It’s ‘stupidity’ to install health IT without re-engineering the entire workflow
“You’ve got to look at your patient-care processes and say, ‘How are we going to do it differently?’ ”
Since 2001, Dr. Glenn Steele Jr. has served as president and CEO of Geisinger Health System, an integrated delivery system based in Danville, Pa., with eight hospital campuses, a 1,100member multispecialty group practice and a 467,000-member health plan.
Steele, named to Modern Healthcare’s list of the 100 Most Influential People in Healthcare for the past six years, is stepping down as CEO in June but will continue as chairman of xG Health Solutions, an independent venture Geisinger launched to disseminate its expertise in care management and health IT. Last month, he received the National Center for Healthcare Leadership’s 2014 Gail L. Warden Leadership Excellence Award. Steele previously served as vice president for medical affairs at the University of Chicago, surgery professor at Harvard Medical School, and CEO of Deaconess Professional Practice Group in Boston. Modern Healthcare reporter Andis Robeznieks spoke with Steele about how his organization is dealing with Medicaid and exchange-plan growth, his concerns about implementation of pay-for-performance and health IT, and his legacy at Geisinger. This is an edited transcript.
Modern Healthcare: How is Geisinger preparing for the possibility of the Supreme Court striking down the Obamacare premium subsidies in Pennsylvania and other states?
Dr. Glenn Steele: I’m not worried about the Supreme Court right now. I’m worried about all those products where we’ve made bets. Obviously, I’m in favor of expanding access. Anything that insures more people is the ethical way to go. But I believe you can make a good business case for it. Still, the turbulence is pretty challenging right now.
MH: What bets are you speaking of?
Steele: Our big bet is going into the Medicaid managedcare market. We’re almost two years into that with about 130,000 Medicaid members. That’s a learning process for us because a significant amount of beneficiaries’ cost utilization has to do with things other than healthcare. We’re still learning about a lot of the life issues that have to be dealt with.
There are a huge number of folks who have to have 24/7 care or monitoring because of a combination of disease, economic deprivation or disabilities. That’s not what health systems generally are good at dealing with. But we think that if we’re in it on both the insurance and provider sides, it’s better than if we’re just in it on one side.
The second big bet is getting into the exchange. We’re now into our second year of product design. We’re committed to the exchange because we think in the future more people will be buying their insurance on the Internet. So we need to learn how to do our various health-plan metal tiers, how to price and how to increase medical literacy. We’ve probably got around 60,000 exchange enrollees now, and 85% are new to our organization, so we don’t know how sick they are or how much they utilize.
The third big bet is Healthy PA, Gov. Tom Corbett’s waiver model for expanding Medicaid. The rules are very complex and they’re still volatile. They’re even more volatile now because Democrat Tom Wolf will be our new governor. But I suspect that we’ll have the Corbett model for at least a couple of years. We suspect we’ll pick up 40,000 to 45,000 additional members.
MH: Have insurers started to take up Geisinger’s bundled-service, guaranteed-price warranty offer? If not, why not?
Steele: Absolutely not. It’s one of the great sardonic aspects of my life. I have a number of suppositions. The vast majority of insurers were transacting fee-for-service and it just wasn’t worth it for the biggies to change their back-office transaction just for Geisinger. As we move toward accountable care organizations and more shared risk, there is a need for even the biggies to transact something different.
MH: Do you have concerns about how pay-for-performance models are being implemented?
Steele: One of my great fears is that we’re going to do for quality exactly what we experienced for interventional work. My great nightmare is we’ll develop an ICD-10 for quality, with lots of parsing of each component of quality. I think that’s crazy. A lot of the pay-for-performance stuff built into fee-for-service is a move in that direction. We haven’t been able to get to something that looks more like taking responsibility
financially for healthcare over time for a population. There’s still a residual fear of capitation, which is legitimate, because people were worried that healthcare systems would withhold service. But I believe we can protect against that now.
MH: How do you know the patient-centered medical home model Geisinger pioneered really works?
Steele: We’ve shown over the last eight years or so that our Proven Health Navigator model has significantly decreased hospitalization per thousand across our entire system. Our system is pretty large, and so the probability of some sort of bias because it’s not a randomized clinical trial goes down.
We’ve now expanded this to the Eastern Maine Health System and the West Virginia University Health System, and we’re expanding it into New Jersey and into Delaware. We’re building up a portfolio of experience with non-Geisinger providers and we’re getting the same effects on hospitalization.
It’s my religion. Anything I can do that extracts unnecessary variation or redundancy in services or unnecessary visits to the emergency room will keep patients in better shape and decrease cost. And because our insurance company is in the same fiduciary as our provider, anything that decreases total cost of care is good for our business model.
MH: Do you understand why physicians complain about health IT hurting their workflow and efficiency?
Steele: Here’s my Jonathan Gruber statement: This is an issue of stupidity. If people believe that you can put IT in, continue working the same way you did before IT, and not get inefficiency, we are talking double-digit IQs here. What everybody’s learned over the last 15 to 20 years is if you put IT in, whether it’s hospital-based or ambulatory, you have to look at the entire workflow and use the IT implementation as an excuse for reengineering your workflow from beginning to end. If you don’t do that, it’s going to create havoc. You’ve got to look at your patient-care processes from beginning to end and say, “How are we going to do it differently? How is this going to make it better?”
On the benefits of health IT, we couldn’t do point-of-service care innovation without having near realtime data fed back to us. You’ve got to have data both from the insurer side and the provider side to predict which patients or cohorts of patients are most likely to need the highest-intensity vigilance. If you don’t have feedback in a timely fashion, it’s not going to work.
MH: How would you describe your legacy at Geisinger?
Steele: Well, I’m not dead yet. I don’t worry about legacy. I’ll be there through June of 2015. I’m certain that we’ll have terrific successor candidates. I suspect that with my involvement in this spinoff, xG Health Solutions, as well as a number of other opportunities not related to Geisinger, I’ll be able to contribute.
I’m most proud of the fact that over my almost 15 years at Geisinger, we’ve spawned eight CEOs and three chief medical officers of other healthcare companies. Sometimes I wonder if it isn’t too much of a good thing because when these great people leave, we’ve got to redistribute work or get new people in. But that’s probably the most important aspect of legacy. I’m really quite pleased.