Geisinger Holy Spirit Hospital, Holy Spirit Hospital, Geisinger, Holy Spirit Hospital Camp Hill Pa, Dr. Ryu, Jaewon Ryu, Harvard, Walmart,
Geisinger is huge — it has 13 hospital campuses, two
research centers, a medical school, and a commercial health plan — and is
famously innovative. Its best-practice approaches have been widely adopted, and
it is spearheading one of the largest DNA-based precision-health projects in
the world. So it’s little surprise that Geisinger is a pioneer in another area,
so-called centers of excellence (COE) destination-care programs. In these
arrangements, employers such as Walmart, Lowe’s, and McKesson fly employees to
selected COEs for complex care — with remarkable results.
HBR’s Gardiner Morse spoke with Dr. Ryu about the benefits
and challenges for providers of embarking on COE programs, and their
implications for both employers and insurers. Following are edited excerpts of
their conversation.
JAEWON RYU
Geisinger Holy Spirit Hospital, Holy Spirit Hospital, Geisinger, Holy Spirit Hospital Camp Hill Pa, Dr. Ryu, Jaewon Ryu, Harvard, Walmart,
Geisinger Holy Spirit Hospital, Holy Spirit Hospital, Geisinger, Holy Spirit Hospital Camp Hill Pa, Dr. Ryu, Jaewon Ryu, Harvard, Walmart,
Why is Geisinger engaging in these arrangements with
employers to fly their employees in for care?
Partly it’s about growth. Being a destination-care provider
for employers like Walmart allows us to reach a patient population that isn’t
already getting its care within Geisinger and is beyond our backyard. So it’s a
good way for us to expand the scope and reach of what we’re doing.
But it also aligns really well with how we deliver care.
We’re big believers in developing best-practice protocols and then designing
workflows to deliver them. We have developed care protocols for many clinical
scenarios, including areas like cardiac surgery, spine surgery, chronic
obstructive pulmonary disease, diabetes management, and many others, and they
yield the best combination of quality and patient experience. It’s a program
that began years ago, and we’ve been refining the protocols and adding new ones
ever since. It’s a chassis, if you will, that these new centers-of-excellence
programs can easily build on. We have the resources, culture, and processes
already in place to develop, say, a joint-replacement bundle with an employer.
And doing that reinforces our culture and processes. There’s a positive
feedback loop.
Where does the destination-care program fit in that feedback
loop, reinforcing how people work?
We’ve seen that sometimes after you go live with a protocol
you can get what we call “beach erosion,” where over time people can become
less diligent or deliberate about making sure everyone follows the protocol.
Being one of the centers of excellence for employers in programs like these
helps prevent that erosion because it’s yet another area where the protocols
are applied. It keeps us on top of our game, as employers are paying close
attention to how we perform. So the program reinforces their consistent use.
What would you say to other providers who maybe don’t have
smooth-running protocols like Geisinger’s about the risks of these types of
programs?
That’s the ultimate question for any system that wants to
embark on this journey. For us, it made sense because it was already ingrained
as our approach to care, so there weren’t the same start-up costs and
culture-change challenges that you might see in an organization that didn’t
already have the culture and protocols in place. Also, we like reimbursement
models like bundles where we’re taking risk, because we tend to do better with
those in driving overall value than we do under an episodic, per-widget model.
But that’s part of the calculus for any provider. Do you have the culture and
operational programs and processes in place to succeed with this kind of model?
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There’s a huge opportunity for a provider that doesn’t yet
have these capabilities fully in place to pursue direct arrangements with
employers as a way to jump-start the shift. Delivering value is the direction
that health care is going — whether to patients, employer groups, the payers
you’re partnering with, or the government. Building the chassis I’ve been
talking about positions any health system better for what’s coming in the
future, and what is in many ways already here. In time, every system is going
to need to have this capability, and this kind of program is a way to get
started.
I’m assuming doing programs like these reflects well on a
provider?
Well, it can help the provider tell the story about the
value they’re offering. For instance, we work hard at making sure that we’re
not doing unnecessary procedures, so we find that a significant number of
patients referred to us for a surgical procedure actually don’t need it after
all. We take a lot of pride in that because it shows that we’re focused first
and foremost on determining what is the best care rather than on how many
procedures we can do. Data from Walmart shows that more than half of their
employees referred to centers-of-excellence programs like ours for spine
surgery end up not needing it. It can be more work to convince a patient that
they don’t need a procedure, but doing that results in the best care.
Let’s talk about the challenges. This can’t be easy.
That’s right. Make no mistake — even if you have the chassis
in place there’s still a lot of work you need to do on the culture to go live
with a program like this. We were lucky — we had a running start, if you will.
But even so, it’s not something you turn on overnight. We’ve been on this
journey for more than a decade. It takes constant work and vigilance. For
instance, even when you recruit physicians you need to make sure they are
brought along into our organizational approach and don’t introduce unwarranted
variation into how we approach care.
It also requires constant attention to make sure your
protocols are up-to-date and to assure that everyone’s aligned with them. It
turns out that if you follow evidence-based best practices reliably, great
things happen for patients. So you need physician leadership that is committed
to pursuing these protocols and tracking performance, and updating them as the
science changes.
What’s an example?
Well, the conventional wisdom that many doctors were taught
in medical school was that patients should have nothing by mouth in the hours
preceding surgery, and should be eased back on a clear liquid diet after surgery.
So essentially you’d starve them before and starve them after surgery.
But so-called enhanced-recovery-after-surgery, or ERAS,
protocols showed that patients do better if you give them enriched-nutrient
shakes before and after. Complication rates go down, length of stay goes down,
and they’re up and mobile more quickly. It runs counter to the traditional
teaching and so it makes some physicians uncomfortable, but we incorporated
this into our own protocols and it’s how we do many elective procedures now.
It’s easier to launch an approach like this systematically when your culture
embraces the need to continuously seek better ways to do things and to do them
more consistently.
Making sure everyone is on board and aligned must require
real transparency about performance. How does that work at Geisinger?
We’re firm believers in transparency. Data is probably more
visible here than you’d see at just about any other health system.
Let me give you a snapshot of what that transparency looks
like. A few years ago, we launched a primary care redesign program that focuses
on closing gaps in care. If you’re due for your mammogram or a colonoscopy, how
often are we making sure that you get those preventive services? We track this
at the level of individual providers. If you walk into any one of our primary
care sites today, there would be a whiteboard where the whole team huddles
every morning and the name of every provider in that clinic is listed on it. It
has information about their appointment availability and also a score for how
they’re doing on closing care gaps, including any missed opportunities they
might have had. Nurses are also listed there, with information about how
effectively each is setting up patients for those care-gap actions. It’s taken
some work to get us to this point, and admittedly the transparency can be
uncomfortable at first. But it helps us reinforce and support each other in
driving for the best outcomes. And I think we could do even more.
How do you manage the discomfort that this transparency must
cause? If a doctor isn’t performing well, and it’s visible to the team, that
must create tension all around.
Well, partly there’s a socialization that makes it acceptable.
Transparency is part of our culture, but it does take a little time to get used
to it. We really try not to do this in an embarrassing or “gotcha” kind of way.
There’s a lot of pre-processing and vetting with the clinical leaders and the
teams around what we’re going to measure and how we will track it, so people
are more aware of the process and reasons for it. We try to do it in a very
objective way — we’re asking, “What can we do to learn from each other and
improve the overall game?” We look at data such as the rate at which patients
within a given primary care panel are landing in the emergency room or how
often our emergency medicine physicians are ordering CT scans for non-serious
head trauma, and look for outlier behavior. Sometimes the outlier behavior is
justified. But shame on us if we’re not asking why there are outliers.
Of course, from time to time you have differences of opinion
about the accuracy of the data or to whom they’re attributed. And if there’s
any question about their applicability at the level of individual providers
we’ll focus instead on the team. So we might identify teams that are behaving
differently than others. That might be a good thing, or it might indicate a
need for change — but let’s have that discussion. I think that’s the key: The
data isn’t the be all and end all, but it can serve to start the discussion,
and framing it that way helps get acceptance.
Let’s move on to the bigger picture. What kind of impact do
you think programs like yours, where employers contract directly for care, will
have at a national level?
I think programs like these are going to grow because they
address the cost and quality problems employers are struggling with. But
destination care for defined episodes like spine surgery is only a piece of
where I think the industry is migrating. The broader approach that I expect
we’ll see a lot more of is employers directly partnering with providers for the
totality of care for their employees — taking care of the whole person, and the
whole employee population. In other words, an employer contracting directly
with a provider in a prepaid model to take care of a population. We’re already
seeing some movement in this direction.
There will be some tension between employers seeking
high-value care in these types of programs and consumers’ desire for choice.
You may get better value when an entity like Geisinger partners directly with
an employer like Walmart, but, to get that, employers need to direct their
employees to a smaller network of providers selected based on performance. If
an employer wants to preserve employees’ ability to have a phone book of
providers to choose from, there’s going to be a trade-off between employee
choice and better value, since a lot of providers may not be as focused on quality
and value in the ways we’re talking about here.
How are commercial insurers responding to all this? I’d
think they’d see it as a threat — but there’s probably an opportunity in this
for them too.
I think that’s right. On the surface, it looks like a threat
because it disintermediates them from the role they currently play in the
relationship between employers and health care providers. But the opportunity
for them is that insurers are good at identifying and contracting with quality
provider networks. And they’re good at pricing. Those capabilities will be very
important as the industry moves this way. Even if the traditional role of the
commercial insurer changes, employers still need to rely on someone to identify
high-value providers and negotiate prices and develop contracts. Currently,
third-party administrators do this, but it’s a space commercial insurers are
well positioned to move into.
What do you think the employer’s role should be in moving
employees toward higher-value networks?
I think they should be encouraging that shift, and some like
Walmart are, for instance, by giving employees a broad choice of providers but
telling them they’ll need to pick up more of the cost if they choose a provider
that’s not a Walmart center of excellence. A challenge is that employees’ and
even employers’ perception of quality and value aren’t always aligned with
reality. Sometimes people equate fancy facilities with great quality, and of
course those things aren’t always correlated. But employers need to be looking
at providers’ data and driving people toward the best ones.
What’s next for Geisinger?
We’re looking to expand the centers-of-excellence,
destination-care model to make it available to other employers as well. There’s
a scattering of local employers that are potentially interested in going down
this path. That’s the beauty of how the model was built. It can be adapted to
serve local markets, and we get the opportunity to deliver care in the way we
think is best, and we grow. The employer and employee/patient get value. I
think that’s a nice win-win-win.
Any final words of advice for employers?
Employers have an important role to play in getting better
value out of their health care dollars. They have a tremendous opportunity to
reward providers that deliver value. The more employers seek out and contract
directly with the best providers, the more traction these types of programs
will get — and everyone benefits.THE BIG IDEA
About the author: Gardiner Morse is a senior editor at
Harvard Business Review.
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