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MANAGED CARE January 2008. ©MediMedia USA
Cover Story
Leading With Its Heart Program
Geisinger’s “warranty” for CABG surgery has gotten a lot of attention, but is it transplantable?
Somewhere along the line the word “warranty” was used to describe ProvenCare, Geisinger Health System’s experimental program for coronary artery bypass graft (CABG) surgery. It stuck.
Geisinger is a health care company in central and northeastern Pennsylvania with about 2.6 million members. It includes Geisinger Health Plan, which has about 210,000 beneficiaries, and a 650-member physician group practice, Geisinger Clinic. Although Geisinger itself doesn’t call ProvenCare a warranty program, it is not above mentioning that publications as diverse as the New York Times and the British Medical Journal describe it that way. When a group of Geisinger clinicians published an article about ProvenCare in the October issue of the Annals of Surgery, “warranty” appeared several times within quotation marks.
Newspapers and medical journals duly expressed some caveats. For instance, since Geisinger Clinic offers the warranty to Geisinger Health Plan, the money stays in-house. There is also more cooperation between insurer and provider than you might expect to find under normal circumstances.
Pure form
Questions have also been raised about whether the sample size of the initial experiment, 137 CABG patients treated between Feb. 2, 2006 and Feb. 2, 2007, was statistically meaningful, though it’s meaningful enough to Geisinger officials for them to have maintained ProvenCare. This “pure form of P4P,” as it was described in the Annals of Surgery, will probably not work for emergency room surgery, for instance. Then there’s the whole issue of transferability. Could it even work as planned for CABG outside of a group model health insurer?
Nonetheless, there’s a lot to like about it, and if it never gets replicated completely, still, aspects of it are bound to have their effect.
ProvenCare works like this. One of the three hospitals involved charges a flat fee for CABG “plus 50 percent of the historically expected cost of management of complications” for the next 90 days, according to Alfred S. Casale, MD, a cardiac surgeon at Geisinger Wyoming Valley Heart Hospital in Pennsylvania.
“What we’ve essentially said to the Geisinger Health Plan and will say to other payers [emphasis added, and more on this later] is that by doing this program and you giving us a package price that includes a 50-percent share of what you could have been expected to pay for post-operative complications, we’ll transfer the risk for that care from you as a payer to us as a health system,” says Casale.
If, because of complications, a CABG patient requires additional care or hospitalization, GHP is not charged for that follow-up care. For instance, Geisinger Clinic will pick up the cost for additional hospital stays, typically $12,000 to $15,000.
In this manner, ProvenCare is an add-on for the traditional diagnosis-related group system, says Jaan Sidorov, MD, a consultant, a member of MANAGED CARE’s Editorial Advisory Board, and a former medical director at Geisinger. “ProvenCare differs in that the global payment for the episode includes not only the patient DRG but certain additional services as well, such as an unplanned re-admission. It also covers for a period of time after discharge of the index hospitalization.”
This is a timely development. Geisinger’s effort coincides with Medicare’s decision to end payment for eight preventable errors in hospitals, so the entire area of what plans or plan sponsors should pay for is very much in focus.
“We feel we’re addressing many of the specifically identified issues that Medicare is addressing in a much more general comprehensive way through the development of quality initiatives specifically in the hospital with ProvenCare,” says Richard J. Gilfillan, MD, president and CEO of Geisinger Health Plan and Geisinger Indemnity Insurance.
Bonuses
All Geisinger physicians receive a base salary and incentive. It’s a ratio of about 80 percent salary to 20 percent incentive based on goals. Those goals include certain benchmarks, including patient satisfaction and quality measures. For ProvenCare doctors, hitting the ProvenCare benchmarks is one of those goals for potential bonuses.
This internal experiment is attracting a lot of external interest.
“Geisinger is addressing an issue that has bothered many insurers and employers — that when quality of care is less than ideal, the extra services often required by patients experiencing complications generate more revenue for the providers and higher spending for those who pay for care,” says Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change. “Geisinger is telling insurers that it will take on this financial risk. It is doing this both to motivate its staff to achieve even higher levels of quality and to make it attractive for insurers to provide incentives to their enrollees to have these procedures done at the Geisinger Clinic. Perhaps Geisinger can also use the warranty as a way to negotiate higher payment rates from insurers.” (To see what other experts are saying, read “Experts weigh in on Geisinger’s experiment” below.)
Physicians must document 40 steps that Geisinger identified as necessary for CABG patients. They are divided into five categories: preadmission, operative, post-operative, discharge, and post-discharge.
“We have taken guidelines from the American College of Cardiology and the American Heart Association and translated those guidelines into best practices that we believe are reasonable,” says Casale. “You can opt out of any one of them as an attending surgeon simply by writing a note in the chart saying I know that I’m supposed to do X, but here’s the reason why I’ve actively chosen to not do it for Mrs. Jones. This isn’t slavish robot medicine, but it is a slavishly robotic need to think about each of 40 points. There is a big difference.” (To see all 40 points, turn to “Physician performance crucial in ProvenCare’s success” below.)
Patients who volunteer to participate must sign a “patient compact” that spells out exactly what they need to do to help themselves post-operation. “It says, I understand that you’re going to be doing a lot of things and you’re committed to doing things right,” says Casale. “So I’ll commit myself to watching my diet, keeping my appointments, telling you if I have a problem. There are about 25 things on the patient compact.”
The steps under “post-discharge” include questions that the patient needs to answer, such as “Did you stop smoking?’ and “Are you correctly taking your beta-blocker, aspirin, and statin?”
“I generally don’t like using the term ‘consumer’ for patients, but in this case it seems appropriate,” says Douglas Kamerow, MD, a columnist in the British Medical Journal.
In his Annals of Surgery article, Casale states, “We considered but rejected as overly draconian at this time doing things like measuring nicotine levels during follow-up or canceling the ‘deal,’ essentially ‘voiding the warranty’ if patients missed appointments, did not participate in rehab, etc.”
What perhaps gives Geisinger officials confidence that any lapse in patient follow-through might be spotted is the hospital system’s much touted electronic records system.
“A provider-driven pay-for-performance process for CABG, enabled by an electronic health record system, can reliably deliver evidence-based care, fundamentally alter reimbursement incentives, and may ultimately improve outcomes and reduce resource use,” the study in the Annals of Surgery noted.
Promising so far
Although Geisinger is still collecting financial outcomes, initial readings seem promising. The Annals of Surgery study says that most adverse events occurred less often in the ProvenCare group, “though only the likelihood of being discharged to home was statistically different.”
In addition, the average length of stay was 5.3 days, compared to 6.3 days before the program launch. Further, the readmission rate went down 15.5 percent.
Geisinger officials are satisfied enough with ProvenCare’s progress that they are trying to license the program to other health plans, which Casale declines to name.
“In fact we’re very interested in knowing if the characteristics of this program that made it so successful and made it so attractive are in fact generalizable outside of the system because in a sense this is still an experiment in our eyes,” says Casale. “We’ve achieved the success that we’ve had based on the electronic medical record that integrated all aspects of the system and the relationship that we fostered with the health plan. However, we’re quite confident that essential components of this are generalizable to other payers. Whether it’s generalizable to other provider networks is something that we’re also interested in and a lot of other delivery organizations have asked for information and we’re in active discussions with our colleagues.”
One insurer that isn’t shy to admit interest is Aetna. “At the moment, we can say that Aetna is very excited about Geisinger’s program,” says Aetna spokeswoman Karin Rush-Monroe. “We have met with the Geisinger leadership and continue to have discussions with them so we can better understand how to apply this approach to Aetna’s products and networks.”
Even those health plans that have no intention of buying ProvenCare feel the need to at least respond to what Geisinger is doing.
“While United Healthcare does not link . . . a warranty to our cardiac specialty centers as Geisinger does, our premium specialty centers program takes a similar approach by designating the efficiency of a hospital compared to others in a market,” says Kirk Stapleton, head of United Healthcare’s cardiac programs. That program recognizes hospitals that consistently produce outstanding patient outcomes, he says.
Meanwhile, Geisinger is happy enough with the results of the CABG program to be exploring other conditions that might benefit from the same intense, guidelines-based attention. ProvenCare techniques are now being applied to hip replacement and to management of the biologic erythropoietin. However, the financial component, the “warranty” that’s received so much attention, applies only to CABG surgery.
As the New England Journal of Medicine argues, whether ProvenCare is exportable might not be the main reason why it’s worth keeping an eye on. ProvenCare’s spillover effect might ultimately make as much of an impact on Geisinger as the program itself. For instance, the several hundred people in the erythropoietin ProvenCare program suffer from chronic anemia and need help managing this complex medication. Geisinger’s pharmacists, who developed the standardized protocols for erythropoietin, work with Geisinger’s clinical teams to manage it.
New form of P4P?
“The real question for Geisinger and for the rest of the health care system is whether this case-rate approach [ProvenCare for CABG surgery] might emerge as a new form of pay for performance,” notes the NEJM. “Many current models of pay for performance (involving, for example, quality-of-care measures for patients with diabetes) focus on populations of patients whose care is managed by primary care physicians. For most specialists and hospitals, existing incentive systems put only a modest amount of revenue at stake, and as would be expected, resulting changes in care have been modest as well.”
For the final objective view of just where this may be heading, we’ll turn again to Kamerow’s column in the British Medical Journal: “It seems to me that the Geisinger bypass surgery programme is both an admirable first step and a scary example of how difficult it will be to totally reinvent medical care.”
The British spelling of “program” should not distract us from appreciating that this is quite an undertaking.