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Future Vision
The 16-year-old soccer player collapsed on the field from apparent dehydration and was brought to one of our emergency departments. While receiving fluids, she agreed to participate in our genomic sequencing study, and we found gene profiles associated with young athletes dying during practice. Collapsing during exercise was probably the first sign of her deadly condition.
Follow-up with 30 family members revealed that her uncle died at age 20, ostensibly from choking, but now more likely from a heart attack. Subsequent testing revealed several who needed a drug regime or pacemaker and a half dozen additional relatives who would be closely monitored.
This striking case represents the future of care and caring at Geisinger and emphasizes the excellence of our overarching value-reengineering path: using data, identifying the best practice pathways, and engaging the patient in the process. Thanks to our longstanding commitment to research and the MyCode® community health initiative, patients are volunteering to have their blood and saliva samples stored in our system-wide biobank and studied. Our ultimate goal is to find ways to make healthcare better, as we fortunately did for the young soccer player and her family. In this respect and many others, the future is now at Geisinger.
IT’S ALL ABOUT CARING
While research and technology continue to advance medical science, in some ways healthcare as an industry has become deficient in caring. Healthcare professionals overwhelmingly enter the field because they want to help patients, but for a variety of reasons this hallmark of interacting with patients and their loved ones falls short. So while we are in the business of caring, we often miss the mark, which marks us for disruption. Someone else will come up with a better way if we don’t take charge of it ourselves. Recall what happened to the railroad, print publishing, photography, and video rental industries. We’ve long been known for being ahead of the curve at Geisinger, as early adopters of the electronic health record (EHR), through our various ProvenCare innovations and chronic disease management, and with our vision and progress toward precision medicine based on solid medical research. It’s the same with our commitment to making sure that, even with all of these advances, our foundation always will be built on doing what is right and best for our patients and doing so in a caring, compassionate manner. Our reengineering efforts always have focused on higher quality at lower cost, and we define lower cost not just as less expensive care but as less aggravation to patients and their families.
It’s not caring, though, when we make patients wait, speak in a language they don’t understand, or provide services that aren’t necessary and, in fact, may be harmful. Caring must go beyond meeting the accepted standards of care, and our caring imperative is a logical extension and growth of our desire to continually make things better for the people we serve. To return to caring, healthcare requires radical change, and once again Geisinger intends to be the model. But we aren’t going to be satisfied with being the best in healthcare; our goal is to be the most caring organization anywhere. It is through striving to be a model for others that we can elevate our caring to new heights.
Let’s put this caring imperative in context with where healthcare now is nationally and where we want it to be. Despite good progress, there still is considerable unjustified variation in quality, access, and cost in healthcare today. There continues to be unwarranted and fragmented caregiving and an addiction to perverse payment incentives that not only encourage but reward units of work, or volume, rather than better care and improved outcomes, or value.
It isn’t caring when we put 35 to 40 percent of our patients through procedures or treatments that are unnecessary and perhaps detrimental, especially when we know that the high cost associated with this unnecessary care almost always represents a quantitative surrogate for poor quality. It isn’t caring when we are inconsistent in providing best practice care to everyone. And it certainly isn’t caring when patients experience higher costs because their providers focus on volume, not value. With the implementation of the Affordable Care Act (ACA) and ongoing post-ACA turbulence, we need to remember why we are in healthcare in the first place—to care for others—and increase our energy, commitment, and hard work toward our ultimate aspiration of where healthcare should be in this country. To be truly caring, healthcare must quickly evolve and be characterized by:
• Affordable coverage for all
• Payment for value
• Coordinated care
• Continuous improvement and innovation
• Empowered patients who take an active role in their good health
• National health goals, leadership, and accountability
• Professional, compassionate service every time for every patient
We have been and remain active at Geisinger in defining this new post-ACA environment and anticipating a huge number of the changes that must occur in hospital-associated care reengineering with our various ProvenCare, ProvenHealth Navigator, and ProvenExperience innovations. Reengineering care has two outcomes that are absolutely essential for us to move healthcare in the United States forward. The first is a focus on improving quality outcomes for patients and their families and the other, almost always correlated, is a decrease in cost.
Further, we have chosen to take as much of our intellectual property as possible into scaling and generalizing experiments that include our own expansion into new markets, our insurance operations expansion into other states with non-Geisinger providers in other non-Geisinger markets, and the founding and nurturing of xG Health Solutions, which is committed to spreading as much of the Geisinger innovations as possible to as many organizations on both the payer and provider side of healthcare as we can.
PATIENTS, PROVIDERS, PAYERS, AND PURCHASERS
What we’re doing at Geisinger and the aftermath of the ACA affect the four major “Ps” in healthcare: patients, providers, payers, and purchasers. The influx of 20 million more Americans with access to healthcare through the increased availability of Medicaid, and the new rules regarding who can provide that care, place added pressure on the structures and business models of providers, payers, purchasers, and all other stakeholders involved in creating various products and services. As Medicaid and Medicare expand, the only reasonable solution for both the federal and state governments’ portion of the cost is to continue the move away from fee for service and toward expansion of Medicaid managed care organizations. The Health Care Payment Learning and Action Network has produced a series of white papers with implementation suggestions regarding how to fundamentally change the behaviors of the four Ps and shares a commitment for Medicare to move to 50 percent non-fee-for-service payment by 2018 and 80 percent non-fee-for-service by 2020.1
Medicare conversion to population-based payment and managed care will extract cost only if the relationship between the payer and provider is fundamentally changed to decrease price per unit and remove unnecessary care. If this is not done, the combination of increased access to care through expanded insurance and the increased ability to give great care using great new drugs and devices will quickly bankrupt not just the healthcare system, but the entire country. There continues to be much pressure on the federal health insurance exchange and speculation that the ACA will be repealed. If that occurs, it likely will be replaced ultimately by some type of expanded public plan (something like Medicare for all) that would probably put even more pressure on healthcare organizations to adopt a reengineering of care approach and a fundamentally different relationship between payer and provider.
Continued mergers and acquisitions activity is likely among the payers and providers, with the justification of providing higher quality at lower cost. But until payment incentives are changed to move away from fee for service, such volume-driven activity will continue and even increase, at least in the short term.
With greater regulatory and other cost pressures, small practices won’t be able to afford to stay in business and will disappear. Providers will adjust and respond appropriately to whatever the payment incentives are, but in every scenario the key is to extract unnecessary or hurtful care and cost in a way that Geisinger has modeled for the past 20 years.
Caring has been at the center of all our reengineering and innovation and will be more important than ever, given fundamental change in the relationship between doctors and their colleagues taking care of patients together and also in the doctor-patient relationship. Patients will be much more equal in relationships with providers and will be more accountable for long-term outcomes. A major responsibility in these relationships will be effective communication with patients and their families about important healthcare outcomes. Providers always hear about the temperature of the food and the cleanliness and quietness of the hospital room, and these concerns must be addressed. But patients must also be more educated about and involved with their actual care. With their increased knowledge and active participation, earning patient satisfaction will be more demanding than ever before.
There will be winners and losers in this healthcare industry evolution. The winners will be those payers and providers who work together to obtain the best outcomes for their mutual constituencies, keeping members and patients so healthy that they need less acute care and less hospitalization and experience less aggravation. Purchasers also will initiate a transformed partnership with selected providers who commit to working continuously with large employers to achieve significantly improved outcomes for employees. Businesses that partner with entities such as the Health Transformation Alliance or the Pacific Business Group on Health to work with payers, providers, device makers, pharmaceutical companies, and intermediaries to keep employees healthier will have a significant competitive advantage. Healthcare costs represent about a third of total compensation expenses for businesses, and the amount of revenue required to accommodate such expense is considerable, especially when those resources could be used for innovation. The winners will be able to approach healthcare in a way that benefits employees and their health status to help offset this huge indirect cost.
The fundamental issues always center on behavior change, and the behaviors of patients, providers, payers, and purchasers will be changing over the next decade. It is imperative to understand and respond effectively to patient and family satisfaction, and success will depend on effectively communicating how working together can create better health for our society.
PREVENTATIVE CARING
Healthcare has a unique opportunity to make things better for populations of people, for example, those with similar health challenges, those in a specific industry, and the members of a community. One way Geisinger plans to return to caring is by taking exceptional care of the communities we serve through prevention. There are many illnesses, demographic challenges, and lifestyle choices causing tremendous suffering across our nation. But healthcare systems often are designed around conditions hospitals can make money on, such as chemotherapy and heart and brain surgery. Essentially, this outdated medicine capitalizes on the old pay-for-volume model by identifying certain illnesses and procedures that pay better than others and doing plenty of them. Advances in these areas are miraculous, but they don’t take care of large populations and aren’t focused on preventing illness.
Geisinger, like other health systems, has a long history of collaborating with other organizations to complete regular community health needs assessments, and we are committed to taking this effort even further and truly focusing on prevention. With that in mind, we will assess the health needs in all the communities we serve to determine whom we’re caring for and how needs differ by geography. The priority might be obesity in one area, lack of immunization in another, and opioid addiction in a third, or, more likely, a combination of conditions and challenges.
In the current payment system, these are losers. No one is advertising about them. This is a different mindset from our outdated sickness care system. The old way is neither preventative nor patient-focused, and it’s wasteful. For example, no one ever advertises to the elderly American male on Medicaid who has congestive heart failure, diabetes, and moderate alcohol use. He is challenging to treat and providers aren’t paid well to do so, but if he represents our community, we have an obligation to find him and care for him in a way that is culturally sensitive, compassionate, private, and connected. Much of our ProvenCare innovations are designed to support payment for value rather than volume, which improves care for such patients and rewards providers appropriately.
UNBELIEVABLE ACCESS
With millions of additional Americans getting health insurance, and the aging of the baby boom generation, demand will continue to challenge healthcare organizations throughout the country. All providers need to commit to providing unprecedented access. Despite everyone’s best prevention efforts, bad things will still happen to people. You develop an irregular heartbeat or get hit by a car, or a family member becomes suicidal. Life changes overnight as something happens environmentally, genetically, or in some combination of both, and you become a patient. When you show up at the hospital or clinic, we’ll be ready because we know you.
U.S. healthcare systems are not good at this right now, and they must improve. They check your name and allergies multiple times, sending the message that they don’t know who you are. They also don’t know much about how you like to receive information or prefer to be treated. Amazon.com knows you better than your doctor does, and that, too, must change.
In the future, we will know who you are and keep that information readily available using the best practices of customer relationship management (CRM), so we can be more patient-centered, knowing and understanding patient preferences. Our newest facilities are moving toward open, social space in place of waiting rooms, and our ultimate goal should be never to make our patients wait.
Rather than a generic approach, we will employ personalized care models that take motivation and behavior into account to help patients follow their care plans and be as healthy as possible. We’ll know whether you prefer frank discussions or a gentler approach, want us to always include your daughter, communicate via Skype, or welcome e-mail messages. We’ll know whether or not you want to try new medications or cutting-edge treatments. And we’ll know how to shift those preferences depending on what’s happening with your health in any given situation.
Thanks to our early adoption and implementation of the EHR and a largely stable patient population at Geisinger, we have 20 years of data we are building upon to make this depth and breadth of knowledge a reality.
Additionally, anytime you touch our system, you’ll understand your financial responsibility accurately. Industrywide, this has been difficult to achieve, as insurance copay, coinsurance, and deductibles are rolling continuously. Because we have an embedded health insurance company, we are building a system that pulls from multiple data streams and can answer the financial responsibility question in real time with total accuracy. Billing for doctor visits and tests will be free from complex terminology that no one understands and will be as clear as though you’re paying for a gallon of gas.
ANTICIPATORY, PRECISION MEDICINE
In addition to being well-prepared for patients when bad things happen, we will also know in advance that something might happen. Thanks to a major DNA study we began in 2014 in collaboration with Regeneron Pharmaceuticals, we are getting to know our patients very precisely at Geisinger. We’re well on our way to collecting patient blood samples from 250,000 consenting volunteers for analysis, sequencing of genetic material, and comparison to long-term health outcomes. With one of the largest U.S. populations of participants, the study’s size and scope will allow great precision in identifying and validating the associations between genes and human disease.
Geisinger brings state-of-the-art sample collection and storage capabilities, our MyCode biorepository, extensive EHRs, and a stable patient population that trusts us and is willing to participate in collaborations, while Regeneron provides the infrastructure to support sequencing and genotyping. The intent is to build a high-throughput platform for discovering and validating genetic factors that cause or influence a range of diseases where there are major unmet medical needs. The partnership is meant to further Geisinger’s ongoing mission to improve population health and individualized care through clinical innovation and cutting-edge, world-class research.
Our rate of participation is more than 85 percent of those invited to join the study, remarkably high for this type of research and a tribute to our loyal patient population. Included in that group is a woman we identified with the BRCA1 gene and its associated increased risk for early breast and ovarian cancer. When presented with this information, she elected for prophylactic removal of her ovaries and fallopian tubes. During the procedure a tumor was detected and removed.
With two decades of clinical data on our stable, multigenerational patient population, from both inside and outside of our clinical enterprise because of our integrated insurance company, we know a tremendous amount about our patients.
Presently, there are only about 70 conditions of genetic abnormality for which there is an effective medical treatment. We’ve taken the stance that we’re going to tell patients of a genetic abnormality only when we can do something about it, because DNA test results are stress-provoking if not actionable. Our initial findings show that results are positive for genetic abnormality about 3 percent of the time, with at least three to four first-degree relatives additionally affected.
If a DNA study comes back with potentially treatable conditions, the information is relayed to the primary care physician, who has five days to communicate with the patient. Meanwhile, the physician can access a 30-minute online primer about the condition and how best to discuss it with the patient. We also have an army of genetic counselors on staff for follow-up.
Does this type of precision medicine make a difference? Projecting from our early experience, we are confident that we will be able to reduce the risk of breast cancer in women under 40 in our population by the identification of high-risk individuals and improved surveillance and treatment. Familial hypercholesterolemia appears to be found in one in 250 of our patients. According to the American Academy of Pediatrics, children in such families should be evaluated and statin treatment started by age eight to reduce the early heart damage and risk of early heart attacks.2 So we add value in this area, too.
We expect that many patients will benefit directly from participation in this research because of our ability to validate and return clinically actionable results to them, such as starting appropriate youngsters on statins. In addition, all patients will benefit from the knowledge we gain regarding setting standards for genome-informed care. The study will transform our ability to foresee disease before the onset of symptoms, diagnose chronic and potentially fatal conditions before it’s too late to intervene, and determine how best to optimize the health and well-being of each patient.
CARE IN PLACE
We believe that every time a patient arrives at a provider for care, the organization should apologize that he or she had to come. Our goal is to treat patients at home, at work, or in the classroom, rather than in the hospital or clinic, and moving forward, providing the right care in the right place will be more important than ever.
For example, a heart failure patient arriving at one of our emergency departments will be started on diuresis, and then “admitted” to his home where hands-on, in-place professional follow-up care will be administered until he’s recovered. A person experiencing a heart attack will be “admitted” to home with a paramedic, who will take care of her for the next three or four days as a “hospital” patient. Her cardiologist will round regularly via Skype until the patient is indeed “discharged” to home.
A recent study demonstrated that for the typical medical appointment, patients drive about 40 minutes, wait approximately an hour to be seen, and spend 20 minutes with the doctor.3 The cost to the American economy of this nonproductive travel and waiting is astronomical. According to Geisinger, being patient-centered and caring means coming to you, either virtually or physically.
If you’ve shown up at one of our facilities, we will make the best use of your time, first by eliminating the wait. In our clinics, there will be no waiting rooms, as they have no value; they will be converted to clinical space. As you enter the parking lot or garage, a transponder on your dashboard will alert us that you’re on site and will arrive in the clinic in three to eight minutes. We’ll get the exam room ready, and the physician will be there waiting with the cardiologist you’ve anticipated seeing for a second opinion because of your heart concern. They know all about you, thanks to our CRM system and clinical and genetic records, and they’ve prepared for your visit ahead of time via the OurNotes system that allows patients to help set the agenda. If you’ve asked a question this morning about needing a dermatologist, one will link in via telemedicine shortly.
The doctor will not spend all of her time entering information into a computer, so the focus will be entirely on you. The computer is there to serve the doctor and provide prompts regarding what she may be missing. For example, the doctor may review your last five blood pressure readings from the EHR using a device that enables her to keep the focus on you personally. An assistant or intelligent system will record the visit notes, and you’re on your way in 15 to 20 minutes, feeling that your time and money were well spent.
We’ve built physical spaces for such innovations, with pilots under way and patients being invited to participate. But it’s not just a physical location that makes it possible; it’s a completely different service mentality: we exist to serve you, and we value your time.
FAMILY AS CAREGIVERS
Consider all of the disruptions in the travel industry during the past decade. You’re now the travel agent and the airline check-in employee. Airline innovations such as online flight booking and check-in were ways to transition labor to the customer and lower costs. Similarly, we will transition care to patients and family members by training them to be part of the care team, but the goal here is to improve the quality of outcomes.
With inpatients, we typically never ask the family member whether they’d like to provide food for the patient or whether someone would like to be the nursing assistant and change dressings. In our future vision, however, families will help care for patients. As we’ve explored this innovation, we’ve found that family members are willing and able to provide care to their loved ones.
For example, one weekend Dr. Feinberg went to visit a patient at home, an Amish farmer who had fractured nine ribs when he was pinned by a large bull in his barn. Despite suffering significant pain and having trouble breathing, he initially refused to seek care and only relented when a physician friend urged him to go to the hospital, where he was admitted to relieve his pain and prevent pneumonia. The patient insisted on being released after two days because he preferred to be treated at home.
Asked about his care in the hospital, the patient noted that he was treating his pain by applying to his ribs an herbal remedy made from plants in his yard, which to him was a more comfortable approach. He also observed that when our healers moved him they were “work hardened,” remarking that his wife was “more delicate” when she moved him. His wife, baking pies nearby, had never moved a trauma patient before, but she did it perfectly. While there were benefits to the patient being in the hospital where we could monitor him more closely, his family was taking better care of him because they were not “work hardened.”
Healthcare often gets so caught up in regulations that the family can’t lay a hand on inpatients. But when they go home, their families become their nurses and often do a better job of caring. We presently are building an experimental inpatient unit to pilot the concept of having family members on the care team and working through the associated regulatory issues.
A RALLYING CRY FOR CARE AND CARING
Geisinger nurse Cassandra Thomas was enjoying a vacation in Florida with her family when the sky darkened and lightning struck the beach. Looking out the window, she saw someone down on the sand, and her nursing instincts told her something was terribly wrong. She ran down 16 flights of stairs and out onto the beach where, with lightning still in the area, she performed CPR on 15-year-old Cameron. Assisted by a police officer who was also on vacation and others, Cassandra continued CPR until paramedics arrived. Little did Cameron know how lucky he was to have someone, who is not only a nurse but a CPR instructor, put herself in harm’s way to help him. Cassandra’s efforts were heroic, but she didn’t think she was doing anything out of the ordinary.4 That is what care and caring are all about.
Today, Geisinger is one of the most scientifically advanced and innovative healthcare organizations in America. But we also know that to be the best, we must care the best. We must never forget what got us here: the values we share with our neighbors, friends, patients, and loved ones. We’re committed to the good health of our community, with compassionate, kindhearted caring along with our advanced, innovative care.
We’re also committed to sharing what we’re learning and doing in our journey. Our solutions are highly reliable, based on processes and tools refined in our clinical settings. Many of our best practices came from studying the ways of others, and we’re eager in turn to share our methods, trials, and results through published research and medical education. Numerous other health systems are replicating our improved patient outcomes, enhanced efficiencies, and reduced costs.
We invite you to join them and us in this quest to be the best in care and caring.
LESSONS LEARNED
• Innovation in healthcare never ends.
• Geisinger is continuing to challenge itself to improve in every way.
• Scaling Geisinger’s innovations is one of our most important strategic commitments.
• Caring is fundamental to caregiving.
• Caring must go beyond meeting the accepted standards of care.
• Know your patients better than Amazon.com knows its customers.