geisinger health system: a model for aco implementation distribution o… · ·...

Geisinger Health System: A Model for ACO Implementation

A i C ll f M di l Q lit N ti l C fAmerican College of Medical Quality National Conference February 18, 2011

Glenn Steele Jr MD PhDGlenn Steele Jr., MD, PhDPresident and CEO

Geisinger Health System

Heal • Teach • Discover • Serve Copyright Geisinger Health System 2011 Not for reuse or distribution without permission

Medical Quality 2011 – Faculty Disclosure - No relevant financial relationships to disclose

Where We Are Now (N ti ll )(Nationally)

Heal • Teach • Discover • Serve

International Comparison of Spending on Health, 1980-2007Total expenditures on health

7000 United States

Average spending on healthper capita ($US PPP)

16

Total expenditures on healthas percent of GDP

$7,290 16%

5000

6000

CanadaNetherlandsGermanyAustralia

12

14

4000

5000United KingdomNew Zealand

8

10

8%

2000

3000

4

6 United StatesGermanyCanadaNetherlands

$2,454

0

1000

1980 1984 1988 1992 1996 2000 20040

2

1980 1984 1988 1992 1996 2000 2004

New ZealandAustraliaUnited Kingdom

Note: $US PPP = purchasing power parity.Source: Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).

1980 1984 1988 1992 1996 2000 2004 1980 1984 1988 1992 1996 2000 2004

Total National Health Expenditures (NHE), 2009–2019Before and After Reform

NHE in trillions

$4.5

$5.0Before Reform*

Aft R f

NHE in trillions

$4.3

6.3% annual growth

$4.6

$3 0

$3.5

$4.0After Reform $4.3

5.7% annual growth

$2.0

$2.5

$3.0

$2.5

$1.0

$1.5

$ 0

$0.0

$0.5

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019Notes: * Estimate of pre-reform national health spending when corrected to reflect underutilization of services by previously uninsured. Source: D. M. Cutler, K. Davis, and K. Stremikis, The Impact of Health Reform on Health System Spending, (Washington and New York: Center for American Progress and The Commonwealth Fund, May 2010).

Where Is the U.S. on Health IT?Only 46% of U.S. primary care physicians have electronic medical records (EMRs),

and only 26% have advanced IT capacityand only 26% have advanced IT capacity

Percent reporting nine or moreof 14 IT functions*Percent reporting EMR

99 97 97 96 95 94 94

72 68

100 92 91 89100

72 68

463750

75 6654 49

3650

75

37

25

3626

19 15 1425

0NET NZ NOR UK AUS ITA SWE GER FR US CAN

0NZ AUS UK ITA NET SWE GER US NOR FR CAN

* Count of 14 functions includes: electronic medical record; electronic prescribing and ordering of tests; electronic access test results, Rx alerts, clinical notes; computerized system for tracking lab tests, guidelines, alerts to provide patients with test results, preventive/follow-up care reminders; and computerized list of patients by diagnosis, medications, due for tests or preventive care.Source: Commonwealth Fund 2009 International Health Policy Survey of Primary Care Physicians.

The Cost Shift (“Cross Subsidy”)

200%

125%

150%

175%

131%130%

154%

75%

100%

125%

78%

119%130%

121% 118%

25%

50%

75%

21%

33%37%

M di id

14%

32%45%37% 34%

A EDB COth

48%

0%

Percentage of Net Revenue to Total Cost by Payor

Medicare MedicaidA EDB COther FFS


20102010 MIDMID--TERM ELECTIONSTERM ELECTIONSQuestion: And Now What?Question: And Now What?Question: And Now What?Question: And Now What?

AAccessDemand Perverse incentives still in play

“Piece rate” Medicare/Medicaid payment

units of workcost costvalue

Plus new incentives!!

Plus new incentives!!

Heal • Teach • Discover • ServeCopyright Geisinger Health System 2011

Consolidation of insurance companiesConsolidation of hospitals

Integrated Delivery SystemsAccountable Care Organizations


Where Do We Want to Be?Where Do We Want to Be?

1 Affordable coverage for all1. Affordable coverage for all2. Payment for value3 Coordinated care3. Coordinated care4. Continuous improvement/innovation5 National health goals leadership accountability5. National health goals, leadership, accountability

The Path to a High Performance US Health System “A 2020 Vision and the Policies to Pave the


g yWay”, pg. 16-21, The Commonwealth Fund

How Do We Get FromHow Do We Get FromWhere We Are

To Where We Want To Be?


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:McGlynn, Elizabeth A.: Asch, Steven M.: Adams, John: Jeesey, Joan: Hicks, Jennifer:DeCristofaro, Alison: Kerr, Eve A.

BACKGROUNDWe have little systematic information about the extent to which standard processes involved in healthcare—a key element of quality are delivered in the United Stateskey element of quality—are delivered in the United States.METHODSWe 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…RESULTSParticipants received 54.9 percent of recommended care. CONCLUSIONSThe 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.


12

p g

Cost/Quality “Correlation”

H h EffLow Efficiency

50th %ile

x ce to

EB

M) High Efficiency

High Quality(Dream Suppliers)

High Quality

Hig

her

L Effi iQua

lity

Inde

x%

adh

eren

c

50th %ile

Low EfficiencyLow Quality(Nightmare Suppliers)

MD

Qtc

omes

or %

High EfficiencyLow Quality

wer pp )

(out

Low Quality

Lo

w

Lower Efficiency/ Higher Efficiency/


Adapted from Regence Blue Shield; Arnie Milstein, MD - Mercer

MD Longitudinal Cost Efficiency Index(total cost per case mix-adjusted treatment episode)

yHigher Cost

g yLower Cost

Cost = Quality 2006-20102006 2010

GHS Innovations

Cost/Quality ≠ RQ y2003

Cost or Quality1993-1994

Hillary Care ‘Debate’


Hillary-Care ‘Debate’

The Legacy

“Make my hospital rightMake my hospital right,make it the best.”

Abigail Geisinger1827-19211827 1921


“Geisinger Quality – Striving for Perfection”…2006 - 2011

Geisinger Health SystemAn Integrated Health Service OrganizationAn Integrated Health Service Organization

ProviderFacilities

Ph i i

Managed CareCompanies

Physician Practice Group

• Geisinger Medical Center - Hospital for Advanced Medicine & the

Janet Weis Women’s & Children’s • ~250,000 members

• Multispecialty group• ~860 physicians• ~460 advanced practitioners

62 i d i lt

Janet Weis Women s & Children sHospital, Level I & II Trauma Center

• Geisinger Northeast (2 campuses)- Geisinger Wyoming Valley Medical

Center with Heart Hospital, HenryCancer Center, Level II Trauma Center

(incl. ~49,000 Medicare Adv.)• Diversified products• >25,000 contracted physicians/ facilities (including 110 non-Geisinger hospitals)

• ~62 primary and specialty clinic sites (37 community practice sites)

• 1 Outpatient surgery center • >2.0m clinic outpatient visits

,- Adult & Pediatric Urgent Care

• Marworth Alcohol & Chemical Dependency Treatment Center

• 2 Ambulatory surgery centers• >48K admissions/OBS & SORU

• 42 PA counties


• ~350 residents and fellows• ~820 licensed in-patient beds

Geisinger Health SystemGeisinger Health System

Last updated 12/16/10

Careworks Convenient Healthcare

Non‐Geisinger Physicians With EHR

Geisinger ProvenHealth Navigator SitesContracted ProvenHealth Navigator SitesGeisinger Medical GroupsGeisinger Specialty Clinics

Geisinger Inpatient FacilitiesAmbulatory Care Facility Geisinger Health System Hub and Spoke Market AreaGeisinger Health Plan Service Area

Electronic Health Record (EHR)• > $130M invested (hardware, software, manpower, training)• Running costs: ~4.4% of annual revenue of > $2.3B• Fully-integrated EHR: 37 community practice sites; 2 hospitals; 2 EDs;

6 Careworks retail-based and worksite clinics6 Careworks retail-based and worksite clinics– Acute and chronic care management– Optimized transitions of care

• Networked PHR - ~155,000 active users (33% of ongoing patients)– Patient self-service (self-scheduling, kiosks)– Home monitoring integrated with Medical Home

• “Outreach Health IT” - 2,600 non-Geisinger physician usersRemote support for regional ICUs– Remote support for regional ICUs

– Telestroke services to regional EDs• Active Regional Health-Information Exchange (KeyHIE)

– 11 hospitals, 90+ practices, 400,000 patients consented• e-health (eICU®) Programs• Keystone Beacon Community

– HIT-enabled, Community-wide care coordination in 5 rural countiesGHS a arded “Most Wired” health care s stem b Comp ter World eight


• GHS awarded “Most Wired” health care system by Computer World eight years running; Dr. Steele awarded HIT CEO of the year, 2006

The Vision

• Quality

The Vision

Quality• Innovation• Market ExpansionMarket Expansion Scale and Generalize Innovation

• LegacyLegacy Personal and Professional Well-being


Targets for Geisinger InnovationTargets for Geisinger Innovation

Unjustified variation• Unjustified variation• Fragmentation of care-giving• Perverse payment incentives• Perverse payment incentives

– Units of workOutcome irrelevant– Outcome irrelevant

• Patient as passive recipient of care


Innovation InitiativesInnovation Initiatives

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

• ProvenCare® Chronic DiseaseProvenCare Chronic Disease • ProvenHealth NavigatorSM (Advanced

Medical Home))• Transitions of Care• GAPP (Geisinger Accelerated PerformanceGAPP (Geisinger Accelerated Performance

Program)


The Geisinger AdvantageThe Geisinger Advantage

• Our professional staff, patients and partners• Our market• Vision and leadership• Operational success and professional integration• Enterprise-wide clinical decision support (via the

EHR)EHR)• Accountability, transparency, incentives – all

alignedaligned• Our insurance/provider “Sweet Spot”


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


ProvenCare® for Acute Episodic CareProvenCare® for Acute Episodic Care

P C ®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 OutcomesyBefore

ProvenCare® ProvenCare® % Improvement(n=132) (n=321)(n 132) (n 321)

In-hospital mortality 1.5 % 0.3 % 80 %Patients with any complication (STS) 38 % 33 % 13 %P ti t ith >1 li ti 8 4 % 5 9 % 30 %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 %y p y pRe-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 %Deep sternal wound infection 0.8 % 0.3 % 63 %Readmission within 30 days 6.9 % 5.6 % 20 %


ProvenCare® CABG

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Not for reuse or distribution without permissionGeisinger Health System Confidential and Proprietary


Not for reuse or distribution without permissionGeisinger Health System Confidential and Proprietary

Heal • Teach • Discover • Serve 26

F De F De F De F De F

ProvenCare® CABG: Financial Outcomes

Hospital:• Contribution margin increased 17.6%• Total inpatient profit per case improved $1946

Health Plan:P id t 4 8% l f CAB ith• 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• Paid out 28 to 36% less for CAB with GHS than with other providers


Not Just SurgeryVirtual Care Models: Epo Managementp g

Epo CKD (n=241)* Control (n=74)**Median days to goal = 35 days Median days to goal = 62.5 daysMedian days to goal 35 days Median days to goal 62.5 days

% Time below goal = 11.6%% Time in goal = 62.7%% Time above goal = 25.6%

% Time below goal = 39.7%% Time in goal = 43.9%% Time above goal = 16.4%

Avg Epo Units/week = 4,400*** Avg Epo Units/week = 12,000

Home/Clinic = 82%/18% Home/Clinic = 39.2%/60.8%

Expanded Dose Utilization = 74% Expanded Dose Utilization = 16%

Avg Hgb at start = 10.4 mg/dl Avg Hgb at start = 10.0 mg/dlg g g g g g

Avg T-Sat at start = 27% Avg T-Sat at start = 18%

***Savings $2,200/pt/year @ASP+6% (After management fee accounted for. Does not take into account benefit of decreased clinic administration cost)account benefit of decreased clinic administration cost)

*VITALine results (as of 12/1/10), Hgb range 10-12 **Bucaloiu et. al, Managed Care Interface, June 2007. Hgb target range 11-13 at this time

ProvenCare® PortfolioProvenCare®:

– CABG– PCI (Percutaneous Coronary

Interventions Angioplasty/Angioplasty + AMI)Angioplasty/Angioplasty + AMI)

– Hip replacement– CataractCataract– EPO– Perinatal– Bariatric surgery– Low back


– Lung cancer

ProvenCare® - Chronic Disease


Chronic Disease PortfolioChronic Disease Portfolio

Diabetes• Diabetes• Congestive Heart Failure

C A t Di• Coronary Artery Disease• Hypertension• Prevention Bundle


Improving Diabetes Care for 24,402 Patients

3/06 3/07 10/09 10/10

Diabetes Bundle Percentage 2.4% 7.2% 12.9% 11.8%

% Influenza Vaccination 57% 73% 72% 74%

% Pneumococcal Vaccination 59% 83% 84% 84%

% Microalbumin Result 58% 87% 79% 78%

% HgbA1c at Goal 33% 37% 45% 50%% LDL at Goal 50% 52% 62% 55%*

% BP < 130/80 39% 44% 52% 53%% BP < 130/80 39% 44% 52% 53%

% Documented Non-Smokers 74% 84% 85% 85%


*Measure change resulted in a 9% decrease February 2010

Cumulative Hazard Function for Macro-Vascular and Micro-Vascular Disease Micro-vascular (Retinopathy and Amputation)

Cumulative Hazard Function for Macro-Vascular and Micro-Vascular Disease Macro-vascular outcomes (MI and Stroke)

Improving CAD Care for 15,268 Patients9/06 3/07 10/09 10/10

CAD Bundle Percentage 8% 11% 20% 22%

% LDL <100 or <70 if High Risk 38% 37% 48% 51%

% ACE/ARB in LVSD,DM, HTN 65% 66% 75% 74%

% BMI measured 79% 86% 99% 99%

% BP < 140/90 74% 74% 79% 79%

% Antiplatelet Therapy 89% 91% 92% 92%

% Beta Blocker use S/P MI 97% 97% 97% 96%

% D t d N S k 86% 86% 87% 87%% Documented Non-Smokers 86% 86% 87% 87%

% Pneumococcal Vaccination 80% 80% 86% 86%




Improving Preventive Care for 213,561 Patients11/07 10/10

Adult Preventive Bundle 9.2% 28%Breast Cancer Screening (q 2 40-49, q 1 50-74) 46% 61%Breast Cancer Screening (q 2 40 49, q 1 50 74) 46% 61%Cervical Cancer Screening (q 3 yr Age 21-64) 64% 73%Colon Cancer Screening (Age 50-84) 44% 64%Prostate Cancer Disc ssion (Age 50 74) 72% 76%Prostate Cancer Discussion (Age 50-74) 72% 76%Lipid Screening (Every 5 yr M > 35, F > 45) 75% 85%Diabetes Screening (Every 3 yr > 45) 85% 88%Obesity Screening (BMI in Epic) 77% 96%Documented Non-Smokers 75% 78%Tetanus Diphtheria Immunization (every 10 yr) 35% 69%p ( y y )Pneumococcal Immunization (Once Age >65) 84% 87%Influenza Immunization (Yearly Age >50) 47% 57%Chlamydia Screening (Yearly Age 18 25) 22% 34%Chlamydia Screening (Yearly Age 18-25) 22% 34%Osteoporosis Screening (every 3 yr Age > 65) 52% 73%Alcohol Intake Assessment 84% 89%

Ongoing IssuesOngoing Issues

• Benefit to patients?• More individualized targets?• Smaller cohorts?• Specialist / PCP interactions


ProvenHealth NavigatorSM

(Ad d M di l H )(Advanced Medical Home)



(Advanced Medical Home)

• Partnership between primary care physicians and• 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• 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)


A Health Insurer Pays More to SaveBy Reed Abelson


August 2010


E i i 2007Expansion since 2007

SitesMA

membersCommercialMembers

Medicare members TotalSites members Members members

Phase 1 3 3,100 800 2,000

7,800

Phase 2

Phase 3

10 7,300 8,50011,000

12 4,600 7,000

5,300

3,000

12 4,300 7,100

7 1,700 5,400

Phase 4

Phase 5

Total 44* 21,000 28,800 29,100 78,900


* 37 Geisinger primary care practices & 7 non‐Geisinger primary care practices


(Ad d M di l H )(Advanced Medical Home)

Currently serves 50 000 Medicare recipients and• Currently serves 50,000 Medicare recipients and ~29,000 commercial patients

• Results from best primary care sites:Results from best primary care sites:– 25% patients’ admissions– 23% days/100023% days/1000– 53% readmissions following discharge– Significant benefit to patients and families, S g ca be e o pa e s a d a es,

avoiding multiple hospital admissions


Cumulative percent difference in spending attributable to PHN

0%

-2%

0%

-6%

-4%

95% Confidence Interval

Median Estimate

-10%

-8%95% Confidence Interval

-12%

10%

2005

2005

2006

2006

2007

2007

2008

2008

2009

2009

Q1

2

Q3

2

Q1

2

Q3

2

Q1

2

Q3

2

Q1

2

Q3

2

Q1

2

Q3

2

Cumulative percent difference in spending (Pre‐Rx Allowed PMPM $) attributable toCumulative 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

Ongoing IssuesOngoing Issues

• Scalability?• Generalizability?• Specialist / PCP interactions


PGP Demo Quality Payments(O ll B fit t M di )(Overall Benefits to Medicare)

Geisinger Results:Geisinger Results: Year 4 Shared Savings– $1.8 Million earned ($1.3 Million paid after holdback)

• $900 Thousand based on Quality• $900 Thousand based on Efficiency

Q ( Q )Physician Quality Reporting Initiative (PQRI)– 100% of earnings based on PGP quality score– $1 1 Million– $1.1 Million

Physician Group Practice Demonstration Performance Year 4 Quality Measures Results


Performance Year 4 Quality Measures ResultsAugust 20, 2010 – RTI International

Transitions of Care


Transitions of Care• Began January 2008 as joint quality/efficiency initiative

that complements ProvenHealth NavigatorSM

(Ad d M di l H )(Advanced Medical Home)• Inpatient and outpatient interventions

– Eliminate unnecessary admissionsEliminate unnecessary admissions– Reduce preventable readmissions

• Free up capacity for more acutely-ill patients• Focused on risk stratification, team communication,

and post discharge communication and follow-up• Program expansion is planned to look at targeted• Program expansion is planned to look at targeted

DRGs (CHF, AMI and Pneumonia)• Modeling and predictive instruments used


Fundamental Innovation at GeisingerH d Wh ?

Anatomy

How and Why?

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)

El t i bl 43 ti


• Electronic enabler across 43 counties

Fundamental Innovation at GeisingerH d Wh ?

Financial Health

How and Why?

Financial Health• Balance sheet• Operating margin• “Hedging” strategy• Planned risk taking

Sociology• IHS culture• Clinical leadership (insurance and provider)• Patient centric design

Th “ d” l


• The “common good” goal

All of the above “permissive” but not enough

Clinical leadership Pride of purpose OverarchingPride of purposeProfessionalism


Question: And Now What? Question: And Now What? A R i i C !A R i i C !Answer: Reengineering Care!Answer: Reengineering Care!


More value for patients!More value for patients!


Or

"Price controls!!"


Caveats I

For all of the InnovationsCost in hospital Hospital volumeTotal cost of care

New relationship to payerp p yor

New payment incentivesor

Backfilled volume with new payer mix


Caveats II

• Scalable?• Applicable to non-Integrated Delivery Systems?• Applicable in absence of real-time EHR?pp• Applicable in fee-for-service settings?• Pending wider use in marketplacePending wider use in marketplace


Scalability Experiments

• PGP ACO

y p

• “Turbo TPA” (Third Party Administrator)

• Geisinger Innovation EnginePlus ACO’s GHS, Jefferson University Health, et. al

P i ACO C ll b ti Premier ACO Collaborative National Collaboration

– Dartmouth et alDartmouth, et. al Geisinger Consulting

• ACS Commission on Cancer Collaboration


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