Building and Sustaining Physician Hospital Integration. HFMA (ANI) June 21, 2010 Glenn Steele Jr., MD, PhD President and CEO Geisinger Health System

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1 Building and Sustaining Physician Hospital Integration HFMA (ANI) June 21, 2010 Glenn Steele Jr., MD, PhD President and CEO Geisinger Health System

2 POST REFORM Question: And Now What? Answer: Reengineering Care! 2

3 Where We Are Now 3

4 Volume 348(26) 26 June 2003 pp The Quality of Health Care Delivered To Adults In the United States McGlynn, Elizabeth A.: Asch, Steven M.: Adams, John: Jeesey, Joan: Hicks, Jennifer: DeCristofaro, Alison: Kerr, Eve A. BACKGROUND We have little systematic information about the extent to which standard processes involved in healthcare a key element of quality are delivered in the United States. METHODS We 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 RESULTS Participants received 54.9 percent of recommended care. CONCLUSIONS The 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. 4

5 Cost/Quality Correlation 50th %ile MD Quality Index (outcomes or % adherence to EBM) Lower Higher Low Efficiency High Quality Low Efficiency Low Quality (Nightmare Suppliers) High Efficiency High Quality (Dream Suppliers) High Efficiency Low Quality 50th %ile Lower Efficiency/ Higher Cost MD Longitudinal Cost Efficiency Index (total cost per case mix-adjusted treatment episode) Adapted from Regence Blue Shield; Arnie Milstein, MD - Mercer Higher Efficiency/ Lower Cost

6 Where Is the U.S. on Health IT? Only 28% of U.S. primary care physicians have electronic medical records (EMRs), and only 19% have advanced IT capacity Percent reporting EMR Percent reporting seven or more of 14 IT functions* NET NZ UK AUS GER US CAN NZ UK AUS NET GER US CAN * The 14 functions are: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt test results; easy to list diagnosis, medications, patients due for care. Source: Commonwealth Fund 2006 International Health Policy Survey of Primary Care Physicians. 6

7 Cumulative Changes in Annual National Health Expenditures, Percent change Net cost of private health insurance administration Family private health insurance premiums Personal health care Workers earnings 109% 91% 65% 25 24% * 2007* Notes: Data on premium increases reflect the cost of health insurance premiums for a family of four/the average premium increase is weighted by covered workers. * 2006 and 2007 private insurance administration and personal health care spending growth rates are projections. Sources: A. Catlin, C. Cowan, S. Heffler et al., National Health Spending in 2005: The Slowdown Continues, Health Affairs, Jan./Feb (1):143 53; J. A. Poisal, C. Truffer, S. Smith et al., Health Spending Projections Through 2016: Modest Changes Obscure Part D s Impact, Health Affairs Web Exclusive (Feb. 21, 2007):w242 w253; Henry J. Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits Annual Surveys, (Washington, D.C.: KFF/HRET). 7

8 Total National Health Expenditures, Projected and Various Scenarios Dollars in trillions $ $4.0 Projected under current system $ $ $ $ * Selected individual options include improved information, payment reform, and public health. Source: Based on projected expenditures absent policy change and Lewin estimates. 8

9 International Comparison of Spending on Health $7,000 $6,000 $5,000 $4,000 Average spending on health per capita ($US PPP*) United States Germany Canada Netherlands France Australia United Kingdom $3,000 $2,000 $1,000 $ The Path to a High Performance US Health System A 2020 Vision and the Policies to * PPP = Purchasing Power Parity. Pave the Way, pg , The Commonwealth Fund Data: OECD Health Data 2008, June 2008 version. 9

10 Where We Want to Be 1. Affordable coverage for all 2. Payment for value 3. Coordinated care 4. Continuous improvement/innovation 5. National health goals, leadership, accountability The Path to a High Performance US Health System A 2020 Vision and the Policies to Pave the Way, pg , The Commonwealth Fund 10

11 The Legacy Make my hospital right, make it the best. Abigail Geisinger Geisinger Quality Striving for Perfection

12 Geisinger Health System Last updated 11/12/09 Geisinger ProvenHealth Navigator Sites Contracted ProvenHealth Navigator Sites Geisinger Medical Groups Geisinger Specialty Clinics Geisinger Inpatienta Facilities Ambulatory Care Facility Geisinger Health System Hub and Spoke Market Area Geisinger Health Plan Service Area Careworks Convenient Healthcare Non-Geisinger Physicians 12 With EHR

13 Geisinger Health System An Integrated Health Service Organization Provider Facilities Geisinger Medical Center with Janet Weis Children s Hospital Geisinger Northeast (2 campuses) - Geisinger Wyoming Valley Medical Center with Heart Hospital, Henry Cancer Center, Level II Trauma Center - Geisinger South Wilkes-Barre Ambulatory Surgery, Adult & Pediatric Urgent Care, Pain Medicine, Sleep Medicine Marworth Alcohol & Chemical Dependency Treatment Center 3 Ambulatory surgery centers >51K admissions/obs & SORU ~790 licensed in-patient beds Physician Practice Group Multispecialty group ~800 physicians ~380 advanced practitioners ~61 primary and specialty clinic sites (37 community practice sites) ~1.7 million outpatient visits ~330 residents and fellows Managed Care Companies ~240,000 members (incl. ~45,000 Medicare Adv.) Diversified products >20,000 contracted physicians 110 Non-Geisinger hospitals 42 PA counties 13

14 Electronic Health Record (EHR) > $120M invested (hardware, software, manpower, training) Running costs: ~4.4% of annual revenue of > $2.3B Fully-integrated EHR: 36 community practice sites; 2 hospitals; 2 EDs; 6 Careworks Retail-based and worksite clinics Acute and chronic care management Optimized transitions of care Networked PHR - 133,000 active users (27% of ongoing patients) Patient self-service (self-scheduling, kiosks) Home monitoring integrated with Medical Home Outreach EHR - 2,300 non-geisinger physician users Regional image distribution Regional Health-Information Exchange (KeyHIE) 11 hospitals, 90+ practices, 2.5 M patients 14

15 The Vision Geisinger Quality Innovation Market Expansion Securing the Legacy *Predicated on maintaining healthy operations 15

16 Targets for Geisinger Innovation Unjustified variation Fragmentation of care-giving Perverse payment incentives Units of work Outcome irrelevant Patient as passive recipient of care 16

17 Innovation Initiatives ProvenCare for Acute Episodic Care (the Warranty ) ProvenCare Chronic Disease ProvenHealth Navigator SM (Advanced Medical Home) Transitions of Care 17

18 The Geisinger Advantage Our physicians and professional staff Our market Vision and leadership Operational and professional integration Enterprise-wide clinical decision support (via the EHR) Accountability, transparency, incentives all aligned Our insurance/provider sweet spot

19 ProvenCare for Acute Episodic Care (the Warranty )

20 Pay-for-Performance Acute Episodic Care ProvenCare Identify high-volume DRGs Determine best practice techniques Deliver evidence-based care GHP pays global fee No additional payment for complications 20

21 Quality/Value - Clinical Outcomes Before ProvenCare ProvenCare % Improvement (n=132) (n=321) In-hospital mortality 1.5 % 0.3 % 80 % Patients with any complication (STS) 38 % 33 % 13 % 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 % Re-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 % Readmission within 30 days 6.9 % 5.6 % 20 % 21

22 ProvenCare CABG 100% 90% 80% % patients 70% receiving all 60% 50% ProvenCare 40% components 30% 20% 10% 0% Feb-06 Apr-06 Jun-06 Fiscal Year 2010 Milestones / Issues Automated reliability report in spec Piloting Episode of Care and Phase of Care functionality within DSS- Plan is for automated financial review ProvenCare CABG ProvenCare patients through Feb 2010 n=388 Aug-06 Oct-06 Dec-06 Feb-07 Apr-07 Jun-07 Aug-07 Oct-07 Dec-07 Feb-08 Apr-08 Jun-08 Aug-08 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 Feb-10 Fiscal Year 2010 Timeline Q1-Update Outcomes Data Q2- Q3-Add urgent cases Q4-Automate reliability and financial reporting 22

23 Hospital: ProvenCare CABG: Financial Outcomes Net revenue increased 3.8% Direct costs decreased 5.1% Contribution margin increased 11.3% Total inpatient profit per case improved $2560 Health Plan: Cost 4.8% less per case for GHS CAB with ProvenCare than it would have without Cost 28 to 36% less for CAB with GHS than other providers 23

24 Not Just Surgery Virtual Care Models: Epo Management Epo CKD (n=184)* Control (n=74)** Median days to goal = 49 days % Time below goal = 25% % Time in goal = 49% % Time above goal = 26% Median days to goal = 62.5 days % Time below goal = 39.7% % Time in goal = 43.9% % Time above goal = 16.4% Avg Epo Units/week = 4667*** Avg Epo Units/week = 12,000 Home/Clinic = 90%/10% Home/Clinic = 39.2%/60.8% Expanded Dose Utilization = 44% Expanded Dose Utilization = 16% Avg Hgb at start = 9.6 mg/dl Avg Hgb at start = 10.0 mg/dl Avg T-Sat at start = 18% Avg T-Sat at start = 18% ***Savings of Epo (p<.001) *VITALine Q4FY2009 results on file, Hgb range since 2007 **Bucaloiu et. al, Managed Care Interface, June Hgb target range at this time 24

25 ProvenCare Portfolio ProvenCare : CABG PCI (Percutaneous Coronary Interventions Angioplasty/Angioplasty + AMI) Hip replacement Cataract EPO Perinatal Bariatric surgery Low back Lung cancer 25

26 ProvenCare - Chronic Disease 26

27 Chronic Disease Portfolio Diabetes Congestive Heart Failure Coronary Artery Disease Hypertension Prevention Bundle 27

28 Diabetes "Bundle" GHS Quality Targets CPSL Measures Performance Criteri a Standard FY07 HgbA1C measurement Ev e ry 6 mont hs 100% X HgbA1C control < 7 7 to 9 >9 < 7.0 X LDL measurement Yearly 00 to 100% X LDL control < 100 <130 >=130 < 100 X Blood pressure control < 130/80 < 140/90 >=140/90 < 130/80 X Retinal exam Yearly 100% Urine (protein) ex am Yearly 100% X Foot exam Yearly 100% Influenza immunization Yearly 100% X Pneumococcal immunization Once* 100% X Smoking status Non-smoker 100% X U se of ACE/ARB for microalbuminuria/dm nephropathy Yes 100% Use of ACE/ARB for hypertension Yes 100% Patients who receive/achieve ALL of the above Yearly 10 0% X Diabetes "Bundle" Measures GHS Quality Targets Performance Criteria Standard HgbA1C measurement Every 6 months 100% X HgbA1C control < 7 7 to 9 >9 < 7.0 X LDL measurement Yearly 100 to 100% X LDL control < 100 <130 >=130 < 100 X Blood pressure control < 130/80 < 140/90 >=140/90 < 130/80 X Retinal exam Yearly 100% Urine (protein) exam Yearly 100% X Foot exam Yearly 100% Influenza immunization Yearly 100% X Pneumococcal immunization Once* 100% X Smoking status Non-smoker 100% X Use of ACE/ARB for microalbuminuria/dm nephropathy Yes 100% Use of ACE/ARB for hypertension Yes 100% CPSL FY07 Patients who receive/achieve ALL of the above Yearly 100% X 28

29 Diabetes Bundle Improvement Movement Since Year 1 30% 25% 6/09 % of all diabetic patients 20% 15% 10% 5% 12/08 6/08 12/07 6/07 12/06 0% ALL 29

30 Improving CAD Care for 14,706 Patients 9/06 3/07 2/09 2/10 CAD Bundle Percentage 8% 11% 19% 21% % LDL <100 or <70 if High Risk 38% 37% 45% 48% % ACE/ARB in LVSD,DM, HTN 65% 66% 76% 76% % BMI measured 79% 86% 98% 99% % BP < 140/90 74% 74% 76% 78% % Antiplatelet Therapy 89% 91% 92% 92% % Beta Blocker use S/P MI 97% 97% 97% 97% % Documented Non-Smokers 86% 86% 87% 87% % Pneumococcal Vaccination 80% 80% 86% 87% % Influenza Vaccination 60% 74% 77% 79% 30

31 Improving Preventive Care for 210,430 Patients Nov. 07 Feb. 10 Adult Preventive Bundle 9.2% 27% Breast Cancer Screening (q , q ) 46% 61% Cervical Cancer Screening (q 3 yr Age 21-64) 64% 74% Colon Cancer Screening (Age 50-84) 44% 62% Prostate Cancer Discussion (Age 50-74) 72% 75% Lipid Screening (Every 5 yr M > 35, F > 45) 75% 83% Diabetes Screening (Every 3 yr > 45) 85% 87% Obesity Screening (BMI in Epic) 77% 94% Documented Non-Smokers 75% 78% Tetanus Diphtheria Immunization (every 10 yr) 35% 65% Pneumococcal Immunization (Once Age >65) 84% 86% Influenza Immunization (Yearly Age >50) 47% 57% Chlamydia Screening (Yearly Age 18-25) 22% 37% Osteoporosis Screening (every 3 yr Age > 65) 52% 74% Alcohol Intake Assessment 84% 88% 31

32 Ongoing Issues More individualized targets? Smaller cohorts? Archimedes? 32

33 ProvenHealth Navigator SM (Advanced Medical Home) 33

34 ProvenHealth Navigator SM (Advanced Medical Home) 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 Telephonic monitoring/case management Group visits/educational services Personalized tools (e.g., chronic disease report cards) 34

35 ProvenHealth Navigator SM (Advanced Medical Home) Currently serves 40,000 Medicare recipients and 25,000 commercial patients Results from best primary care sites: 25% patients admissions 23% days/ % readmissions following discharge Significant benefit to patients and families, avoiding multiple hospital admissions 35

36 Acute admissions continue to show improvement 350 Risk-adjusted acute admits/1000 (Medicare population) Jan-Aug 06 Jan-Aug 07 Jan-Aug 08 Jan-Aug 09 GHS Phase 1 1/07 GHS Phase 2 1/08 GHS Phase 3 1/09 Medicare Control Group 36

37 ProvenHealth Navigator SM significantly expanded since 2007 Date Sites Gold members Commercial members PGP members Phase 1 October 2006 May GHS 1 non-ghs 3, Phase 2 November 2007 May GHS 7,300 6,000 10,200 Phase 3 August 2008 January GHS 3 non-ghs 4, ,500 1,400 6,200 Phase 4 July 2009 November 2009 Total 11 GHS and 1 non-ghs 4,300 12,300 4, GHS and 5 non-ghs 19,300 25,000 21,100 37

38 38

39 Ongoing Issues Scalability? Generalizability? Specialist PCP 39

40 Transitions of Care 40

41 Transitions of Care Began January 2008 as joint quality/efficiency initiative that complements ProvenHealth Navigator SM (Advanced Medical Home) Inpatient and outpatient interventions Eliminate unnecessary admissions Reduce readmissions Free up capacity for more acutely-ill patients Focused on heart failure, medical/surgical inpatient wards, and Emergency Department) Program expansion is planned, including addressing LOS Modeling and predictive instruments used 41

42 Preliminary First Quarter Results GWV Medicine Service 30 Day Readmission Rate GMC Medicine Service 30 Day Readmission Rate 18.0% 18.0% 16.0% 14.0% 16.0% 13.3% 17% Reduction 16.0% 14.0% 13.7% 12.0% 12.0% 10.7% 22% Reduction 10.0% 10.0% 8.0% 8.0% 6.0% 6.0% 4.0% 4.0% 2.0% 2.0% 0.0% 0.0% Q1 FY2008 Q1 FY2009 Q1 FY2008 Q1 FY

43 Ongoing Issues Sustainability? Inpatient Continuum of Care? 43

44 Fundamental Innovation at Geisinger 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) Electronic enabler across 43 counties 44

45 Fundamental Innovation at Geisinger 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 The common good goal 45

46 All of the above permissive but not enough Clinical Clinical leadership leadership Pride of purpose Professionalism Pride of purpose Professionalism Overarching 46

47 Prognosis (National) Access Demand Perverse incentives Piece rate Medicare/Medicaid payment units of work cost value 47

48 Winners will provide More value for patients! 48

49 Caveats Scalable? Applicable to non-ids? Applicable in absence of real-time EHR? Applicable in fee-for-service settings? Pending wider use in marketplace 49

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