What Makes Geisinger’s Destination Care Program Tick

Before he arrived at Geisinger in 2016, Jaewon Ryu, an emergency medicine doctor with a law degree, held a raft of leadership roles in health care, insurance, and government, including at Kaiser Permanente, Humana, and the Centers for Medicare and Medicaid Services. He joined the Pennsylvania-based health system as an executive vice president and chief medical officer, and this December became interim president and chief executive officer when its former CEO David Feinberg headed to Google to lead its health care strategy. 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. 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? 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 preprocessing 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 nonserious 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

What Makes Geisinger’s Destination Care Program Tick

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