Transcript Slide 1

Innovations in Reducing Cost and Improving
Quality of Health Care:
Geisinger Health System Example
Ronald A. Paulus, MD
EVP, Clinical Operations and Chief Innovation Officer
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Geisinger Health System
Last updated 07/09/09
Geisinger ProvenHealth Navigator Sites
Geisinger Inpatient Facilities
Contracted ProvenHealth Navigator Sites
Ambulatory Care Facility
Geisinger Health System Hub and Spoke Market Area
Geisinger Medical Groups
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Geisinger
HealthConfidential
Plan Serviceand
Area
Geisinger
Health System
Proprietary 2
Geisinger
Specialty
Clinics
Careworks Convenient
Healthcare
Non-Geisinger Physicians
With EHR
Geisinger
Transformation Infrastructure
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Clinical Decision Intelligence System
(CDIS)
Other Inputs
Decision
Support
EBM Guidelines
Patient Preferences
Formulary/Economics
Real-time Clinical Status
…
Effectors
EHR
Alerts
Prompts/Reminders
Order Sets
Automated care plans
Patient messages
Information Rx
CDIS
Clinical,
Schedule
…
…
Claims
Finance
Ops
Normalization, Transformation,
Analytic Application
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Creating Real Value: Geisinger’s Core
Care Transformation Initiatives
• Population Health Optimization
– Geisinger Medical Home
• ProvenHealth NavigatorSM
– Chronic Disease Care Optimization
• ProvenCare - Chronic®
• Acute Episodic Care Optimization
– ProvenCare - Acute® (aka the “surgical warranty”)
• Transitions of Care Optimization
– ProvenTransitionsSM
• Patient engagement and activation throughout
all initiatives
– ProvenEngagementSM (dealing with “non compliance”
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ProvenHealth Navigator®
Geisinger’s Value-based PatientCentered Medical Home
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Functional Components
1. Team-based, patient-centered primary care
(including embedded care management nurse)
2. Joint payor-provider population management
3. High quality, efficient specialist identification
and referral
4. Quality Outcomes Program
5. Value-based Reimbursement Program
1. Baseline FFS
2. Practice transformation stipends
3. Quality-gated gain sharing
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Acute Admissions Show Improvement
Risk-adjusted acute admits/1000 (Medicare)
350
330
310
290
270
250
230
210
190
170
150
Jan-Aug 06
GHS Phase 1
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Jan-Aug 07
GHS Phase 2
Jan-Aug 08
GHS Phase 3
Jan-Aug 09
Medicare Control Group
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Readmissions Show Improvement
Medicare Readmissions/1000
75
55
50
43
51
41
48
53
39
31
0
2006
2007
2008
Medicare Comparison Phase 1 Sites Phase 2 Sites
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Spending Decreased
Compared to Expected Trend
Spending (-8%)
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ProvenCare - Chronic®
Chronic Disease Optimization
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DM Best Practice Alert/Order Set
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MyGeisinger
Patient Reminder View
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Patient
Education
Letter
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Most recent values displayed
Patient
Trend
Report
Therapeutic goals are stated
Clinical consequences are stated
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Diabetes Bundle
Primary Care Average (n=23,404)
16%
13%
10%
7%
R2 = 0.8142
3%
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Dec-09
Sep-09
Jun-09
Mar-09
Dec-08
Sep-08
Jun-08
Mar-08
Dec-07
Sep-07
Jun-07
Mar-07
0%
Dec-06
DM Bundle Percentage
Diabetes Bundle Improvement (12/06-12/09)
CAD Bundle Primary Care
Average (n=14,714)
25%
20%
15%
10%
R2 = 0.785
5%
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Dec-09
Sep-09
Jun-09
Mar-09
Dec-08
Sep-08
Jun-08
Mar-08
Dec-07
Sep-07
Jun-07
Mar-07
0%
Dec-06
CAD Bundle Percentage
Primary Care Average CAD Bundle 12/06-12/09
Adult Preventive Care (n=209,090)
11/07
12/09
Adult Preventive Bundle
9.2%
25%
Breast Cancer Screening (q 2 40-49, q 1 50-74)
46%
61%
Cervical Cancer Screening (q 3 yr Age 21-64)
64%
73%
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%
87%
Influenza Immunization (Yearly Age >50)
47%
53%
Chlamydia Screening (Yearly Age 18-25)
22%
33%
Osteoporosis Screening (every 3 yr Age > 65)
52%
66%
18
88%
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Alcohol Intake Assessment
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84%
ProvenCare Acute®
Geisinger’s Bundled Episodic Care
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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
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Process Redesign: Work Flow
GMC Elective PCI Patient Flow
Inpatient-Hospital
admission or ER patient
with suspected CAD
Referred to
Cardiology
for work up
Clinical
assessment
warrants cath?
Pt returns to
floor
Yes
No
Returns to
cardiology clinic
for f/u
Yes
Yes
PCP referredOutpatient with
suspected CAD
Referred for
Diagnostic
Cath
ECG & Labs
ordered (CBC,
BMP, +/- PT/INR,
+/- lipid panel, +/ALT, +/- Hgb A1C)
Current
inpatient?
Referred back
to cardiology for
continued care?
No
Pt has
established
PCP?
No
Yes
No
Pt returns
home w/o f/u
Day of Cath
Reschedule GMC pt
(underwent recent
diagnostic cath that
warrants PCI)
No
Isolation pt?
No
Yes
Pt clearly
meets criteria
for PCI?
Cath
performed
Cath done by outside MD & PCI
requested or outside MD clinical
assessment and/or + stress test
warrants diagnostic cath
Hx done
over phone
by mid-level
or MD
Pt referred
for Cath
Direct
Pt
brought to
CRS
RN
physical
Labs reviewed
and informed
consent
completed, if not
done
Physical
completed by
cath lab team
person
No
Surgery
recommended
?
Does the case
warrant a discussion
w/pt, +/- another
MD?
Yes
No
No
Yes
No
Yes
Trx
started
Pt returns to
CRS or floor
(isolation pt)
Does pt
have a cath site
problem?
Yes
Obtain
CK-MB,
Triponin
ECG, CBC,
BMP
Cardiac
rehab
offered
Does pt have
increased
creatinine?
Does pt
have a cath site
problem?
Trx
started
Pt d/c to
home
Pt ready
for d/c?
Trx given
No
PCI
performed
today?
Yes
CK-MB
Q8 hrs
HD #2
No
Does pt have
another
problem?
No
Immediate
surgery
needed?
Pt scheduled
for PCI
another day
No
Does pt
have a cath site
problem?
Provider
performs cath
site exam
Yes
Yes
Yes
No
Pt accepted by
surgery?
Proceed with
PCI?
Does pt have
increased CKMB levels?
No
Pt goes to
floor
Pt returns
to CRS
No
No
Yes
Trx
started
Seen by
CT
surgery
Discussion with pt,
+/- another MD
Instructions
given to pt
(meds &
activity)
Yes
Yes
ECG, +/ lipid
panel, +/-Hgb
A1C
PCI
Performed
Yes
Does pt
have a cath site
problem?
Returns to
PCP
Pt admitted/
stays in
hosptial
Yes
Yes
Pt returns to clinic
2-12 weeks
Pt returns home w/
appt in CTVS Clinic,
schedules surgery
Yes
Devised 3/5/07
Revised 5/30/07
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Require GMC
cardiology f/u?
No
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Pt instructed to see PCP 1-4 wks &
if pt has referring cardiologist,
schedule appt. in 8-12wks
No
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Pt admitted, added
to surgery schedule
Process Redesign: Hardwiring
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®
ProvenCare CABG: Reliability
Fe
b
Ap - 06
r
Ju - 06
n
Au -0 6
g
O - 06
ct
De - 06
c
Fe -0 6
b
Ap - 07
rJu 07
n
Au -0 7
gO 07
ct
De - 07
c
Fe -0 7
b
Ap - 08
r
Ju - 08
n
Au -0 8
gO 08
ct
De - 08
c
Fe -0 8
bAp 09
r
Ju - 09
n09
% patients
receiving all
ProvenCare
components
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
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CABG Clinical Outcomes
Before
ProvenCare®
(n=132)
In-hospital mortality
Patients with any complication (STS)
Patients with >1 complication
Atrial fibrillation
Neurologic complication
Any pulmonary complication
Re-intubation
Blood products used
Re-operation for bleeding
Deep sternal wound infection
Readmission within 30 days
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1.5
38
8.4
24
1.5
7
2.3
24
3.8
0.8
6.9
%
%
%
%
%
%
%
%
%
%
%
ProvenCare®
(n=321)
0.3
33
5.9
21
0.9
5
0.9
22
2.8
0.3
5.6
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%
%
%
%
%
%
%
%
%
%
%
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% Improvement
80
13
30
13
40
29
61
8
26
63
20
%
%
%
%
%
%
%
%
%
%
%
Hospital Financial Outcomes
Time Period
July 2006 –
March 2009
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Net
Revenue
Change
Cost Change
(Variable
Direct/Total)
Net
Margin
Change
+7.8%
-5.1% /
-5.2%
+160%
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Other ProvenCare Acute Programs
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ProvenEngagement®
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The Real Caregivers…
“People with chronic conditions are the
principal care-givers. Each day, patients
decide what they are going to eat,
whether they will exercise and to what
extent they will consume prescribed
medicines.”
Bodenheimer et al, JAMA 2002
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Population by Activation Level
12% of the population
29% of the population 37% of the population
Source: J.Hibbard, University of Oregon
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22% of the population
HTN Patients Who Engage in Selfmanagement Behaviors
Source: J.Hibbard, University of Oregon
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Patient Data Capture Tools
• Give patient a voice
• Structured data
– Higher Quality
– Actionable
• Real time analytics
– Guideline based
evaluation
• Guide patientphysician dialogue
– Real time display of
advice
–
–
–
–
–
–
Why are you here?
What do you have?
What do you want?
How are you doing?
What are you taking?
How is your medicine
working?
– What are your risk factors?
– What are your barriers to
improving outcomes?
– … and the list goes on.
• Save time and money
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Summary
• Quality and efficiency are inextricably
linked together
• Efficiency originates from the same place
as quality – fundamental care model
redesign
• At Geisinger, we are trying to reinvent
many aspects of the care process
• Geisinger has many advantages due to
our integrated delivery system and its
“Sweet Spot”
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Thank You.
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ProvenTransitions®
Care Hand-off Optimization
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A Major Medicare Issue…
• “Potentially Preventable”
admissions account for
$12+ billion in Medicare
spending (>8% of $146B
total Part A spend in
2006)
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30 Day
Readmission
Rate
60 Day
Readmission
Rate
90 Days
Readmission
Rate
18%
35%
67%
(or dead)
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Drivers to Reduce Readmissions
GOAL
DRIVERS
KEY TACTICS
Early identification of readmission risk
Screening
Target interventions based on risk level
Early DC needs assessment of high risk pts
Care Mgmt:
Inpatient/
Outpatient
Team
Communications (IDTs)
Readmissions
Patient
Education/ Med
Rec
PostTransition
Care
40
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DC Planning – choose best next care setting
Outreach to OP Care Mgmt based on risk level
Seamless transition between IP & OP Care Mgt
Consistent documentation (location, content)
Multi-disciplinary care coordination
Ready the patient for successful self-care
Multidisciplinary Teaching - patient and family
Teach Who-What-When-Where if help needed
IP Pharmacist consult on high risk pts/meds
Post-DC Follow-up appt for EVERY patient
Instant communication of hospital course and followup needs to post-DC providers/agencies
MH with tele-monitoring, follow up phone calls, SNF
management
Social issues addressed (non-compliance, ability to
buy meds, advanced directives)
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ED Screening Instrument
GWV % Readmissions
6/2008 – 8/2008
3%
4%
Low
9%
Medium
2%
9%
High
11%
0%
5%
3M
10%
15%
DSS
Based upon combination of literature review, expert
interviews, Geisinger data and clinician experience
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Patients Screened
GWV MS05 Patients Screened
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
5/21
6/4
6/18
7/2
7/16
7/30
8/13
8/27
9/10
Percent of Patients Screened
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9/24
10/8
10/22
FY 09 Final Results: GWV
GWV Readmission Rate Comparison
FY 08 vs. FY09
10.0%
9.0%
8.0%
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
MS05
MS5E
MS06
3M Readm FY08
GWV Pilot
Total
GWV Non
Pilot Total
3M Readm FY09
30 Day Readmission Rate
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GWV Total
Next Up: Bundled Readmission
Payment
• Bundle proportion of historical readmission
rate/payment into up-front DRG rate
• Step down the % of historical over a 3-5 year
period (say, 95% to 60%)
• Key Advantages:
– Provides a direct incentive to reduce rates
– Enables hospitals to earn “windfall profits” during
early years
– Avoid abrupt change with negative impact
– Sets a high bar, that can be reconsidered
– Even 60% is higher than best performing Medical
Home sites, so not unrealistic
– Administratively simple
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