Constructed Response Questions

1. What lessons can managers learn from Geisinger to improve the operations of their hospital?
2. What lessons can patients learn from Geisinger to help them improve their hospital stay or visit with their physician?
3. Should all hospitals and physician offices use electronic medical records (EMRs) in order to reduce medical errors and improve clinical outcomes?
4. Could other health systems implement lessons learned from ProvenCare in their treatment of CABG patients?
5. Should physicians be financially rewarded and penalized based on the clinical outcomes of their patients?
6. What lessons can patients learn from the ProvenHealth Navigator?

Vignette: The Geisinger Experience

• Geisinger Health System (Geisinger), in Danville, Pennsylvania, is a premier U.S. academic medical center.
• This major center adopted technology and case management to reduce cost and improve clinical outcomes.
• The president highlighted Geisinger in speeches about its successful use of technology and efficient chronic care.
• Geisinger is a recognized leader in specialty care.

Medical Technology

• Geisinger provides care in 43 Pennsylvania counties and serves 2.6 million patients a year.
• The patient mix is rural, older, and sicker, with multiple chronic conditions, and is either on Medicare or Medicaid.
• Geisinger employs approximately 800 physicians in more than 50 clinical sites throughout Pennsylvania.
• At Geisinger, there are bundled payments for acute procedures, improved support for primary care physicians and care teams, and better management of chronic disease and transitions of care.
• Geisinger reduced admissions for multiple chronic conditions by 25 percent.
• Readmissions following discharges decreased by as much as 50 percent in community sites.
• Fourteen years ago, Geisinger began using enterprise-wide electronic health records (EHRs) and has more than 3 million records.
• Health care's MostWired magazine has named Geisinger "Most Wired" seven times.
• EHR allows patients to book appointments, resulting in 95 percent attendance versus 60 percent for receptionist-booked appointments.
• Physicians immediately see what tests have been done, reducing duplicative care and delays.
• Patients can access lab results and radiology; request prescription refills; and email doctors, nurses, and staff.
• Geisinger's size allows it to provide a health care insurance product.
• The Geisinger Health Plan enrolls nearly 250,000 members, 35,000 Medicare beneficiaries, 18,000 network physicians, and 90 hospitals (not including Geisinger hospitals), and it spans most of Pennsylvania.

Medical Home Initiative

• Geisinger's Medical Home program (ProvenHealth Navigator) improves care coordination.
• The plan covers more than 30,000 Medicare recipients and 3,000 commercial patients.
• It is used in 37 physician practices, most of which are part of its own network.
• Offices make the most impact and nurses are assigned to follow patients through the continuum of care.
• Nurses are personally acquainted with patients and their families, whose care they follow, helping these patients and their families gain access to specialists and social services.
• Nurses follow patients when they are admitted to the hospital, and contact or see them when they are sent home, to confirm that they are taking appropriate medication dosages. The nurses are available for advice 24 hours a day.
• Patients manage conditions with home-based monitoring and interactive voice-response surveillance.
• Patients are also provided support for end-of-life care decisions.
• Physicians get additional reimbursement to implement medical home features.
• Bonus payments are based on whether the practice adds staff, provides extended hours, and reduces cost of care, as well as on other medical home initiatives.
• The providers implementing the medical home closely track performance reports to monitor progress.
• In top-performing practices, admissions for the sickest and chronic diseases decreased by 25 percent; days in hospital decreased by 23 percent; and readmissions following discharge decreased by 53 percent.
• The success of the medical home model is dependent on nurses who work closely with doctors.
• The nurses schedule appointments at last minute, notify physicians of early signs of trouble, keep in close contact with patients, and monitor health through evaluating lab results.

Care Management of Chronic Conditions

• Geisinger has identified the most common chronic diseases (diabetes, coronary artery disease, congestive heart failure, kidney disease) and applied evidence-based best practices to manage care.
• Bundled care incorporates best care practices into care pathways 100 percent of the time with EMR.
• Only 100 percent compliance with recommended bundled care practices is considered successful.
• EMR: Care plan needs are identified and incorporated into physician care plans, with automatic alerts.
• Condition-specific dashboard captures relevant clinical information on a single screen.
• Care for diabetic patient consists of nine different evidence-based best care practices.
• Diabetics are automatically identified prior to arrival, and patient-specific orders are generated (HbA1c).
• After a visit, patients can access their after-visit summary with information about their progress in reaching goals and risks associated with failure to reach those goals.
• Patients receive their own report card through their EHR.
• Performance reports are presented to the physician practice, detailing both individual physician and practice-site performance compared with historical trend and other similar practices.
• Primary care physicians are reimbursed based on how many patients receive best practice care services.

Reimbursement for Physicians

• Geisinger rewards clinical quality improvements and reimburses for better clinical outcomes.
• Physicians are benchmarked against their peers (within Geisinger and nationally).
• Salaried physicians have 20 percent of compensation based on bonuses awarded for quality.
• Different from fee-for-service, where doctors are paid a fee for each treatment.
• ProvenCare: encourages staff to use best practices in using episodic acute procedures (CABG).
• Best practices are programmed into EMR to prompt the physician at each step; there is one price for bundled services, and Geisinger absorbs the costs of additional treatment due to complications from the procedure.
• Employers are attracted to cost savings with the single-episode package price for CABG.
• The package includes preoperative evaluation and work-up, hospital and professional fees, all routine post discharge care (e.g., smoking cessation counseling and cardiac rehabilitation), and care for any related complications within 90 days of elective CABG.
• Three months after onset of the program, 86 percent of CABG patients were receiving best care; this increased to 100 percent.
• Complications were reduced by 21 percent; infections decreased by 25 percent; re- admissions fell by 44 percent; costs for treatment were reduced; and average length of stay decreased by half a day.
• ProvenCare was expanded to include bundled services for hip replacement; cataract surgery; obesity surgery; prenatal care for babies and mothers, from an infant's conception to birth; and heart catheterization.
• The Geisinger experience provides insights into successful strategies for using technology, evidence-based best practices, and a medical home to deliver superior care and improve clinical outcomes.
• Geisinger is unique both in its health plan and its widespread delivery network, and in its insights into proven successful strategies that cut costs while improving care for a diverse patient population.
• Geisinger has an integrated delivery system (IDS) and enjoys strong physician support in implementing its initiatives.
• Geisinger has substantial financial resources to invest in EMR and medical technology.
• Its physicians are committed, entrepreneurial, and willing to attempt new unproven strategies.