ProvenCare
Page 9
A second engine for scaling and generalizing ProvenCare was our intentional expansion of Geisinger insurance into Delaware, Maine, New Jersey, and West Virginia, with no intention of any Geisinger provider overlapping expansion. In most of these new insurance markets, working with non-Geisinger delivery systems was enabled by partnering the insurance products with our third scaling engine, the xG Health Solutions consulting group, which was created in 2013 as a for-profit spin-off.
The first evidence of scaling success was with one organization in Virginia and another located in rural Illinois and Wisconsin. These partnerships occurred even before we formalized xG as a for-profit Geisinger spin-off and were instructive in both positive and negative ways. Significant results in redesigning hospital-based care, changing the fundamental doctor-hospital leadership relationship, and decreasing hospitalization needs by improving ambulatory care for patients with multiple chronic diseases were accomplished almost as quickly in the non-Geisinger markets with non-Geisinger providers as they had been accomplished at Geisinger.
This proved to be the case for each of our subsequent experiments in exporting ProvenCare. In the joint Geisinger Health Plan and xG ventures in Delaware, Maine, and West Virginia, quality and cost benefits in managing hospital-associated and chronic disease patient populations became obvious after one year. (See Figures 6.1 and 6.2.)
FIGURE 6.1 Significant Reduction in Utilization at Client A
FIGURE 6.2 Significant Reduction in Utilization at Client B
But limits to the sustainability of the reengineering also were evident after several years. First was the effect of leadership change. Regardless of whether a strong leader left when a system was in disarray or handed over an intact system with a strong operational trajectory, our successful joint experiment would wither quickly if good hospital margins were dependent on fee-for-service and if the leader’s successor was not committed strategically to fundamentally transforming how care should be financed. If the hospital-centric CFO saw a volume decrease because the organization was taking better care of patients with multiple chronic diseases, unit prices would rise precipitously. Second, if the dominant payer was in a position to threaten the fee-for-service reimbursement to our provider partner if the Geisinger beta test continued or, even worse, expanded, most system leaders would cave, and we were quickly dismissed. Most important, though, we learned that our costly infrastructure used to initiate and enable our initial innovation engine did not need to be reproduced in our forays into these non-Geisinger markets.
xG HEALTH SOLUTIONS
As word of our ProvenCare success spread throughout the healthcare industry and the country, many leaders from integrated delivery networks and organizations that wanted to become integrated delivery networks visited Danville to discover firsthand the Geisinger approach to innovation. The number of visit requests became so great that we initiated quarterly innovation conferences where we explained the Geisinger innovation portfolio and its key infrastructure. Attendees were impressed with our structure, culture, innovations, and sustainability; however, they often felt what they learned at Geisinger could not be replicated in their particular organization or geography.1
We pushed back with those visitors who believed our innovations could not be exported outside of Geisinger. As healthcare in the United States entered a period of unprecedented turmoil and opportunity, particularly with the ACA, many policy makers and integrated provider system leaders came to believe the Geisinger model and innovation accomplishments were well positioned for the move from volume- to value-based reimbursement. To us, the situation provided an attractive business opportunity to assist providers who wanted to operate successfully in a value-based payment environment. We determined we could export the following:
• Customization of the Geisinger electronic health record
• Bolt-on or embedded software programs to enhance primary care and subspecialty work flow in clinical decision support
• Data warehouse updating in near real time from both the electronic health record and claims data
• Extensive data analytic algorithms to enable change in managing individual patients and populations
• Evidence and consensus-based care pathways integrated into clinical work flows
• Multidisciplinary clinical service lines with leadership teams to ensure how care should be given
• Fundamental change to ensure caregivers all operate at the top of their license
• Care management partnering between our payer and provider components targeted to patients and issues that yield the greatest benefit (for example, concierge care for the sickest patients)
• A curriculum and incentive system affirming and promoting continuous care innovation2
Rather than assign responsibility for scaling to our leadership team’s already long list of responsibilities, we decided to recruit new team members devoted specifically to this effort and to position them in a new entity that could control its own resources rather than compete with other parts of Geisinger. And while launching an entity to help other healthcare delivery systems improve their performance was similar to our not-for-profit mission, the goal of creating a meaningful financial return to Geisinger through this endeavor could best be realized through the creation of a for-profit entity, particularly if we partnered with a credible and repeatedly successful private equity co-investor. We also felt it would be easier and require less investment to recruit and maintain the caliber of talent required for a new entrepreneurial venture to be successful if the venture was a for-profit entity in which employees could be incented primarily through equity self-interest.3
While the Geisinger board agreed to invest the required capital, we looked for an outside partner to affirm our business model, bring market-based discipline, add significant subject matter expertise and market networking, and increase the likelihood of success while at the same time reducing Geisinger’s financial risk. Through a process assisted by JP Morgan, which had been Geisinger’s banker for more than 30 years, Oak Investment Partners became co-investor and xG Health Solutions was launched in 2013 as an independent, for-profit company. Although the Geisinger board understood it could not possibly know what intellectual property the health system would produce over the next decade, it also recognized there would be substantial cost related to finding potential commercialization partners and negotiating and renegotiating license agreements if it decided to license each intellectual property separately. We agreed to a perpetual license agreement, allowing xG Health to retain its rights over the long term even if it was acquired by another entity, and with a noncompete provision to ensure that Geisinger would present a single face to the marketplace for selling its innovations outside of its traditional service area. In addition, the license was exclusive for a specified period of time and reciprocal—xG Health Solutions licensed to Geisinger any derivative work and new intellectual property that xG Health acquired or developed. Governance and management structures have ensured a close working relationship between xG Health and Geisinger, and the product portfolio has been sharpened over the past three years. xG Health’s client base has been broadened to include significant distribution channel opportunities by embedding content into high-market-share electronic health records, becoming the design architect of a new cooperative of 40 self-insured companies intent on working together to purchase value-based healthcare for their employees, and continuing to accrue provider clients.4
LESSONS LEARNED
• Assigning responsibility for strategy is key to attaining an important strategic destination.
• Making space and resources available for innovation as a nonoperating unit is important to start the process.
• Pairing great clinical leaders with administrative and/or financial coleaders creates an accountable team.
• The enabling structure varies over time and should become less costly.
7
ProvenCare Acute: Taking It to the Next Step
Annual wellness exams and cardiac stress tests were all normal, but Dr. Steele saw his general internist and a cardiologist after noting a significant change in his resting pulse rate. Nothing else—no pain, no change in exercise tolerance—just a pulse rate of 85 when it previously had been 60. In retrospect, there were some brief unexplained episodes of shortness of breath, as well as some decrease in speed and intensity when skiing during the past few years.
Dr. Steele’s coronary angiogram showed occlusions not easily corrected by angioplasty or stent placement. Shopping for the desired opinion and a less invasive approach would have been possible, but the combination of internist and cardiologist opinion and Internet literature search all pointed to the preferred therapeutic approach, open heart surgery.
As a physician and healthcare leader, Dr. Steele had extensive access to publicly available and private data on cardiac surgery outcomes at all the best places and on the world’s best cardiac surgeons. He was well known enough that he would have been treated as a VIP (not necessarily a good thing in getting the best care) no matter where he decided to have his care.
Why did he choose to stay in his own system? With comparable individual outcome numbers for the best institutions and the best individual practitioners, what differentiated one institution from another in this superb group? It was how explicit the system was in ensuring that it actually functioned as a system.
What was the evidence, from the time of diagnosis through rehabilitation and into secondary prevention of an ongoing chronic disease, that everyone involved was incentivized, enabled, and motivated to work together to achieve an optimal outcome? What was the evidence that the system not only was committed to but actually had achieved continuous improvement, not just in the setting of a formalized, randomized clinical trial but all the time? What was the evidence that the fundamentally asymmetric relationship between caregiver and patient had begun to change to achieve a true therapeutic partnership, so that even if a bad outcome occurred, the patient would understand that both partners had worked together to minimize the chances of complication and, in the case of Geisinger’s ProvenCare, that the caregiver would fix the problem at no extra charge?
All of these components critical to achieving the highest probability of best outcome were built into Geisinger’s design and transaction of ProvenCare. The ProvenCare method is a structured approach to provide quality care at a reduced price for acute hospital-based surgical procedures and for select chronic diseases managed in an ambulatory setting. ProvenCare incorporates current evidence-based best practice elements into the work flow to reduce unwarranted variation in indications for a test or procedure and in the delivery of care processes. The goal is to extract the 35 to 40 percent of services and costs that do not produce benefit or may actually harm those served.
Return on investment in ProvenCare includes (1) improved clinical outcomes; (2) increased efficiency in resource use and patient throughput; (3) reduced total cost of care; (4) enhanced patient and provider satisfaction; and (5) program differentiation. We assumed that doing this care design reengineering would give us a market share advantage because of the unlocked value produced.
GETTING STARTED
To establish a baseline before care reengineering, the easiest way to learn how much unjustified variation is built into any routine caregiving is to ask a simple question at a key site of care. For hospitalized patient interventions, the recovery room is one of the most critical sites. Determinants of good outcome following most major surgeries are prevention of infection and blood clots that migrate from the leg veins to the lungs.
To determine the degree of care variation following surgery, ask the recovery nurse, “What’s the antibiotic protocol being used? Or what’s the blood-clot prevention protocol?” If the nurse asks you to wait a moment to check who the patient’s doctor is, that is all you need to know! This is straightforward confirmation of no consensus driving best practice and of continued “seat of the pants” non-evidence-based healthcare delivery. Providing care is similar to every other complicated task in life; the more unjustified variation is involved in the process, the more cost will be incurred and the higher the probability of a bad outcome.
Consider the following attributes of typical acute care in America today:
• Uncertain appropriateness
• Limited patient engagement
• Unreliable compliance with evidence-based guidelines
• Lack of accountability for outcomes and quality
• Incomplete communication across the continuum of care
• À la carte payment for services
• Perverse incentive with more payment for more complications
• Stunning geographic disparities in frequency of care
• Widely variable outcomes not explained by severity stratification
• Often an inverse relationship between quality of care and cost of care
Compare this to the attributes of a high-performance health system, where U.S. healthcare desires to be:
• Designed to achieve high-quality, safe care
• Access to care for all people
• Efficient, high-value care
• Capacity to continuously improve
How do we get from where we are to where we want to be? The following classic approaches are no longer reasonable or effective: overdependence on diligence and hard work; benchmarking to the mean (which ensures mediocrity); permissive clinical autonomy; and inadequate use of human factors knowledge in reliability science (understanding human error).
ProvenCare is a formalized process initiated to document appropriateness of care; establish evidence- or consensus-based best practices for all high-frequency services; reliably deliver default best practices by redesign of complex clinical systems that embeds new behaviors into everyday patient flow; activate patients and their families and engage them in the care processes as symmetrical partners with caregivers; and provide a packaged price for the episode of care, including a so-called “warranty” that transfers the risk for the financial effects of preventable complications to the caregiver.
There are six core components to our ProvenCare Acute program (reengineering of hospital-based or hospital-associated episodes of care): (1) documenting the appropriateness of care; (2) establishing all key elements of evidence-based or consensus-based best practices; (3) socializing and making routine the complex clinical systems that embed default best practices into new provider behaviors for everyday patient flow (the new care processes must be easier than what’s being replaced); and (4) activating patients and families so they are fully engaged in the care process redesign and implementation (caregivers and patients working together to achieve optimal outcomes). The last of the ProvenCare components comprise the product packaging: (5) negotiating a single bundled price for the entire episode of care with the payer or the actual buyer of the care, in the context of an employer self-insured buyer; and (6) transferring risk for the financial effects of preventable complications to the provider and to the health system via the bundled payment.
There are seven stages in the implementation of ProvenCare Acute:
1. Start-up
2. Literature review, best practice elements identification
4. Process redesign and electronic health record (EHR) tool development
5. Database and report build
6. Soft go-live
7. Go-live
Best practice elements are derived from evidence-based literature or from the consensus of the in-house multidisciplinary team. A given best practice is included only if there is 100 percent provider agreement to include it. At any time, a member of the multidisciplinary team can request changes in the best practice elements.
Performance measure sets embedded into the team’s work flow, through the EHR or bolt-on EHR applications, and all-or-none compliance for each patient is monitored in real time. For example, the appropriate antibiotics begun at the appropriate time preoperatively and stopped at the appropriate time postoperatively.
The structure of the team is critical to socializing the behavior change, and the weekly time commitment for the various team members must be made explicit for the reengineering to succeed. Consider the weekly time commitment various team members must make for the reengineering to succeed. (See Figure 7.1.)
FIGURE 7.1 Reengineering Implementation Time Commitments
It’s important to understand operational complexity in the current care pathway before redesigning the process. Two preexisting beliefs represent the most frequent objections to change. The first is, “We do not have unjustified variation here. Our providers are driven by common goals and shared value systems, and we come to consensus on a regular basis.” The second is, “We already have informally established our best practice consensus, and we are certain it is uniformly applied by our superbly trained, highly productive specialists, hence our good outcomes.”