1

Why Geisinger?

The little boy was essentially dead. He had no heartbeat, no breathing, and an extremely high blood-acidity level. But the team at Geisinger’s Janet Weis Children’s Hospital and Level One Pediatric Trauma Center refused to stop efforts to save his life. It was amazing that the toddler had made it even this far, pulled from an icy stream hours earlier.

Paramedics started CPR almost immediately after a neighbor found little Gardell unresponsive in the water. That effort continued as the boy was taken to an excellent independent hospital in Lewisburg, Pennsylvania, and then transported by Geisinger’s Life Flight helicopter to our advanced trauma center close by in Danville.

Frank Maffei, vice chairman of pediatrics, knew it didn’t look good for Gardell, but he and more than 30 colleagues continued CPR, inserted a breathing tube, and worked to raise Gardell’s body temperature, which had fallen to 77 degrees. An hour and 41 minutes passed before the boy’s heart started beating again, a long time for his brain to be without oxygen. Dr. Maffei told Gardell’s mother that he was alive, but there was concern about his brain function. That concern faded over the next few days as Gardell awakened and progressed. A week later, he was back home playing, acting as if nothing had happened.

The teamwork in this case was incredible, from the on-site paramedics to the community hospital emergency staff, Geisinger’s Life Flight team, and colleagues at Geisinger Medical Center and Children’s Hospital. No one gave up, and we have a happy ending to what certainly could have been a tragedy.

Geisinger regularly celebrates miracles such as this, patients who overcome amazing odds to recover from a wide variety of devastating illnesses and injuries. Similar lifesaving heroics occur daily at healthcare organizations across the United States and abroad.

However, Gardell’s care, coupled with efforts to provide it cooperatively, efficiently, innovatively, and economically, highlight why Geisinger increasingly is considered the example of how healthcare can best be provided, not just in Pennsylvania, but throughout the nation and, indeed, the world.

Our innovative approach is known as ProvenCare®, and it is about ensuring that quality, cost-efficient care comes standard. Throughout our organization, we strive to deliver the right care at the right time and to treat everyone as though they were a member of our own family.

Systematically applying national guidelines and results from clinical trials and our own care reengineering studies, Geisinger team members work together to discover what kind of care works—and doesn’t—and to develop reliable healthcare methods that improve quality, maximize safety, and get patients feeling better faster. For 10 ProvenCare acute and chronic services, we charge a flat fee that in essence includes a commitment or “warranty” to cover complications and readmissions for 90 days. Our value reengineering has revolutionized healthcare, increasing quality while decreasing cost.

Consider, for example, our anticoagulation therapy management service, which recently achieved best-in-world scores¹ for creating and offering an effective and safe anticoagulation plan for patients, an accomplishment that has caught people’s attention far and wide. The experience of an elderly farmer who limped into Geisinger’s primary care practice in rural Lewistown at 6:30 p.m. one evening demonstrates our high degree of care coordination. Within two hours, the patient was diagnosed as having deep vein clots in his legs and examined by ultrasound performed at the site but read in central radiology at Geisinger Medical Center in Danville. The patient was immediately started on an anticoagulation protocol designed and administered by the Danville anticoagulation clinic but performed on-site in Lewistown. By 9:00 p.m. he was back home with instructions to follow up with his primary care doctor, and a health navigator from Lewistown visited him the following day. His ultrasound images and interpretation, visit summary, therapeutic recommendations, and future course of treatment all were recorded directly in the patient’s electronic health record (EHR) and sent with his permission to a daughter in Texas.

Other achievements of ProvenCare include:

•   For coronary artery bypass graft surgery (CABG), a 67 percent decrease in mortality, a 4.8 percent decrease in cost per case, and a 17.6 percent increase in contribution margin

•   With ProvenCare Perinatal, a decrease in C-section rates from 28 to 20 percent and a reduction in neonatal intensive care unit admissions from 9.4 percent to 5.9 percent

•   With ProvenCare Knee, a reduction in average acute and rehabilitation time from 16 to 9.9 days

Since our founding in 1915, Geisinger has evolved from the original George F. Geisinger Hospital in Danville to become one of the nation’s largest health systems—a physician-led, vertically integrated system with some 30,000 employees, including nearly 1,600 employed physicians, 13 hospital campuses, two research centers, a 583,000-member health plan, and Geisinger Commonwealth School of Medicine, all of which leverage an estimated $12.7 billion annual economic impact in central, south central, and northeast Pennsylvania and most recently in New Jersey.

Coauthors Glenn D. Steele Jr., who served as Geisinger president and CEO from 2001 to 2015, and David T. Feinberg, who in turn began his tenure as Geisinger’s top leader in May 2015, both were attracted to the organization for the opportunity to accomplish real change to help patients. Dr. Steele became convinced that Geisinger could become a national laboratory for healthcare innovation not previously conceived or transacted anywhere, then oversaw a 15-year groundbreaking evolution. Dr. Feinberg perceived an opportunity to begin Geisinger’s second century of service capitalizing on a legacy of innovation and elevating the patient experience to historic levels.

HEALTHCARE’S VALUE REENGINEERING CRUCIBLE

Geisinger’s growth and success in healthcare value reengineering are due in large measure to:

•   A systemwide culture of innovation and early adoption of best practices

•   Pioneering implementation of the EHR

•   A stable, loyal patient population

•   The ability to permit and recover from failure

•   An embedded health insurance unit partnering with clinicians to improve outcomes

Bedrock Culture of Innovation

Put simply, Geisinger does things differently. Our organization began a century ago, when Abigail Geisinger founded the Danville hospital in memory of her husband. Her charge to “make my hospital right, make it the best” defined the organization’s founding mission and set the tone for a culture of caring and a never-ending quest toward perfection that continue to this day. Mrs. Geisinger modeled her hospital after Mayo Clinic and recruited her first chief medical officer, Harold Foss, who was on his way to private practice in Philadelphia following a fellowship with founder Will Mayo. Mrs. Geisinger insisted on an employed physician group, although today Geisinger has both employed and independent physicians on staff. Even over a hundred years ago she was concerned about cost and each day discussed with Dr. Foss the detailed expenses that patients in her hospital had to pay. With her directive to make it the best, Mrs. Geisinger inspired Dr. Foss to create a healthcare system grounded in the concepts of group practice and an interdisciplinary approach to patient care. A century later, Geisinger remains rooted in Mrs. Geisinger’s vision of an organization unwilling to be bound by convention.

This propensity to innovate surfaced multiple times throughout Geisinger’s history, including the development during the mid-1970s of our vertically integrated payer/provider fiduciary, Geisinger Health Plan (GHP). It was also during this time that CEO Henry Hood negotiated an important agreement with Geisinger’s trustee so that our board of directors could select its chair instead of the trustee’s chairman automatically serving as our board chair, a change Dr. Hood and his leadership team felt necessary for swift and appropriate forward movement. To better assist other hospitals approaching us for administrative and management advice, we formed a for-profit management corporation in 1978. Through regional expansion in the 1980s, we ensured that no matter where patients lived, they were within a half hour of a Geisinger doctor, and we attained the first certified adult and pediatric trauma center designation in a rural setting in 2002.

Vanguards in the Electronic Health Record

Geisinger’s leadership made an incredibly wise and fortunate choice long ago to partner with Epic as the organization’s EHR vendor. Quite remarkable in 1995, we decided to employ the EHR in the ambulatory setting before implementation in our hospitals, and Epic was the only EHR that had our desired functionality. Only after the ambulatory EHR was fully installed throughout Geisinger’s 78 ambulatory sites in 42 counties were the two major inpatient facilities at that time converted from paper. There were growing pains, of course, with patients complaining that their caregivers were constantly pecking away at computer keyboards. But implementation became an efficient stabilizer and drove the reengineering that provided major productivity increases. Our EHR continues to be an important tool helping to drive innovation, and as Geisinger has expanded, we now work with both Epic and Cerner regarding EHR functionality.

Our EHR is a critical success factor in ProvenCare, providing the important information for clinicians to interact appropriately with patients. Histories, test results, and physician notes all are readily available, as well as best practice reminders to ensure that every patient receives the same level of care. For example, the EHR reminds clinicians about beta blockers and aspirin therapy for heart patients and ensures that we talk with patients regarding annual flu shots and other preventive care. And through our web-based portals, patients can connect easily with clinicians and access information to better understand and participate fully in care.

A Patient Population Unique in Stability and Loyalty

The population, particularly in central Pennsylvania around Geisinger Medical Center, is older, sicker, and poorer than just about any demography in the United States outside of the Deep South. It is extraordinarily homogeneous and stable, with approximately 15 percent of our patients being second and even third generation. The ability to change care and determine long-term effects over generations is a unique advantage that allows Geisinger to have a remarkably long vision.

In addition, the social values in the Geisinger patient population are traditional, old-time ones. Most of the men and women in this economically deprived area are incredibly family-oriented, see Geisinger as a great strength with significant credibility as both provider and payer, and still respect caregivers. Almost all of Geisinger’s constituents are remarkably willing to participate in a variety of forward-thinking approaches, whether they involve attempts to change how Geisinger cares for type 2 diabetes or to create a new best practice for heart surgery. Patients readily accept Geisinger’s assurances regarding genome sequencing that the information will remain confidential and be shared with them and their families, regardless of whether there’s something that immediately affects how they live or should be cared for in the future.

The Ability to Permit and Recover from Failure

There are a number of other factors that enabled Geisinger to begin its ProvenCare innovation journey. For instance, our physician group is highly stable, with only six leaders in 100 years. We were one of the nation’s first regional health systems and pioneers in the design of a rural hub-and-spoke delivery system, with primary care in 50-plus community sites throughout our service area. We made the transition from discipline-based physician care to 28 cross-disciplinary service lines with a patient-centered approach, not based on how specialists and subspecialists wanted to deliver care but on how patients and their families wanted care to be delivered. In the 1980s, we established clear-cut self-replicating governance for the entire entity.

However, among the most critical factors is a subtle institutional advantage: the ability to permit and recover from failure.

To illustrate, at the time of ProvenCare’s inception, Geisinger had merged with Penn State Hershey Medical Center, from which we painfully demerged three years later. The period had been marked by lost clinical leadership and three years of posturing to see which culture would predominate, followed by a subsequent focused strategic intent to dissolve the marriage as quickly as possible.

The separation was a perfect time not simply to rebuild, but to do so in a way that would have a positive impact on healthcare throughout Geisinger and beyond. As we emerged from this failure, we asked, what could Geisinger do to help define a new vision for healthcare as it shifted from payment for volume to payment for value, particularly for a population of patients?

A consistent operational return was imperative to fund innovations to enhance patient care. We knew that not every innovation would be successful and that we would no doubt spend time and money on ideas that would not succeed. Operational recovery allowed Geisinger to develop and implement a set of radical innovations, where 15 to 20 percent failure could be allowed without putting at risk the balance sheet, operations, expansion, morale, or credibility with the Geisinger board of directors. We were able to remain true to our fiduciary responsibility, which then translated into improvements over time to our primary mission of taking better care of our patients. It would have been most difficult, for example, to cover the costs for complications without an overall strong organizational bottom line. Ultimately, our innovations all have been about doing what is right and best for patients. It has been our operational recovery and sustainability, though, that makes such enhancements possible.

Geisinger’s Sweet Spot

Geisinger started an insurance company in the mid-1970s. Over the past 15 years in particular, we have attempted to change how our insurance company could work with its providers and members to move to higher quality at lower cost. While Geisinger contracts with most major insurances, and GHP contracts with numerous non-Geisinger providers, the sweet spot is those patients who are cared for by the Geisinger employed physicians and insured by a Geisinger insurance product. We were able to move ProvenCare forward because GHP partners with Geisinger clinicians to improve outcomes.

Our experiment worked out incredibly well, and we delivered on providing better care at lower cost. We set up a quality fund that was able to transfer literally tens of millions of dollars from the return on investment in attacking total cost of care. This was an immediate gain for the patients, decreasing the need for hospitalizations and rehospitalizations due to inadequately treated chronic diseases. It came directly back to the insurance company because of decreased costs, and those savings could be transferred to the providers (primary care and specialists) who were doing a better job taking care of their patients with illnesses such as diabetes, congestive heart failure, or chronic obstructive pulmonary disease. The internal transfer pricing allowed the benefit of the financial model to be redistributed to those who actually changed for the better how care was given. This all led to better outcomes and decreased need for acute care, which was the first major benefit in mitigating the total cost of care.

ACCLAIM FOR THE GEISINGER MODEL

When we started an effort to achieve nine best practice goals for our 30,000 type 2 diabetes patients, for example, we initially focused on the usual intermediate markers like hemoglobin A1C, microalbumin, pneumococcal vaccination, cholesterol, and blood pressure. What we really were interested in, however, was the actual long-term benefit to our diabetes patients who had been included in the improved bundle of best practices. We were pleased to find that there were 306 prevented heart attacks and 141 prevented strokes, compared to what would have been predicted, and 166 prevented cases of retinopathy, simply by having the patients cared for within our best practice value reengineering change.

Results such as these have drawn the world’s attention and emulation. For example, the Commonwealth Fund, a private foundation dedicated to promoting a high-performing healthcare system with improved access, quality, and efficiency, was well aware of what was taking place in Pennsylvania. The fund inventoried healthcare quality and value throughout the United States and made worldwide comparisons, consistently referencing Geisinger as one of the few high-quality/low-cost delivery systems.² This is particularly noteworthy given Geisinger’s medically needy, rural, and postindustrial market.

In 2007, the New York Times reported on the ProvenCare approach to CABG surgery in a major feature article.³ “Geisinger’s effort is noteworthy as a distinct departure from the typical medical reimbursement system in this country, under which doctors and hospitals are paid mainly for delivering more care—not necessarily better care.”

In 2009, President Barack Obama cited Geisinger before a joint session of Congress on healthcare.⁴ “We have to ask why places like Geisinger in rural Pennsylvania … can offer high-quality care at costs well below average, but other places in America can’t,” he observed earlier that year in a Green Bay, Wisconsin, town hall meeting.⁵

In the June 11, 2012, TIME magazine cover story “How to Die: What I Learned from the Last Days of my Mom and Dad,” political columnist Joe Klein described Geisinger as a model for providing better care in an economic manner and Geisinger physicians as understanding, compassionate, professional, and intent on doing what was best for the patient, rather than driving revenue-producing volume.⁶

On November 11, 2015, U.S. News & World Report cited our commitment to refund all or part of the copay for spine and bariatric surgery to patients dissatisfied with their care, calling this “the latest, and perhaps most radical, innovation of a system recognized for continually reinventing medical care.”⁷ Feedback and service recovery are processed via a mobile app.

As other healthcare organizations became interested in Geisinger’s unusual success in changing how care was delivered, they initially doubted that our innovations could be applied and sustained in their particular cultures, fiduciary structures, and demographics. This trepidation about scaling and generalizing elsewhere has evaporated, and our care reengineering and population health techniques have been adopted by health systems outside Pennsylvania.

Several clients across four states all have shown similar results to what was achieved in Geisinger’s traditional service area with our unique structure and sociology. For example, the accomplishments of one Virginia client partnered with Geisinger include growing the health system from four to seven hospitals; integrating the medical group and expanding it to more than 450 physicians; establishing 32 advanced patient-centered medical home sites that have improved physician productivity; optimizing payments with managed care and the Centers for Medicare & Medicaid Services, increasing downstream revenues, decreasing downside risk by reducing 30-day readmission rates from 2.96 percent to 0.82 percent, and securing managed care contracts for medical home; implementing ProvenCare Navigator CABG at two hospitals; and securing risk-sharing contracts with three major insurers.

This book is about how Geisinger has reengineered healthcare value and quality. We demonstrate that our principles are applicable anywhere, tell you how we did it, share our success secrets as well as what didn’t work, and reveal where we’re going next. The goal is nothing short of a complete transformation of the U.S. healthcare industry into one that provides affordable coverage for all, payment for value rather than volume, care coordination, continuous improvement and innovation, and empowered patients and their families who are active partners in care. Join us in the revolution!