the accountable care organization - geisinger health system

1. The Accountable Care Organization - Geisinger Health System

3. “We have long known that some places, like the Intermountain Healthcare in Utah or the Geisinger Health System in rural Pennsylvania, offer high quality care at costs below average.” President Obama Sept. 9, 2009

4. Geisinger Health System Mission Enhance the quality of life through an integrated health service organization based on a balanced program of patient care, education, research, and community service. Geisinger Brand Quality Value Partnerships Advocacy

5. Strategic Plan and Goals 2007-2012 Quality Clinical Market Innovation Secure the Legacy

7. Dollars in each bubble represent FY09 budgeted revenueDollars in each bubble represent FY09 budgeted revenue

11. Characteristics of High-Performing Integrated Delivery Systems Strong physician leadership Organizational culture Clear, shared aims Governance Accountability and transparency Selection and workforce planning Patient-centered teams Tollen, LA The Commonwealth Fund (2008)

12. Exhibit 1. Continuum of Delivery System Organization in the United States

13. “The (Group Practice) culture attracts individuals who see the practice of medicine best delivered when there is an integration of medical specialties functioning as a team.”

14. The Group Practice of Medicine Physician leadership Physician-Administrator partnerships Self-Governance (subject to Board) Mission Vision Values Operational Policies/Issues

15. The Group Practice of Medicine – cont’d Culture Patient-centeredness Involvement Peer leadership Decision-making focused on needs of the group Work ethic Sophisticated business operations Team-based care (not physician centric)

19. Matrix Management Approach Clinic Structure 26 Service Lines 3 Hospital Based Service Lines Nursing Service Line Platform Structure CAO/CMO/CNO/CFO Matrix relationship with VP’s Matrix relationship with Operations Managers Matrix relationship with Support Services, Finance and Quality Agency for Healthcare and Research Quality Agency for Healthcare and Research Quality

21. Service Line Organization Clinical Service Line Chief(s) partnered with administrative Vice President Joint accountability: Program vision and growth Clinical and financial “budget” performance Staff recruitment, retention and mentoring Common management discussion at monthly Service Line meetings

22. Geisinger Clinical Service Lines Anesthesia Cancer* Cardiovascular* Community Practice* Dental and Oral Surgery Dermatology Emergency Medicine Endocrinology ENT Gastroenterology General, Pediatric and Trauma Surgery Laboratory* Medicine Specialties Neuroscience* Ophthalmology Orthopedics Pediatrics* Plastic Surgery Psychiatry Pulmonary and Critical Care Medicine Radiology* System Therapeutics* Transplant Urology Vascular Surgery Women’s Health*

23. Core Management Framework: Meetings Service Lines (monthly) Clinical Operations Leadership Team (monthly) Vice Presidents’ Meeting (monthly) Clinical Enterprise Management Committee (bi-monthly)

24. Clinical Operations Leadership Team (COLT) Meets Monthly – Two Hours Master Agenda Quality Innovation Market Access Legacy Finance Month and YTD revenue and expenses Other Business

25. Putting It All Together: Redesigning Healthcare to Provide Value

26. ProvenCare Acute® Geisinger’s Bundled Episodic Care

28. Common Acute Care Scenario Clinical Uncertain appropriateness Variable compliance with known-to-be beneficial evidence-based care Limited patient engagement Variable outcomes Business Lack of accountability for outcomes and quality A la carte payment for services No relationship between cost and quality Perverse incentives: more payment for complications

29. ProvenCare® Guarantee “Best Practice” = Evidence-based Medicine Financial Package “All in fees” Split difference in cost of decreased complication rates with purchaser All related complications for 90 days

30. GHS Receives “All In” Global Fee One fee for the ENTIRE 90-day period including all surgery-related care: ALL surgery-related pre-admission care ALL inpatient physician and hospital services, including cardiologists, cardiac surgeons, anesthesia, consultants, etc ALL surgery-related post-operative care ALL care for any related complications or readmissions Aligns incentives across provider, patient and payor

31. Delivering Evidence-Based Care ACC/AHA Class I Recommendations Pre-op antibiotics Pre-op carotid doppler studies Aspirin Epiaortic echocardiography to identify atherosclerotic ascending aorta Aggressive debridement and revascularization for deep sternal wound infections Perioperative beta blockers (or amiodarone) to reduce atrial fibrillation Statins Smoking cessation education and pharmacotherapy Cardiac rehab Withholding of clopidogrel for 5 days pre-op Left internal mammary artery as graft for the LAD artery ACC/AHA Class II Recommendations Pre-operative use of a CABG operative mortality risk model Anticoagulation for recurrent/persistent postoperative Afib Anticoagulation for postoperative anteroapical MI with persistent wall motion abnormality Carotid endarterectomy for carotid stenosis that is symptomatic or >80% Inta-aortic counterpulsation for low LV ejection fraction Blood cardioplegia Delay operation for patients with recent inferior MI with significant RV involvement Tight peri-operative glucose control

32. ProvenCare Timeline Key Points: Stages – Engagement; Evidence Compilation; Best Practices; Process Redesign; Beta; Go live production Timeline Project optimum duration = 6 months + (collaborative longer) Minimum return to evidence is 1 year Broken out in Stages but often is a continuous transition Content expert interviews & outcome discussions helpful for engagement Evidence compilation and best practice consensus often evolve simultaneously; often extend into Process redesign Ongoing redesign is an integral part of the Go-live Beta stage Key Points: Stages – Engagement; Evidence Compilation; Best Practices; Process Redesign; Beta; Go live production Timeline Project optimum duration = 6 months + (collaborative longer) Minimum return to evidence is 1 year Broken out in Stages but often is a continuous transition Content expert interviews & outcome discussions helpful for engagement Evidence compilation and best practice consensus often evolve simultaneously; often extend into Process redesign Ongoing redesign is an integral part of the Go-live Beta stage

33. CLINIC FLOW: How does a patient currently flow through this clinic? What are all of the different PATHWAYS? ILLUMINATE ANY PHYSICIAN PREFERENCES THAT CREATE VARIATION IN THE PROCESS e.g. CABG HAD 3 DIFFERENT PATHWAYS done by observing and talking with patients and clinicians – improvement specialists are heavily engaged in this process Challenge Question: Requires a level of knowledge at the front line level to complete – is it present or do we need to educate around this? Are physicians willing to standardize their practice?CLINIC FLOW: How does a patient currently flow through this clinic? What are all of the different PATHWAYS? ILLUMINATE ANY PHYSICIAN PREFERENCES THAT CREATE VARIATION IN THE PROCESS e.g. CABG HAD 3 DIFFERENT PATHWAYS done by observing and talking with patients and clinicians – improvement specialists are heavily engaged in this process Challenge Question: Requires a level of knowledge at the front line level to complete – is it present or do we need to educate around this? Are physicians willing to standardize their practice?

34. HARDWIRING THE CRITERIA IN EHR: Example: Documentation flow sheet used during pre-op CABG phase. Process steps are embedded into flow sheet, reminds the provider of the BP Facilitates the right action: automatic creation of orders (MIKE WILL COVER IN MORE DETAIL) IN PAPER MEDICAL RECORD: Creation of Check Lists Standardization of standing orders which employ “opt out” strategies so MD’s do the right thing HARDWIRING THE CRITERIA IN EHR: Example: Documentation flow sheet used during pre-op CABG phase. Process steps are embedded into flow sheet, reminds the provider of the BP Facilitates the right action: automatic creation of orders (MIKE WILL COVER IN MORE DETAIL) IN PAPER MEDICAL RECORD: Creation of Check Lists Standardization of standing orders which employ “opt out” strategies so MD’s do the right thing

35. ProvenCare CABG and PCI Note: CABG graph – small “N” causes great swings ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention & Physician Recommendation* PCI element examples: Areas such as pre- and post clopidogrel therapy Bi-carb loading 60 minutes before procedure ASA therapy Post operative groin check Challenges Patient pop managed by interventionalists and cardiologist Design a process that incorporates all the appropriate evidence based care for the quick transition from PCI diagnostics to intervention Note: CABG graph – small “N” causes great swings ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention & Physician Recommendation* PCI element examples: Areas such as pre- and post clopidogrel therapy Bi-carb loading 60 minutes before procedure ASA therapy Post operative groin check Challenges Patient pop managed by interventionalists and cardiologist Design a process that incorporates all the appropriate evidence based care for the quick transition from PCI diagnostics to intervention

36. 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 % The 117 elective CAB patients treated within the ProvenCare program in 2006-7 were compared to the 137 similar patients treated before initiation of the new processes of care. Their pre-operative characteristics and operative details were similar except that the ProvenCare patients had left main disease more often (23 vs 12%), reflecting the well described trend toward catheter intervention for lesser degrees of coronary disease in this era of drug-eluting stents. Although a trend toward improved outcomes from an already excellent baseline was observed… the only difference reaching statistical significance was in the likelihood of being discharged direct to home, favoring ProvenCare patients. The 117 elective CAB patients treated within the ProvenCare program in 2006-7 were compared to the 137 similar patients treated before initiation of the new processes of care. Their pre-operative characteristics and operative details were similar except that the ProvenCare patients had left main disease more often (23 vs 12%), reflecting the well described trend toward catheter intervention for lesser degrees of coronary disease in this era of drug-eluting stents. Although a trend toward improved outcomes from an already excellent baseline was observed… the only difference reaching statistical significance was in the likelihood of being discharged direct to home, favoring ProvenCare patients.

37. ProvenCare® CABG: Financial Outcomes Hospital: 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 Based on comparison of entire PC group (2.75 years) to baseline period.Based on comparison of entire PC group (2.75 years) to baseline period.

38. Current ProvenCare® portfolio Total hip replacement Cataract removal Percutaneous coronary intervention Bariatric operations Perinatal care and delivery Low back pain management CKD and erythropoietin Lung cancer resection Although we believe that the redesigned delivery process we’ve described is significant, we acknowledge important limitations in this work… This is not a randomized trial, and was not designed to validate individual best practices…but was intended to test our ability to reliably deliver any modification of care… Whether this can be done on a larger scale or indeed on a smaller scale is not certain… The degree to which this reengineering can be done in the absence of system integration and the support of a robust HER has not been determined… And we’re not yet sure how fee for service settings could be adapted in this scheme. GHP, our health plan partners in this project, have found that market interest in this concept is greatly increased if additional clinical areas are included.Although we believe that the redesigned delivery process we’ve described is significant, we acknowledge important limitations in this work… This is not a randomized trial, and was not designed to validate individual best practices…but was intended to test our ability to reliably deliver any modification of care… Whether this can be done on a larger scale or indeed on a smaller scale is not certain… The degree to which this reengineering can be done in the absence of system integration and the support of a robust HER has not been determined… And we’re not yet sure how fee for service settings could be adapted in this scheme. GHP, our health plan partners in this project, have found that market interest in this concept is greatly increased if additional clinical areas are included.

39. What are the cost savings with ProvenCare? Standardized supplies/drugs Standard instrument sets Reduced length-of-stay Fewer costly complications (DRG) Potential decreased liability

40. EBM in Chronic Disease

42. Improving The Reliability and Consistency of Care Delivered to a Population Chronic Care DM Improvements CAD Improvements Congestive Heart Failure Chronic Renal Failure Preventive Care Childhood Immunizations Adult Preventive Bundle

43. Operational Flows Improving reliability and safety in health care is about designing consistent operational flows An electronic health record is a tool to help create consistent designs, but is not itself the answer Sustained improvement does not rely on “I’ll remember to do it the next time”, does not rely on vigilance and hard work Operational flows make sure that the care we all know should be provided, happens every time

44. Workflow Principles Eliminate non-value added work Automate work that can be done outside of an office encounter Delegate work that is done at an office visit to trained non-physician staff when possible Create reminders and EMR tools to enhance the reliability and efficiency of care provided at the office encounter Delegate work to the patient with EMR assistance when possible

45. Systems of Care - Diabetes All or None “Bundle” measure for Diabetes Clinical process redesign – Automating the processes Clinical decision support – Health Maintenance and Best Practice Alerts Patient specific strategies using registry report data Patient centered strategies – Patient report cards Compensation

46. Diabetes Bundle Score Not all patients should achieve each measure – for instance not all diabetics should have a HgbA1c < 7 Individual component scores for GHS were very good – above the ADA recommended goals Yet initial GHS score was only 2.4% Easy to recognize that a dramatic restructuring of the care provided to diabetics was needed

47. Diabetes Bundle

48. DM Clinical Process Redesign Standardization of clinical practices – Nurse Rooming Tool, Standing Orders Automated identification of diabetics and care plan status – Health Maintenance Alerts, Disease Summary Screen Automated identification of suboptimal care – Best Practice Alerts Automatic generation of appropriate orders – Smartsets and Order Panels Automatic generation of patient specific report cards at checkout Automatic outreach to patients – Influenza / Pneumococcal Campaign, Chronic Disease Return Visit program

49. Patient Education Letter

50. Diabetes: Patient Letter/Report Card

51. Improving Diabetes Care for 23,822 patients

52. Diabetes Bundle Primary Care Average

53. Pneumococcal Immunization Age >65

56. Design of Primary Care for Basic Medical Home Continuity of care Clinical information systems = EHR Decision support: EBM protocols for chronic/acute disease Delivery system design: Open access model Patient/Family engagement Coordination of care

57. The PHN model has five core components

58. Embedded Case Managers are Key to Success Embedded Case Manager (per 700-800 Medicare pts) High risk patient case load 15 - 20% (125 - 150 pts) NOT disease education – focus those at most risk and what is driving issue with the care First steps for case identification – Predictive modeling and post-discharge Personal patient link Comprehensive care review – medical, social support Transitions follow up (acute/SNF discharges, ER visits) Direct line access – questions, exacerbation protocols Family support contact Recognized site team member Regular follow ups high risk patients Facilitate access – PCP, specialist, ancillary Facilitate special arrangements (emergency home care, hospice care) Linked to remote tele-monitoring for specific populations

59. Results have been very positive in our first 2 years* Health status Diabetes bundle Coronary disease bundle Preventive care bundle Readmissions Admissions Member/Provider satisfaction Total Medical Cost *All results are measured across the entire population of patients, not just chronic disease patients

61. ER visits, Ambulatory Surgery and High-end Imaging Have Slowed…

62. Total PMPM is Lower and Growing Less Rapidly

63. Professional PMPM increased at half the comparison group rate

64. Total PMPM is lower than the Medicare Comparison Group

65. Physician Group Practice (PGP) Demonstration Project (CMS) April 1, 2005 – March 30, 2010 Do large multispecialty group practices deliver higher quality care at lower cost than surrounding physicians and hospitals?

66. PGP Demonstration Participants NAME STATE Billings Clinic MT Dartmouth-Hitchcock Clinic NH Everett Clinic WA Forsyth Medical Group NC Geisinger Clinic PA Marshfield Clinic WI Middlesex Health System CT Park Nicollet Health Services MN St. John’s Health System MO University of Michigan MI

67. Geisinger PGP Timeline Year 1 – Chronic Disease Management Diabetes Call Center for Chronic Heart Failure Year 2 – Chronic Disease Management Diabetes, Chronic Heart Failure Gaps in Care Coding Year 3 – Chronic Disease Management Gaps in Care Coding Start Medical Home

68. Geisinger PGP Timeline – cont’d Year 4 – Chronic Disease Management Problem List Management Medical Home Chronic Heart Failure Home Monitoring Transitions of Care Year 5 - Chronic Disease Management Problem List Management Medical Home Chronic Heart Failure Home Monitoring Transitions of Care

69. PGP Demo Project Results Geisinger Clinic+ Year Total Saved % Quality Metrics 1 959 73% 2 <1,123> 100% 3 7,035 100% 4 6,977 ? +(n=26,707)

70. Caveats Beneficiaries newly assigned had a larger cost Only 30% of admissions are to Geisinger facilities Highest dual eligible population of all 2nd highest disabled population

72. ACO Lessons Reorganization of healthcare delivery to make it proactive Healthy relationship with a health plan to provide timely data and expertise is needed Use HIT to engage patient and provider

73. Lessons Learned Along the Way It is possible to improve patients’ health while reducing costs Requires change in primary care delivery model; the change is not easy Needs active, engaged providers Needs active, empowered team – “Top of the License” Access for acute care and post discharge transitions Transitions of care create specific gaps and opportunities Patients with very complex conditions need very close follow-up through every system of care Critical to have case manager embedded in primary care site

74. QUESTIONS???