underserved by our medical system. Glenn Steele and David Feinberg argue that the patient must always come first, and demonstrate that it is through coordination and collaboration, as well as a singular focus on outcomes, that we can improve care while lowering costs. This excellent book is both an exposé and personal guide that provides powerful support for the collaborative and evidenced-based approach to practicing medicine championed by Geisinger, an approach that is leading the way in the transformation in American healthcare.”
—Ann Lamont
Managing Partner, Oak Investment Partners
“ProvenCare beautifully illustrates how, together, Dr. Steele, Dr. Feinberg, and Geisinger have created proven strategies that balance innovative, integrated technologies with high-touch personal care. ProvenCare, where care and caring go hand in hand, is a model for the future that can be implemented today. PeaceHealth looks forward to adopting Geisinger’s approach to care delivery to further our own patient-centric focus on transforming the health and well-being of our patients and communities.”
—Liz Dunne
President and CEO, PeaceHealth
“Drs. Steele and Feinberg provide a rare blend of visionary thinking and practical and tactical acumen. Our cooperative of America’s leading self-insured health plans benefits immensely from Dr. Steele’s leadership. This book is focused on our transformational mission, but also zooms in on the healthcare problems of today and offers solutions to them.”
—Rob Andrews
CEO, Health Transformation Alliance
“Grounded within the context of our rapidly changing healthcare landscape, Drs. Feinberg and Steele offer a thought-provoking look at Geisinger’s pioneering approach to reengineer care management and improve health outcomes for patients. The lessons learned from Geisinger’s innovations to truly integrate care offer new insights to help tackle the fundamental challenges of access, quality, and cost in healthcare that have remained with us for decades.”
—Sheila Burke, RN, MPA, FAAN
Senior Public Advisor, Baker, Donelson, Bearman, Caldwell & Berkowitz; and Adjunct Lecturer in Public Policy, Harvard University
“Regardless of what happens in Congress or state legislatures, the healthcare industry is in the throes of massive transformation. For leaders of health systems, as well as clinicians trying to lead successful transformation, ProvenCare is a terrific playbook that shares the insights and passion of Drs. Steele and Feinberg, who have positioned Geisinger as a role model for what is needed in American healthcare. The book is full of insights into the who, what, when, why, and how of this transformation. It is not a coincidence that many Geisinger leaders have moved on to have significant impact at many prominent healthcare organizations, and now xG Health Solutions, the Geisinger spin-off, is assisting others. Follow the journey and use the insights gained to help accelerate the transformation taking place across this industry.”
—Lee B. Sacks, MD
EVP and Chief Medical Officer, Advocate Health Care
“Dr. Glenn Steele and Dr. David Feinberg, well known for their creativity and leadership in helping to solve the complexities of providing value and quality in healthcare, have provided valuable insights into the success of Geisinger as a delivery model for today and tomorrow. Beyond telling the story of the success and creation of the care model with thought and creativity, the lessons learned can be adapted not only to larger systems but also to our struggling rural hospitals. Refreshingly straightforward and practical.”
—Lou Hochheiser, MD
Professor Emeritus, University of Verm
ont; and former CEO, St. John’s Medical Center
“Steele and Feinberg have given us a timely and inspiring procedural on how to improve clinical outcomes and patient satisfaction and reduce the cost of healthcare. ProvenCare is a must-read for anyone who desires to fix our broken health system.”
—George F. Lynn
President Emeritus, AtlantiCare; and former Chairman, American Hospital Association
*The quote represents Dr. Conway’s personal views and not necessarily the views or policies of the Centers for Medicare and Medicaid Services.
Copyright © 2018 by Geisinger Health Foundation. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a data base or retrieval system, without the prior written permission of the publisher.
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To all our Geisinger patients and insurance members,
it is our privilege to care for you.
And to everyone in the Geisinger family who
works daily to care for the people we serve.
CONTENTS
PREFACE
ACKNOWLEDGMENTS
1 Why Geisinger?
2 The Problem
3 The Fix
4 Effective Governance
5 Getting Started
6 Enabling Change
7 ProvenCare Acute: Taking It to the Next Step
8 ProvenCare Chronic
9 ProvenHealth Navigator: Geisinger’s Advanced Medical Home
10 Leading and Managing a Successful Practice Transformation
11 ProvenCare Biologics
12 ProvenExperience
13 Future Vision
NOTES
INDEX
PREFACE
The fundamental challenges in healthcare have not changed significantly in the nearly five decades of our involvement in health system leadership. Access, quality, and cost have always represented the underlying combination of intersecting and sometimes conflicting goals.
During President Lyndon B. Johnson’s Great Society and the inception of the public payer with the introduction of Medicare and Medicaid in the 1960s, the focus was solely on ensuring adequate access for the elderly and poor citizens who could not then afford available insurance either on their own or through their employers. Interestingly, the opening lines of the Medicare law asserted that the new entitlement would not in any way influence how medicine should be practiced. Through the “Hillary care” debates in the 1990s and into the new millennium, it became obvious to the entire nation and even more so at the individual state budget level that increased access to care without formal expectation of better outcome would drive societal cost to unsustainable and uncompetitive levels.
Amazingly, state and federal regulations continued to demand unfettered fee-for-service reimbursement, as it was felt to be critical to maintain the sacrosanct relationship between patients and providers. Implicit in all of this was the fantasy that all doctors were practicing optimal caregiving and all hospitals were uniformly motivated to do what was right for patients, not what was most convenient and financially beneficial for the hospitals themselves.
Inevitably, the percentage of U.S. gross domestic product (GDP) spent on healthcare grew into double digits and is now approaching 20 percent. And as the public payer has expanded to represent more than 60 percent of the provider payment mix, the question of what everyone is getting for their money has become as important, if not more so than access. The original Dartmouth College studies in the 1970s through the 1990s first reported there was no apparent relationship between cost of care and short- or long-term quality outcomes. Most notable was a region-to-region variation in frequency and cost of most diagnostic and therapeutic interventions.1
At Geisinger and other innovative integrated systems, particularly those with insurance and provider components in the same fiduciary structure committed to working together to analyze total cost of care for their mutually shared populations, a relationship between cost of care and quality outcome was established. The link at first, though, seemed counterintuitive. Almost always, the highest-cost patients were those with the least acceptable short- and long-term health outcomes. In a very important way, this inverse relationship helped those of us who were leading the transformation to high-quality, low-cost care to establish a rationale to fundamentally reengineer hospital and ambulatory care to achieve better outcomes for patients and not focus primarily on extracting cost. If unnecessary or hurtful care was removed, a better outcome would result.
Healthcare professionals are motivated to do things differently by knowing that the changes are better for patients—not merely saving money for the insurance company, hospital, or purchaser. So much the better if the reengineering results in increased quality with lower cost as a side effect. That’s a double value win. And since professional pride of purpose is what truly motivates the needed behavior change, it was key that the rationale for change focused on patients achieving better outcomes.
All of this created a natural progression in the discussion of how expanding Medicare and Medicaid could influence the access, quality, and cost triangle. Then came the turbulence of our society
’s attempt to provide insurance for a majority of the 45 million Americans who were uninsured prior to the inception of the 2010 Patient Protection and Affordable Care Act (ACA). Although the primary intention of Obamacare was to decrease dramatically the number of uninsured, there were many incentives to move the provider system as quickly as possible away from what was acknowledged as the key promoter of unhelpful or hurtful costs: fee-for-service reimbursement.
The two main components of the soon-to-be 20 percent U.S. GDP commitment to healthcare spending were higher prices compared to any other developed country in the world and a dominant fee-for-service payment incentive. This incentive based financial success on number of units of work performed, adding irrational momentum to producing more and more units, regardless of whether those units of work helped patients. If pressure successfully pushed down the price per unit, the rational response of any successful provider system would be to produce more units, whether or not that work helped to achieve better patient outcomes.
Depending on political point of view, one could argue whether ACA/Obamacare achieved even its primary goal, but it definitely altered the unsustainable trajectory of significantly rising medical utilization and expenditure. And whatever comes next post-ACA will have to address the same fundamental interplay of access, quality, and cost. Nothing has changed in these fundamentals, and we believe that nothing has diminished the value of the lessons learned at Geisinger summarized in this book. As turbulence in the public payer undoubtedly will increase with the Trump administration’s commitment to repeal the ACA, we believe financial pressure will increase on providers facing an uptick of uninsured patients for whom they still are obligated to provide care. Cost shifting will not be the usual easy way out, as commercial payers increase their leverage through continued consolidation. Even the large self-insured employers are banding together—for example, the Health Transformation Alliance and Pacific Business Group on Health—to begin to define high-performing provider networks or centers of excellence to transact value-based healthcare for their employees. Quite simply, these big companies do not want to be the last standing redistribution engines providing caregivers high margins as all the other payers squeeze down.
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