Contributor: Jaewon Ryu, MD, JD
To learn more about Jaewon, click here.
Before ‘value-based care,’ ‘alternative payment models,’ and even ‘electronic health record’ became buzzwords, Geisinger was thinking about what went wrong in U.S. healthcare, which also meant thinking about ways to improve it. Nearly 20 years ago, our leadership questioned the rationality of a reimbursement system that solely rewards quantity over quality in care delivery. Revenue derived from illness and its complications rather than preventing illness in the first place simply made no sense.
We decided to do something about it.
To upend the status quo of misaligned incentives in healthcare, Geisinger refocused on optimizing health clinically, operationally, and financially. That meant our care delivery services needed to move upstream of acute care delivery. To improve the health of the people we serve – and to do so at lower cost – we needed to prevent illness from happening in the first place.
We recognized, however, that no matter how effective such preventive programs were, acute illness would still always impact some portion of the people in our care. We developed a new payment model of bundled services of evidence-based, condition-specific protocols that would ensure high-quality, consistent, and complete care without incentivizing unnecessary care. It would align clinicians, payers, and patients in achieving better outcomes at lower overall cost.
The solution we landed on over 10 years ago – and discussed when we first contributed to the Wharton Healthcare Quarterly in 2012 – became known as ProvenCare,® and we piloted it with coronary artery bypass graft (CABG) procedures. ProvenCare sought to reduce unwarranted variation across certain episodes of care and, by doing so, it lowered complication rates and reduced readmissions. Now, several iterations later, we’ve expanded to dozens of additional procedures and, more recently, we applied this same framework to incorporating ‘enhanced recovery after surgery’ into a series of protocols now called ProvenRecovery. From 2017 to 2020, ProvenRecovery led to a 75% reduction in mortality, 18% reduction in complications, 13% reduction in lengths of stay, and 15% reduction in readmissions. ProvenRecovery is even helping solve the opioid epidemic by systematically managing pain in order to minimize the need for opiate analgesics. In the past three years, ProvenRecovery has cut post-operative opioid prescriptions by more than half. And, in an example like bariatric surgery, costs have been reduced by more than 16% compared to industry benchmarks.
ProvenCare
The common sense, patient-centered concept of ProvenCare and ProvenRecovery has become the foundation of how Geisinger thinks about healthcare. Today, Geisinger is an integrated health system built on a culture of innovation and continuous improvement, a place where all stakeholders – providers, payers, and patients – are aligned to move care further upstream, provide complete care and, together, prevent unnecessary and costly care.
Today, we’re adapting this thinking to continually shift from the traditional notion of focusing most of the delivery of care services in large tertiary/quaternary campuses to developing care programs and meeting people and communities closer to where they are, whether in the home, in smaller and more convenient access points out in the communities, or even virtually. Our strong belief, rooted in real-world data, is that the modern-day approach to value-based care should focus on building great programs and deploying them right into the communities that need them most. This thinking has spawned a number of value-based innovations with proven value clinically, operationally, and financially:
- 65Forward is a senior-focused primary care model that combines health services and wellness activities within its centers. With patient panels limited to a fifth of the size of typical primary care panels, 65Forward provides seniors with same-day appointments and longer visits, often up to a full hour with their PCP. The centers try to co-locate many of the most common services under one roof, including lab, imaging, mental health, and dietary guidance. They also offer seniors fitness and exercise equipment, as well as activities from yoga to card games to promote socialization, friendships, and a true sense of community. Each member is provided a personal wellness plan and wellness coordinators to help them stay on track. The result of this kind of integrated, convenient health care? 65Forward members have about 15 percent lower inpatient hospitalization rates and about 40 percent lower rates of emergency room visits.
- The Fresh Food Farmacy program provides food as medicine to treat type 2 diabetes and other diet-sensitive conditions. By supplying fresh produce and lean meats for about 18,000 meals weekly to participants and their household members, it has proven to be a successful program for battling food insecurity and managing chronic disease. Participants require hospital admission 22 percent less often and go to the ER 18 percent less, which of course leads to lower total cost of care. Not to mention that Fresh Food Farmacy has been about twice as effective as traditional medications in controlling blood sugar levels.
- Mail-Order Pharmacy, our pharmacy delivery service, delivers maintenance medications to patients dependably and timely. Use of the program exploded during the COVID-19 pandemic, but even before that, the program was growing in popularity for its convenience and affordability. When patients didn’t have to worry about refills or travel to the pharmacy, they were able to stay on their medications more consistently, with a nearly 40 percent increase in medication adherence. The Mail-Order Pharmacy program is proof that convenience pays dividends in better health.
- Geisinger at Home moves team-based monitoring and actual care into the homes of our sickest 3 to 5 percent of patients, particularly frail seniors who live alone, and coordinates with primary and specialty care to provide ongoing clinical services as needed. For the more than 7,600 patients who have been enrolled in the program, we’ve seen a 23 percent drop in ED visits and a 35 percent decline in hospital admissions.
- The Geisinger Commonwealth School of Medicine is a critical piece in how we get upstream to provide care closer to home in our communities. We’re now several years into offering the Abigail Geisinger Scholars program, which provides medical students a tuition-free education and living stipend in exchange for a work commitment back to Geisinger in critically needed areas like primary care. Abigail Geisinger Scholars now make up about 40% of our M.D. admissions. By removing financial anxieties that could sometimes steer students away from primary care and into specialized practices, we’re building a pipeline of primary care providers who are trained in our innovative models, which bolster the ability to develop care models that manage total health and prevention. Through all of this, medical education becomes more accessible to people who may be the first in their families to go to college or pursue medicine while fostering a more diverse healthcare workforce.
Across all these programs and those still to come, addressing total health is at the core of how Geisinger moves care upstream. These and other programs meet people where they are — in their homes, communities, virtually, and in rural and urban areas — and help to identify and overcome the barriers to care (social and otherwise) in order to achieve better health. Of course, bringing such programs to life is enabled by investments in technology and people, but we have seen firsthand that improved health in the community’s results from these efforts.
ProvenCare was just the first chapter in Geisinger’s value-based care book ten years ago – one we are still writing today. It was the beginning of a mindset built on the belief and confirmed by data that more care isn’t always better care. While building a value-based health model is admittedly very difficult and we still have much left to do, we believe Geisinger has proven that pursuing a single north star – moving upstream to create better outcomes – can restructure care delivery so it aligns and creates value for providers, payers, and patients alike.
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