Innovations That Have Driven Geisinger’s Performance Earl Steinberg, MD, MPP EVP, Innovation & Dissemination Geis

1. Innovations That Have Driven Geisinger’s Performance Earl Steinberg, MD, MPP EVP, Innovation & Dissemination Geisinger Health System

2. GEISINGER–An Integrated Health Services Organization Provider Facilities $1,671M Physician Practice Group $757M Managed Care Companies $1,541M • ~322K members (including ~68K Medicare Advantage members) • Diversified products • ~34K contracted providers/facilities • 43 PA counties • Geisinger Medical Center & Geisinger Shamokin Area Community HospitalGeisinger Wyoming Valley Medical Center Geisinger Community Medical CenterGeisinger Bloomsburg Hospital2 Nursing Homes • 3 Surgery Centers77K admissions/OBS & SORUs1,619 beds • Multispecialty group~1,029 employed physicians~600 advanced practitioners • 73 primary & specialty clinic sites~2.1M clinic outpatient visits~464 resident & fellow FTEs Strictly Confidential and Proprietary

3. Geisinger Health System coverage area Revised 12-12-12. Geisinger PR & Marketing Department

4. Overview of Strategic Plan • Quality and Innovation • Patient centered focus • Patient activation (empowerment) • Culture of quality, safety and health • Value re-engineering • Transformational changes – embedding innovations • Market Leadership • Collaboration/partnerships (local, regional, national) • The GHS Brand • Scaling and generalizing • The Geisinger Family • Personal and professional well being Strictly Confidential and Proprietary

5. Key Process Redesign Strategies Focus onquality and efficiency of care. Agree onstandardized “production functions”. Eliminatesteps that are unnecessary. Automateany work that can be automated. Delegate work to appropriately trained non-physician staff when possible. (All personnel to “operate at the top of their license”.) Support agreed upon workflowswith various types of EMR reminders, decision support tools and work flow facilitators to increase the reliability of the care provided. Activate and engage the patient and their family. Strictly Confidential and Proprietary

6. Major Geisinger Re-Engineering Initiatives • Enterprise Data Warehouse • Make the EMR a Member of the Team • Primary Care Redesign • ProvenCare® (Acute and Chronic) • ProvenHealth® Navigator (Advanced Medical Home) • Transitions of Care • GAPP (Geisinger Accelerated Performance Program) Strictly Confidential and Proprietary

7. OtherInputs Decision Support EBM Guidelines Patient Preferences Formulary/Economics … Empirical Norms Real-time Clinical Status Effectors Population Trends … Alerts EHR Prompts/Reminders CDIS Order Sets Automated care plans Clinical, Schedule … Patient messages Information Rx … Claims Finance Ops Normalization, Transformation, Analytic Application Clinical Decision Intelligence System (CDIS) … Strictly Confidential and Proprietary

8. Electronic Health Record (EHR) • Decision to implement Epic®: 1995 • ~$135M invested in hardware, software, manpower, trainingprior to 2012 hospital acquisitions • EPIC Team: 200 employed FTEs + 70 contracted FTEs • Operating costs: >$25M per year • EHR fully-integrated across all ambulatory and inpatient sites of care (In process for recently acquired hospitals) • > 3.8 million distinct patient records • ~ 4,000 non-Geisinger users (referring physicians) | Strictly Confidential and Proprietary

9. Reengineering Clinical Care Population Identification Patients and Conditions Populations Bundle Development 100% Care Processes and Protocols (Digital) Low Efficiency and Reliability High Workflow Modification Regular Care Delegation and Algorithms Automation Patient Activation Strictly Confidential and Proprietary

10. Closing Care Gaps: Content, People and Health Information Technology (HIT) Content People HIT Prevention Outpatient Reengineering and Innovation Oversight Diagnosis Naming Conventions Diabetes Problem List Manager CAD Care Gaps Team Clinical Data Capture CKD Clinical Workgroups Patient Reported Data Capture Heart Failure Innovation Vascular Disease Office-Based Decision Support Osteoporosis Medical Informatics Obesity EPIC Design Team Automating orders HTN and Lipids Automating outreach Analytics and IT Asthma/COPD Real-time opportunity reports Scheduling Services *End of Life *Medication Safety Data Visualization *Atrial Fibrillation Care Gaps Manager Patient Communication Strictly Confidential and Proprietary

11. ProvenCare® for Acute Episodic Care Identified best practices Developed operational definitions when needed Obtained MD buy-in Developed tools to facilitate compliance with best practices and integrated them into work flow Provided financial incentives to comply Monitor performance Strictly Confidential and Proprietary

12. ProvenCare® CABG: Process flow Return Clinic Clinic OR Pre-op Post-op • Antibiotics • Glycemic Control • IABP use • Atherosclerotic Aortas • Cardioplegia • Arterial Conduits • Carotid Eval • Vascular Consult • Inf.MI/RV • Clopidogrel • Warfarin • Beta Blockade • Smoking Cessation • Antibiotics • Glycemic Control • Beta Blockade • ASA Therapy • Afib prevention • Lipid management • Ant.MI/WMA • Smoking Cessation • Beta Blockade • Clopidogrel • Warfarin • Beta Blockade • ASA Therapy • Lipid management • Cardiac Rehab • Smoking Cessation 11 Strictly Confidential and Proprietary

13. ProvenCare® & the Electronic Medical Record (EMR) Strictly Confidential and Proprietary

14. Strictly Confidential and Proprietary

15. Strictly Confidential and Proprietary

16. Clinical Outcomes: O / E ratios for STS risk-adjusted outcomes Strictly Confidential and Proprietary

17. Financial Results: CAB Strictly Confidential and Proprietary

18. Current Status: NICU Admission Rates NICU Admission Rates and LOS for Pre and Post-ProvenCare Implementation Chi square p-value for NICU admission: <0.01 Definitions and inclusion criteria • All patients are classified as "GHS patients." This means the mothers of the infants were seen for at least 13 weeks prior to delivery by a GHS provider and delivered in a GHS hospital. • All patients were admitted to the NICU within 24 hours of birth. • Pre-ProvenCare represents the period from January 2007-March 2009 (27 months) • Post-ProvenCare represents the period from April 2009-Dec 2010 (21 months) Strictly Confidential and Proprietary

19. ProvenCare® - Chronic Disease

20. Improved Care for 25,071 Diabetics * Represents % of pts in whom all indicated services were provided Strictly Confidential and Proprietary

21. Improved Care for 15,532 CAD Patients Strictly Confidential and Proprietary

22. Improved Preventive Care for 220,946 Patients 21 Strictly Confidential and Proprietary

23. ProvenHealth Navigator® (Advanced Medical Home) Partnership between primary care physicians and Geisinger Health Plan (GHP) GHP nurses embedded in primary care practices Easy, reliable phone access for patients Follow-up calls after hospitalizations and ER visits Telephonic and digital monitoring Group visits/educational services Personalized tools (e.g., chronic disease report cards) Strictly Confidential and Proprietary

24. Medicare Risk Adjusted Acute Admissions Per 1000 Strictly Confidential and Proprietary

25. Medicare Risk Adjusted Readmissions/1000 Strictly Confidential and Proprietary

26. Medicare Risk Adjusted ER Visits/1000 Strictly Confidential and Proprietary

27. ProvenHealth Navigator® Reduces Cost Trend • Medical expense trend reduced by 7.1%, p<.01 • ROI for all years 2007-2010, with Rx coverage = 1.7 95% Confidence Interval Median Estimate 95% Confidence Interval Cumulative percent difference in spending (Pre-Rx Allowed PMPM $) attributable to PHN in the first 21 PHN clinics for calendar years 2005-2009. Dotted lines represent 95% confidence interval. P = < 0.003 Source: Reducing Long-Term Cost by Transforming Primary Care: Evidence From Geisinger's Medical Home Model (Am J Manag Care. 2012;18(3):149-155) Strictly Confidential and Proprietary

28. Key Characteristics of Geisinger Health System • Strong physician leadership paired with admin. partner • Organizational culture that prioritizes quality, efficiency and innovation • Work force that embraces the culture • A clinical enterprise and a health plan • Clear, shared aims • Incentives aligned with aims • Team and system of care orientation • Infrastructure (IT, IM, EMR, Data Analytics) • Skunk works and transformation units • Focus on work flow and reliability • Performance measurement and feedback Strictly Confidential and Proprietary

29. Payment Changes Creating New Market Needs • Changes in the way health care is paid for is prompting many health care providers to begin to change how they are organized and deliver care. • Most providers lack the capabilities that will be required to be successful under risk- and/or performance-based payment. • Health care providers thus will need help to transition from a volume- to a value-oriented payment system Strictly Confidential and Proprietary

30. Consulting • Population Health Data Analytics • Care Management • Third Party Administration • EHR Applications, Including Licensing Intellectual Property

31. Assets in Newco Financial Capital Human Capital Partner relationships Administrative resources Technology Resources Newco IP “Productization” Relationship between GHS and xG Health Solutions GHS “Core Operations” xG “Product Development & Service Delivery” Execute Core Business/Innovate Generalize/Disseminate/$ Return Quality & Safety Innovation & Transformation Health Care Delivery Systems Products/Services ACO Support Services Consulting Software Apps ASP Software Solutions IP Licensing Medicare FFS / Advantage IP Insurers Product Manufacturers EMR Vendors Strictly Confidential and Proprietary

32. xG Products and Services • Services to Support Value-Driven Care • Population Health Data Analytics • Care Management • Consulting Services • Licensing Geisinger IP to product manufacturers and health care delivery systems • Software apps based on Geisinger IP (possibly) Strictly Confidential and Proprietary

33. Target market for xG service offerings Commercial Customers Health System Employees and Dependents Self-insured providers seeking to reduce their own health care costs; view as “safest” place to start, no need to share savings • 250+ systems with 10,000+ EE opportunity Large Local/Regional Employers Large regional employers looking to reduce medical costs through direct partnership with health systems; health systems looking to “lock in” lives • 158 MSAs with population 300,000+ • 314 MSAs with population 120,000+ Health System All Payer Shared Savings Model • Health systems want to employ more uniform infrastructure for shared savings plans across all commercial payers • Commercial and Government business • 194.5mm Americans have private health insurance • Concentration amongst the largest 25 providers Medicare ACO Many providers participating in CMS ACO programs looking to buy vs. build capabilities needed to be successful • 49mm Medicare lives • 154 shared savings programs in place • 400 LOIs for 1/13 MSSPs Medicare Customers Medicare Advantage Provider (or insurer) offering MA plan benefits from capabilities that improve their performance • 1,974 plans • >13mm MA lives Strictly Confidential and Proprietary

34. Geisinger Consulting Group Services • Organizational strategy, leadership and transformation • MD compensation and alignment • ACO readiness • Primary care redesign • EMR optimization • ProvenCare® • Patient-centered medical home model • Embedded case manager certification • Care transitions • Bundled payment • Inpatient efficiency Strictly Confidential and Proprietary

35. Information Management/Data Analysis/Reporting Svcs. Data management • Substantial experience/expertise in obtaining and integrating data • Exceptional experience and expertise in QA-ing data Data Analytics • Algorithms/Software programs to perform actuarial analyses • Experience analyzing EMR data and Algorithms/Software programs to perform clinical analyses of claims data and EMR data • Expertise in interpreting the results for those analyses – much of this can be automated Care Management • ProvenCare®, ProvenHealth Navigator®, numerous templates used by case managers, primary care re-design methods, etc. Strictly Confidential and Proprietary

36. Actuarial informatics process Assess Customer’s Current and Historical Care Costs • Produce Medical Expense Trend Report (METR) • Utilization Per 1,000; Unit Costs, Cost Projections • ID of cost and utilization drivers; drill down capability Identify Opportunities to Reduce Care Costs • Compare experience to Geisinger and national benchmarks and identify drivers of admissions, readmissions, Rx costs etc. • Are costs driven by excess Utilization, high Unit Costs or both? What utilization represent biggest opportunities? • Prospects for reduction of unit costs and out of network utilization? Gain “Action Item” Consensus Estimate Anticipated Cost Savings Monitor Actual Cost Savings Strictly Confidential and Proprietary

37. Clinical data analytics process • Predictive modeling to identify patients with highest cost risk • Clinical segmentation to identify patients with highest clinical risk • Identification of specific, actionable “gaps in care” • Assessment of quality of care being delivered to entire population • Provider profiling • Quality of care • Cost of care • Drivers of cost of care • Reporting • Executive dashboard • Clinical overview for CMO • MD-specific profiles Strictly Confidential and Proprietary

38. Differentiated Medical Management Patient Identification and Stratification Chronic Care Management Acute Care Management • Screenings • Data-analytically driven ID of needs • Automated outreach • Primary care re-design • Proven PCMH Model • Specially selected/trained embedded case managers • Standardized processes/protocols, including ProvenCare® chronic, case management workflows • Data analytically driven EBM • Medical Neighborhood (Continuum of Care) • Transitions of Care Model • ProvenCare® Acute • Strategies to increase efficiency • Transitions of Care Model Strictly Confidential and Proprietary

39. Licensing Geisinger IP • Types of IP • - Software prototypes (e.g. for managing workflow in anatomic and cyto- • pathology labs; for managing patients with rheumatoid arthritis, low back • pain or headache) • - Clinical content (e.g. care protocols, order sets, discharge instructions) • - Clinical decision support tools (e.g. triggers for best practice alerts for • MDs, nurses and patients) • - Work flow facilitators (e.g. flow sheets, templates, algorithms) • - Technical specifications for data analyses and reports • Potential Licensees • - Health care delivery systems • - Insurers • - EMR vendors • - Other product/software manufacturers (e.g. McKesson, Trizetto, IBM) • - Consulting firms Strictly Confidential and Proprietary

40. Web-based Apps Based on Geisinger IP (“Geisinger in the Cloud”) • Exploring feasibility of having apps exchange data with EMRs • Examples of Potential Apps: • - Management of patients with particular problems (e.g. rheumatoid arthritis) • - ProvenCare modules (e.g. CABG, diabetes, perinatal care), including reports on compliance • - Patient referrals to highest quality/lowest cost providers • - Patient scheduling • - Hospital discharge (transition of care) • - Work flow support for case manager embedded in PCMH • - Clinical decision support tools • - Templates for collection of standardized data for research collabs. Strictly Confidential and Proprietary

41. Questions We Hope to Answer Reproducible? Scalable? Similar impacts? Strictly Confidential and Proprietary