Post on 02-Apr-2015
© 2012 by Geisinger Health System – All Rights Reserved
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Innovations That Have Driven
Geisinger’s Performance
Earl Steinberg, MD, MPP EVP, Innovation & Dissemination
Geisinger Health System
GEISINGER–An Integrated Health Services Organization
Provider Facilities$1,671M
PhysicianPractice Group
$757M
Managed Care Companies
$1,541M
Geisinger Medical Center & Geisinger Shamokin Area Community Hospital Geisinger Wyoming Valley Medical Center Geisinger Community Medical Center Geisinger Bloomsburg Hospital 2 Nursing Homes 3 Surgery Centers 77K admissions/OBS & SORUs 1,619 beds
Multispecialty group ~1,029 employed physicians ~600 advanced practitioners 73 primary & specialty clinic sites ~2.1M clinic outpatient visits ~464 resident & fellow FTEs
~322K members (including ~68K Medicare Advantage members)
Diversified products
~34K contracted providers/facilities
43 PA counties
Strictly Confidential and Proprietary
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Geisinger Health System coverage area
Revised 12-12-12. Geisinger PR & Marketing Department
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Overview of Strategic PlanQuality 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
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Strictly Confidential and Proprietary
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Key Process Redesign StrategiesFocus on quality and efficiency of care.
Agree on standardized “production functions”.
Eliminate steps that are unnecessary.
Automate any 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 workflows with 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
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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
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Alerts Prompts/Reminders Order Sets Automated care plans Patient messages Information Rx …
Effectors
…
EBM GuidelinesPatient Preferences
Formulary/Economics
Other Inputs
EHR
Clinical, Schedule
…
Real-time Clinical Status
Decision Support
CDIS
Normalization, Transformation, Analytic Application
FinanceClaims Ops
…
Clinical Decision Intelligence System (CDIS)
…Po
pula
tion
Tre
nds
Empi
rica
l Nor
ms
Strictly Confidential and Proprietary
Electronic Health Record (EHR)
• Decision to implement Epic®: 1995• ~$135M invested in hardware, software, manpower,
training prior 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)
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Strictly Confidential and Proprietary
Regular Care
100% Care Processes and Protocols (Digital)
AutomationPatient
Activation
Populations
Workflow Modification
Patients and Conditions
Population Identification
Bundle Development
Delegation and
Algorithms
Low Efficiency and Reliability High
Reengineering Clinical Care
Strictly Confidential and Proprietary
Closing Care Gaps: Content, People and Health Information Technology (HIT) PeopleContent HIT
Heart Failure
HTN and LipidsObesity
CKD
*End of Life
Vascular DiseaseOsteoporosis
Asthma/COPD
*Medication Safety
Automating orders
Real-time opportunity reports
Clinical WorkgroupsClinical Data Capture
DiabetesPrevention
CAD Problem List Manager
Office-Based Decision Support
Automating outreach
Diagnosis Naming Conventions
Medical Informatics
Innovation
EPIC Design Team
Data Visualization
Patient Reported Data Capture
*Atrial Fibrillation
Analytics and IT
Care Gaps Manager
Patient Communication
Care Gaps Team
Outpatient Reengineering and Innovation Oversight
Scheduling Services
Strictly Confidential and Proprietary
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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
• Carotid Eval• Vascular Consult• Inf.MI/RV• Clopidogrel• Warfarin• Beta Blockade• Smoking Cessation
• Beta Blockade
• Clopidogrel
• Warfarin
• Antibiotics• Glycemic Control• IABP use• Atherosclerotic
Aortas• Cardioplegia• Arterial Conduits
• Antibiotics• Glycemic Control• Beta Blockade• ASA Therapy• Afib prevention• Lipid
management• Ant.MI/WMA• Smoking
Cessation
• Beta Blockade• ASA Therapy• Lipid
management• Cardiac Rehab• Smoking
Cessation
Clinic Pre-op OR Post-opReturn Clinic
1211
ProvenCare® CABG: Process flow
Strictly Confidential and Proprietary
ProvenCare® & the Electronic Medical Record (EMR)
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Strictly Confidential and Proprietary
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Strictly Confidential and Proprietary
Reporting Period: FY2011 Q4 Apr-JunUpdate Date: July 5, 2011
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Strictly Confidential and Proprietary
Clinical Outcomes:O / E ratios for STS risk-adjusted outcomes
BeforeProvenCare®
N = 132
AfterProvenCare®
N = 554
% Improvement
(Deterioration)
Mortality 0.85 0.46 46 %
Prolonged ventilation 1.22 0.97 20 %
Deep sternal wound infection
1.15 0.41 64 %
Re-operation 1.14 1.07 6 %
Patients with any complication (STS)
1.00 1.08 (7 %)
Permanent stroke 1.04 1.18 (13 %)
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Strictly Confidential and Proprietary
Base Line (FY2006)
Look Back (FY2010)
Variance
Cases 116 131 15
LOS (days) 7.60 6.28 (1.32)
CM Per Case ($) 17,810 21,949 4,139
Net Revenue per Case ($) 35,482 43,429 7,947
Financial Results: CAB
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Strictly Confidential and Proprietary
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Current Status: NICU Admission Rates
NICU Admission Rates and LOS for Pre and Post-ProvenCare Implementation
• 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)
Definitions and inclusion criteria
Chi square p-value for NICU admission: <0.01
Patient GroupGHS NICU
admitsTotal GHS deliveries
% admitted to NICU Average LOS
Pre-ProvenCare 427 4435 9.6 18.7Post-ProvenCare 321 4176 7.7 16.8
Strictly Confidential and Proprietary
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ProvenCare® - Chronic Disease
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Improved Care for 25,071 Diabetics3/06 3/07 8/10 8/11
Diabetes Bundle Percentage* 2.4% 7.2% 13.0% 12.5%
% Influenza Vaccination 57% 73% 75% 76%
% Pneumococcal Vaccination 59% 83% 83% 82%
% Microalbumin Result 58% 87% 78% 78%
% HgbA1c at Goal 33% 37% 52% 50%
% LDL at Goal 50% 52% 54% 55%
% BP < 130/80 39% 44% 55% 57%
% Documented Non-Smokers 74% 84% 85% 85%
* Represents % of pts in whom all indicated services were provided
Strictly Confidential and Proprietary
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Improved Care for 15,532 CAD Patients
9/06 3/07 8/10 8/11
CAD Bundle Percentage 8% 11% 22% 23%
% LDL <100 or <70 if High Risk
38% 37% 50% 52%
% ACE/ARB in LVSD,DM, HTN 65% 66% 76% 77%
% BMI measured 79% 86% 99% 99%
% BP < 140/90 74% 74% 79% 81%
% Antiplatelet Therapy 89% 91% 92% 93%
% Beta Blocker use S/P MI 97% 97% 97% 97%
% Documented Non-Smokers 86% 86% 87% 87%
% Pneumococcal Vaccination 80% 80% 86% 86%
% Influenza Vaccination 60% 74% 78% 78%
Strictly Confidential and Proprietary
Improved Preventive Care for 220,946 Patients11/07 8/11
Adult Preventive Bundle 9.2% 31%
Breast Cancer Screening (q 2 40-49, q 1 50-74) 46% 61%
Cervical Cancer Screening (q 3 yr Age 21-64) 64% 71%
Colon Cancer Screening (Age 50-84) 44% 66%
Prostate Cancer Discussion (Age 50-74) 72% 77%
Lipid Screening (Every 5 yr M > 35, F > 45) 75% 87%
Diabetes Screening (Every 3 yr > 45) 85% 90%
Obesity Screening (BMI in Epic) 77% 97%
Documented Non-Smokers 75% 78%
Tetanus Diphtheria Immunization (every 10 yr) 35% 72%
Pneumococcal Immunization (Once Age >65) 84% 86%
Influenza Immunization (Yearly Age >50) 47% 59%
Chlamydia Screening (Yearly Age 18-25) 22% 37%
Osteoporosis Screening (every 3 yr Age > 65) 52% 73%
Alcohol Intake Assessment 84% 92%
Strictly Confidential and Proprietary
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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
Medicare Risk Adjusted Acute Admissions Per 1000
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2006 2007 2008 2009 2010 20110
50
100
150
200
250
300
350309 300 303 292 286 276
257240 232 240
226
295
PHN Non-PHN 44 Current PHN Sites
Strictly Confidential and Proprietary
Medicare Risk Adjusted Readmissions/1000
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Strictly Confidential and Proprietary
2006 2007 2008 2009 2010 20110
5
10
15
20
25
30
35
40
45
50 47 46 4744
42 4141
3034 34
31
44
PHN Non-PHN 44 Current PHN Sites
Medicare Risk Adjusted ER Visits/1000
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2006 2007 2008 2009 2010 20110
50
100
150
200
250
300
350
264250
264284 295
329
293
262 257 260 262267
PHN Non-PHN 44 Current PHN Sites
Strictly Confidential and Proprietary
ProvenHealth Navigator® Reduces Cost Trend
-12%
-10%
-8%
-6%
-4%
-2%
0%Q
1 2
00
5
Q3
20
05
Q1
20
06
Q3
20
06
Q1
20
07
Q3
20
07
Q1
20
08
Q3
20
08
Q1
20
09
Q3
20
09
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 = < 0.003Source: Reducing Long-Term Cost by Transforming Primary Care: Evidence From Geisinger's Medical Home Model (Am J Manag Care. 2012;18(3):149-155)
• Medical expense trend reduced by
7.1%, p<.01
• ROI for all years 2007-2010, with Rx
coverage = 1.7
95% Confidence Interval
95% Confidence Interval
Median Estimate
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Strictly Confidential and Proprietary
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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
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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
Consulting
Population Health Data Analytics
Care Management
Third Party Administration
EHR Applications, Including Licensing Intellectual Property 30
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Relationship between GHS and xG Health Solutions
GHS “Core Operations”
Engine of
IP Development
Clinical
Enterprise
Geisinger
Insurance
Organization
Researc
h
Geisinger
Support
Services
Newco IP
“Productization”
Health Care Delivery Systems
Insurers
Product Manufacturers
Execute Core Business/Innovate Generalize/Disseminate/$ Return
EMR Vendors
IP
xG“Product Development & Service Delivery”
Innovation & Transformation
Quality & Safety
Products/Services
ACO Support Services
Consulting
Software Apps
ASP Software Solutions
IP Licensing
Medicare FFS / Advantage
Assets in Newco
Financial Capital
Human Capital
Partner relationships
Administrative resources
Technology Resources
Strictly Confidential and Proprietary
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
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Target market for xG service offerings
Strictly Confidential and Proprietary
Commercial
Customers
Medicare
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
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
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+
Medicare Advantage
Provider (or insurer) offering MA plan benefits from capabilities that improve their performance
• 1,974 plans
• >13mm MA lives
Medicare ACOMany 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
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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
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Information Management/Data Analysis/Reporting Svcs.
Data management
• Substantial experience/expertise in obtaining and integrating data
• Exceptional experience and expertise in QA-ing data
Strictly Confidential and Proprietary
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.
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Actuarial informatics process
Strictly Confidential and Proprietary
• Produce Medical Expense Trend Report (METR)• Utilization Per 1,000; Unit Costs, Cost Projections • ID of cost and utilization drivers; drill down capability
Assess Customer’s Current and Historical 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?
Identify Opportunities to Reduce Care Costs
Gain “Action Item” Consensus
Estimate Anticipated Cost Savings
Monitor Actual Cost Savings
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• 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
Clinical data analytics process
Strictly Confidential and Proprietary
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Differentiated Medical Management
Strictly Confidential and Proprietary
Acute Care Management
Chronic Care Management
• 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
Patient Identification and
Stratification
• Screenings• Data-analytically driven ID
of needs • Automated outreach
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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
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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
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Questions We Hope to Answer
• Reproducible?• Scalable?• Similar impacts?
Strictly Confidential and Proprietary