ProvenCare

by Glenn D Steele

  What do these changes mean in the face of unchanging fundamentals in caregiving, payment for care, and our society’s continued expectation of improved health status? And who should be held responsible for its improvement? We believe that unlocking value by changing how care is provided and received remains the only serious way to improve access and quality while lowering cost. This is not easy to transact, but nevertheless is doable as we have seen with the ProvenCare innovations at Geisinger.

  The following chapters are designed to provide tangible, practical learnings, and four transformational themes underpin nearly all of the straightforward innovation road tests. The first and most basic transformation is our definition of an integrated health system. In a truly integrated health system, all employees—pharmacists, nurses, administrators, desk clerks, security guards, engineering, food services, employed and nonemployed associated physicians, specialists, subspecialists, PCPs, trainees, and even financial officers—know they are working together and are incentivized to ensure that everyone is focused on benefiting individual patients.

  During Dr. Steele’s tenure, it was with great pride, and some occasional anxiety, that job applicants were invited to randomly stop any Geisinger employee—pushing a food cart, providing security in the parking lot, or sitting behind a reception desk—and ask what it was like to work at Geisinger and what was the employee’s mission. Almost always, the answers to these questions from the frontline workers carried more weight than anything the CEO said about shared mission and staff morale. And the answers most often were about true integration; everyone involved understood how what they did made a difference in achieving optimal patient outcomes. Without this basic definition and understanding of integration, most so-called integrated delivery networks are really no more than financial contrivances to obtain better rates in the capital markets. Without true integration, none of the innovation road tests we describe here could have happened.

  Second and even more unique to the Geisinger concept of integration was the unusual structure where both the insurance company and all of the providers involved in caregiving ultimately are overseen by a single parent fiduciary. Numerous attempts to create new models of the Geisinger vertical integration, either real or virtual integration between payer and provider, have proliferated over the past decade. Hospital-centric integrated delivery networks have created new insurance companies. Large independent insurance companies have purchased doctor groups and even hospitals. Nonfiduciary partnering has been structured between large independent insurance payers and a variety of provider systems throughout the country. And of course, the whole concept of accountable care organizations is based on payer and provider working together to benefit their mutual constituency. How many of these actually will achieve higher quality outcome and lower cost is unknown, but the prognosis is not good when the main currency of interaction is simply a change in reimbursement incentives.

  True transformation in the Geisinger vertical integration represents a fundamental change in the relationship between payer and provider, sharing information as well as financial risk and, most important, sharing a joint mission to improve health outcomes for individual and populations of patients. Whether this new relationship can be scaled will definitely be affected by the radical change under way in our political environment. It remains to be seen exactly how and when this change will happen.

  At Geisinger, because of our unusual payer/provider structure and century-old culture, it really doesn’t matter which component of the system does better financially as long as patient outcomes improve and costs decrease. We have the ability to focus together on total cost of care, with access to healthcare delivery data as well as insurance claims data, because patients we care for also are, by and large, those we insure.

  A third critical transformation on the provider side of Geisinger was our concept of leadership. We assumed that the combination of a great clinician, great teacher, great administrator, great financial mind, and great innovator would be rare indeed in any single human being. Historically, the most important pillar of credibility at Geisinger always had been to be a great clinician, so that was our starting point. But we insisted that the great clinical leader be paired with a great administrative partner or partners. If the facility or service was large enough or critical to our clinical mission, we often added a financial expert to the leadership team. These leaders together were held responsible for strategic plans, operating budgets, performance metrics, and performance evaluations. Leadership partners also were celebrated together when success occurred. Clinical leaders either learned to share the spotlight or were replaced.

  We were trying to change behavior in all of our care reengineering processes. Doing a simple inventory of the details of each care process at the initiation of reengineering was eye-opening. During Dr. Steele’s three-day hospitalization for his heart surgery, 147 different individuals legitimately logged in to his electronic health record. The complexity of changing processes and behaviors among everyone involved in the care process was hard enough, but even more difficult was the subsequent transformation in the relationship between caregivers and patients. Fundamental to most of our innovation efforts was an attempt to create an active and much more symmetrical interaction between patient and provider, whether in the context of an acute care episode or when reengineering the management of chronic diseases.

  The progression from activated patients and more symmetrical interactions between caregivers and patients to Dr. Feinberg’s focus on achieving extreme patient satisfaction is natural. This is not just about the quality and temperature of the food provided in the hospital. It isn’t just about having aesthetically pleasing and functional facilities. And it’s not simply about giving patients exactly what they want even when that doesn’t make sense. It is about understanding that the ultimate choice in the patient/provider transaction is in fact the patient’s choice. Getting to an optimal outcome depends critically upon a unique blending of provider expertise and an activated, fully engaged patient who feels every interaction with Geisinger and our people is beneficial.

  Most recently, as mentioned earlier, the purchaser of care has been added to the traditional patient, provider, and payer triad. Not just the Medicare and Medicaid public payers, but also the self-insured employers who represent the buyer of healthcare for about 169 million U.S. workers and retirees2, are demanding better outcomes for their sponsored employees and are pushing their employees to better understand and choose real value in maintaining optimal health or getting better when they are sick.

  A fourth and final transformation underpinning the kind of continuous innovation that Geisinger is about is the need not only to create value from the care reengineering process (higher quality and lower cost) but also to ensure that the benefit is distributed to the patient, to the provider, and back to the purchaser. All of these stakeholders have to experience direct benefit from the value created. If there is no sustainable benefit (or sustainable business model in the case of the provider) plus some allowance for innovation failure, good intentions alone or an altruistic mission will not survive. Innovation stops if all of the value is perceived as going exclusively to one stakeholder in the system, such as the insurance company. And if the patient can’t feel a tangible benefit in service, decreased aggravation, and improved outcome, he or she will have no motivation to seek out value-based innovative systems. Instead, the patient will continue to demand access to the best-known brands, regardless of whether those brands have anything to do with higher quality at lower cost. Finally, for the purchaser who is footing a significant amount of the bill in either direct or indirect costs, recruiting and retaining the best and healthiest group of employees (and keeping them as healthy as possible) is an absolutely critical factor in staying competitive, particularly in an increasingly global market.

  So the fundamentals are exactly the same pre- and post-ACA. Higher quality at lower cost, plus access to health insurance, are critical and intersectin
g goals. And the transformational themes will continue to cut across all of the necessary innovations in which we take great pride at Geisinger.

  Going from innovation—even continuous innovation, which is hard enough to systematize—to scaling innovation is a huge leap. But scaling is what we need as a society, not just more boutique innovation efforts. What we’ve learned at Geisinger and at Geisinger’s scaling engine, xG Health Solutions, about the dynamics of scaling, the very different areas of expertise required, the differences in market forces between for-profit and nonprofit settings, and the importance of committed leadership in both the payer and provider components of the healthcare system could fill a book. But that would be the next book, not this one. What we attempt to do here is describe how we’ve innovated at Geisinger and our first scaling attempts outside of our system. We hope you will take what seems interesting and applicable to your own organization, modify it, customize it, even claim it as homegrown if necessary, and begin to see the value proposition work. We stand ready at Geisinger and at xG Health Solutions, should you need any help.

  ACKNOWLEDGMENTS

  Many people did the work we are summarizing in this book, but some deserve special mention. Most important were those who created the innovation infrastructure and those in the various clinical and health plan units that created the individual care reengineering examples detailed in these pages.

  The initial rebuilding of Geisinger’s physician leadership, the organization’s evolution from discipline-based to interdisciplinary service line-based caregiving, and the transformation from “piecework” payment for each unit of work (RVU-based compensation) to physician compensation based on strategic goal achievement began under the leadership of Dr. Bruce Hamory and Dr. Joseph Bisordi, and subsequently was supervised by successor chief medical officers Dr. Howard Grant, Dr. Albert Bothe, and Dr. Steven Strongwater. Interestingly, Dr. Bisordi became chief medical officer of Ochsner Health System, Dr. Grant became chief executive officer of Lahey Clinic, and Dr. Strongwater became CEO of Arius following their times at Geisinger.

  The establishment of our “Skunk Works” innovation group was initiated by Geisinger’s first chief of innovation, Dr. Ronald Paulus, who is now CEO of Mission Health in Asheville, North Carolina. His key recruits, Meg Horgan and Seth Frazier, helped expand the enabling capabilities of this nonclinical unit and helped create a separate transformation group committed to scaling innovation throughout all of the Geisinger clinical operations. Seth Frazier became a key principle of Evolent, an organization like our own xG Health Solutions committed to scaling the volume- to value-based healthcare transformation throughout the country.

  The innovation and transformation groups both reported to Joanne Wade, Geisinger’s first executive vice president for strategy. Joanne and Dr. Steele justified the resource commitments and the patient quality and value returns on those commitments to the management and compensation committee of the Geisinger Health System Foundation (now Geisinger Health Foundation) board of directors. Without this innovation and transformation infrastructure, none of the specific payer or provider side innovations would have occurred. Taking a chance on this investment before there was any substantive evidence of return, both in terms of benefit for patients and a viable business model, was a function of three key Geisinger board members: Frank Henry, our chairman at that time; William Alexander, then our finance committee chair; and Allen Deaver, management and compensation committee chair.

  As explained in the text, the key structural advantage for innovation to occur at Geisinger was the interaction between Geisinger insurance and Geisinger clinical care. The most important proof of this possible payer/provider synergy was led by Dr. Norman Payson. Although we only “rented” his expertise and credibility, the time he spent with us, as well as the ramifications of the new Medicare Advantage reimbursement rules in the 2003 Medicare Modernization Act (MMA) budget process, and the initiation of the Hierarchical Condition Categories (HCCs) all solidified the fundamentally positive interaction that began to occur between our payers and providers for the 50 percent of patients we both cared for and insured. An equally important contribution from Dr. Payson’s interim GHP leadership was our recruitment of his immediate successor, Dr. Richard Gilfillan, as the Geisinger Health Plan CEO. Dr. Gilfillan and Dr. Duane Davis, our insurance company chief medical officer, became the critical translators of what was known as the Geisinger payer/provider “sweet spot,” making the concept of payer and provider entities working together for the benefit of their mutual constituents real. Dr. Gilfillan subsequently became head of the innovation center (CMMI) at CMS and later CEO of Trinity Health. Dr. Davis became chief executive officer of the Geisinger insurance entities.

  Additional critical enablers of our acute and chronic care reengineering included Geisinger’s two IT leaders at the inception of ProvenCare, Dr. James Walker, chief medical information officer, and Frank Richards, chief information officer. Without these two visionaries, the embedding of our reengineering content into the Epic electronic health record system would not have happened, and routine care would not have changed without the embedding of the new care pathways. Jean Adams, Joan Topper, and Tammy Anderer were key translators of both the internal IT content embedding and our new outreach to many non-Geisinger, nonemployed provider partners in the innovation experiments. As senior leaders strategized, conceptualized, and articulated the need for fundamental change in employed and nonemployed provider behavior, they translated the necessary infrastructure modifications so caregivers could provide added value to their patients and our insurance company members. Karen McKinley, Scott Berry, Janet Tomcavage, and Dr. Thomas Graf were critical leaders in redesigning community practice and the interaction among our 55 community-based sites and the hospital-based specialists and subspecialists. Without these valuable, committed, and aspirational leaders and doers, none of the specific innovations would have happened.

  Based largely on the good clinical leadership of Dr. Al Casale, chief of cardiothoracic surgery and co-chair of the heart care service line, Dr. James Blankenship, chief of cardiology at Geisinger Medical Center, and Michael Doll, cardiothoracic surgery chief physician assistant, our first acute care episode reengineering—elective interventional heart care—assured the success of our original heart surgery “warranty” and significant internal and external affirmation. Extension of ProvenCare acute reengineering to other hospital-based interventions including hip and knee replacement and spine surgery has been led most recently by Dr. Michael Suk, chairman of the department of orthopaedic surgery, and Dr. Jonathan Slotkin, director of spinal surgery.

  The predicates for success of our commitment to bundled best practice in reengineering care for patients with prevalent chronic diseases should be credited to Dr. Steve Pierdon and Lee Myers, the “founders” of Community Practice Service Line (CPSL), Geisinger’s first and most innovative service line. This initial interdisciplinary approach to caregiving was subsequently expanded to 27 other service lines. Dr. Thomas Graf and Dr. Suzy Kobylinski followed Dr. Pierdon as CPSL leaders, ensuring the Geisinger patients first and continuous innovation commitments. Dr. Fred Bloom, now the chief medical officer at Guthrie Healthcare System headquartered in Sayre, Pennsylvania, was the key leader of much of our ProvenHealth Navigator medical home reengineering efforts, along with Janet Tomcavage and Dr. Duane Davis from Geisinger Health Plan. These leaders created a fundamentally different interaction among our caregivers largely located in the community sites, the hospital-based specialists and subspecialists, and our Geisinger insurance plan. Major leaders on the specialty side of these new relationships included Dr. Eric Newman, head of rheumatology and vice chairman of medicine; Dr. John Kennedy, head of endocrinology; Dr. Paul Kettlewell in child psychology; Dr. Edward Hartle, chairman of medicine; Dr. Jonathan Hosey and Dr. Steven Toms in the neurosciences; and Dr. David Franklin in surgery. Dr. Hosey, Dr. Toms, and Dr. Franklin have all assumed leadership positions at other academic or integrated del
ivery systems.

  Most recently, the extension of Geisinger reengineering to specialty drug purchasing and management has been led by Michael Evans, Deb Templeton, and Dr. Robert Weil. In addition, Dr. Ray Roth, who was the GHP chief medical officer at that time, was critical in partnering with Mike Evans and Janet Tomcavage in coordinating both the Geisinger insurance platform and the clinical enterprise in all of the organization’s drug purchasing and caregiving reengineering. Dr. Weil is now chief medical officer of Catholic Health Initiatives.

  Two individuals who were major contributors during Dr. Steele’s tenure as CEO and continue to be the key translators of Dr. Feinberg’s ProvenCare patient experience are Dr. Greg Burke, chief patient experience officer, and Susan Robel, executive vice president and system chief nursing officer.

  Most of the ongoing innovation at Geisinger and most of the bets on future innovation are under the direct supervision of Dr. David Ledbetter, Geisinger’s chief scientific officer; Dr. Alistair Erskine, chief informatics officer; and Dr. Greg Moore, who initiated the Institute for Advanced Application and is a senior leader at Google.

  The strategic goal of innovation was broadened during the last five years of Dr. Steele’s tenure at Geisinger to include scaling and generalizing both within Geisinger and outward into non-Geisinger systems and markets. It soon became clear that scaling was significantly more complicated than innovating, particularly when extrapolating from the ideal Geisinger culture, fiduciary structure, and market demography and penetration into more complex milieus. Dr. Earl Steinberg is Dr. Steele’s partner in founding and running our primary scaling engine, xG Health Solutions. xG would not exist without Dr. Steinberg’s vision and resilience, the confidence of the Geisinger board of directors, and the literal buy-in of our private equity partner, Annie Lamont of Oak Investments. Colleagues pirated from Geisinger to lead the xG efforts include Meg Horgan, Dr. Steven Pierdon, Dr. Ray Roth, Joanne Wade, and many individual Geisinger subject matter experts whose commitment to spreading the Geisinger model has led to significant successes in California, Delaware, rural Illinois, Maine, New Jersey, northern Virginia, Washington state, West Virginia, Wisconsin, and even Singapore, to name a few client locations.