‘Let’s stop com­plain­ing about so­cial de­ter­mi­nants of health, and let’s fix them’

Modern Healthcare - - Q & A -

Danville, Pa.-based Geisinger Health Sys­tem, an in­te­grated de­liv­ery net­work with 12 hospi­tal cam­puses, a 1,600-physi­cian mul­tispe­cialty group prac­tice and a 551,000mem­ber health plan, re­cently com­pleted the ac­qui­si­tion of Com­mon­wealth Med­i­cal Col­lege in Scran­ton, Pa. In January, Geisinger an­nounced what it’s call­ing Spring­board Healthy Scran­ton, a mul­ti­year pro­gram aimed at im­prov­ing com­mu­nity health by pro­mot­ing health­ier eat­ing and life­style changes co­or­di­nated with chronic care man­age­ment. Mod­ern Health­care re­porter Dave Barkholz re­cently spoke with Geisinger CEO Dr. David Fein­berg about these and other de­vel­op­ments. The fol­low­ing is an edited tran­script.

Mod­ern Health­care: Why did you buy a med­i­cal school?

Dr. David Fein­berg: It was a great com­ing to­gether of an or­ga­ni­za­tion and a med­i­cal school. Both have been re­ally fo­cused on com­mu­ni­ty­based, in­no­va­tive kind of post-Flexner med­i­cal care. It’s a per­fect combo. And for us, it’s a way to say (to prospec­tive stu­dents), “Do you want to be trained in one of Amer­ica’s most in­no­va­tive sys­tems?”

It’s also im­por­tant for us for work­force de­vel­op­ment. We don’t think ev­ery Geisinger Com­mon­wealth School of Medicine stu­dent will be­come a Geisinger res­i­dent. And not ev­ery Geisinger res­i­dent will be­come a Geisinger fac­ulty. But we think we’ll in­crease our per­cent­age long-term by build­ing our own farm league.

MH: : What are your plans for Scran­ton?

Fein­berg: Scran­ton is a typ­i­cal kind of U.S. city— post-in­dus­trial, di­verse with high rates of sub­stance abuse, high rates of obe­sity, high rates of un­em­ploy­ment and high rates of di­a­betes. We said, “Let’s stop com­plain­ing about so­cial de­ter­mi­nants of health, and let’s fix them.”

We’ve put to­gether at Geisinger an ad­vi­sory board of in­cred­i­ble peo­ple who have done this kind of so­cial en­trepreneur­ship be­fore. We then went to Scran­ton, met with peo­ple who are al­ready do­ing that work, and, most im­por­tantly, we met with folks who are al­ready get­ting those ser­vices. We lis­tened. We said, “What can we do so that no­body sui­cides here, that ev­ery­body has ac­cess to

food, ev­ery­body has ac­cess to health­care, that we stop child abuse?”

We’ve been work­ing at it for about a year, and we’ve al­ready seen the nee­dle move con­sid­er­ably. We think if we get it right there, it be­comes a model we can take to other com­mu­ni­ties and around the coun­try.

MH: What are the in­ter­ven­tions?

Fein­berg: We’re go­ing to run ev­ery­one’s genome. We’ll know who­ever is BRCA-pos­i­tive, who­ever has a fa­mil­ial hy­per­c­holes­terolemia, car­diac ar­rhyth­mia genes, etc. We’re go­ing to make sure that ev­ery­body has ac­cess to food. We’ve al­ready done that in other parts of our catch­ment area. … Not only have we given peo­ple a health­ier fu­ture, we’ve given them hope

back. So, we’re tak­ing that food pro­gram through­out Scran­ton.

We’re us­ing a lot of data to un­der­stand pa­tients who are fre­quent fly­ers in our emer­gency room. How do they in­ter­act with the crim­i­nal jus­tice sys­tem? We’re putting to­gether all kinds of data­bases to un­der­stand these in­di­vid­u­als much bet­ter so we can in­ter­vene.

The last pil­lar is the com­mu­nity. We’ve been in this com­mu­nity for a while. We have our med school there. We’ve got hos­pi­tals there. It’s say­ing to the com­mu­nity mem­bers, “What can we do? What pro­grams have been here be­fore that have worked or haven’t worked so we can help tweak them?” It’s a part­ner­ship.

MH: What’s it go­ing to cost, and what’s it go­ing to save?

Fein­berg: We’re not sure yet of the to­tal cost. We think it’s go­ing to save lives, and it’s go­ing to ul­ti­mately be sus­tain­able and save money. We re­ally think it will demon­strate that it de­creases health­care cost and thus be­comes sus­tain­able.

“We can make amaz­ing changes in peo­ple’s lives by hav­ing this ge­netic in­for­ma­tion and com­bin­ing it with the clin­i­cal in­for­ma­tion.”

MH: How is your genome se­quenc­ing pro­gram work­ing out?

Fein­berg: We do this across our en­tire area. We say to pa­tients, “Can we look at your whole genome?” Ninety per­cent of them say yes, which is just in­cred­i­ble. It shows trust in the or­ga­ni­za­tion. We look at their med­i­cal record. We look at their fam­ily his­tory. We look at that genome. (Then) it’s time to have a con­ver­sa­tion with that pa­tient. “You have some­thing, in essence, a time bomb, and there’s some­thing we can do about it.”

That con­ver­sa­tion takes place with a pri­mary-care provider and the pa­tient, sup­ported by ge­netic coun­selors and ge­neti­cists. The pa­tient and fam­ily de­cide what to do next. The cases have been un­be­liev­able. A six­teen-year-old girl comes in de­hy­drated from soc­cer. We give her some flu­ids. She par­tic­i­pates in our MyCode study. It turns out she has two genes as­so­ci­ated with fa­tal car­diac ar­rhyth­mias in young adults. We treat 30 peo­ple in her fam­ily. Un­cle Bill, let’s call him, choked in a restau­rant and died two years ago. Well, in ret­ro­spect, he didn’t choke. He had a heart at­tack. She wasn’t de­hy­drated. She was hav­ing her first sign of a car­diac ab­nor­mal­ity.

Now we bring in the 30 fam­ily mem­bers, and some of them need to get pace­mak­ers be­cause we’ve now fig­ured out the ge­netic risk that’s as­so­ci­ated with some of them. Some need mon­i­tor­ing, and some we can say, “You’re good, but this is in your fam­ily, and we should check your kids in the fu­ture if that’s part of your life.” We can make amaz­ing changes in peo­ple’s lives by hav­ing this ge­netic in­for­ma­tion and com­bin­ing it with the clin­i­cal in­for­ma­tion.

MH: How big is your repos­i­tory now?

Fein­berg: We’ve con­sented over 150,000 pa­tients to look at genomes. Our av­er­age elec­tronic health record is 14 years old. We have all the claims data if they were in­sured by us. In Cen­tral Penn­syl­va­nia, there’s a sta­ble pop­u­la­tion, so we have multi­gen­er­a­tional in­for­ma­tion. We think we’ll be at 250,000 pa­tients at the end of this calendar year.

MH: You an­nounced your plan to get this health sys­tem to zero wait in the ER. How are you go­ing to do that?

Fein­berg: We’re go­ing to do it by set­ting it as a goal. When you come to the ER, it’s a real has­sle. I’ve never seen any­body’s ap­pendix, bro­ken arm or sui­ci­dal­ity get bet­ter in a wait­ing room. It is a non-val­ueadded place. So, the way to do it is not only reengi­neer the ER, but also to de­cant the pres­sure on the ER. What can we push to ur­gent care? What can we push to on­line?

If we im­prove ac­cess, which we’ve worked on with our spe­cialty care for non­se­ri­ous con­di­tions, you see a de­crease in use of the ER. So a lot of get­ting to zero min­utes in the ER is get­ting stuff out of the ER that shouldn’t be in the ER. That means pri­mary care, ur­gent care, telemedicine and spe­cialty care.

MH: Where are you now with your wait times?

Fein­berg: We’re still ter­ri­ble. I don’t know, maybe 200 min­utes—not the wait to be seen, but the wait to be treated. We’re like any­one else. We should get peo­ple who are not hos­pi­tal­ized in and out of the ER in un­der 50 min­utes or for hos­pi­tal­ized pa­tients, in your hospi­tal bed up­stairs within an hour to an hour-and-a-half.

MH: What’s the ra­tio­nale for of­fer­ing same-day ac­cess for see­ing a physi­cian— bet­ter pa­tient care or higher pa­tient sat­is­fac­tion?

Fein­berg: It’s both. Not only is it sat­is­fy­ing for pa­tients to get seen, it also makes great busi­ness sense. It de­creases un­nec­es­sary care in the ER. It de­creases anx­i­ety. It’s just chang­ing our frame of ref­er­ence from be­ing provider-cen­tered to be­ing pa­tient­cen­tered. Ev­ery other busi­ness has that kind of ac­cess. If you want to watch TV, you can down­load what­ever movie you want now. Health­care is just so far be­hind. We want to dis­rupt our­selves.

MH: You’ve changed the way you in­cen­tivize physi­cians. What are you after?

Fein­berg: Ev­ery doc­tor at Geisinger at a min­i­mum— at a min­i­mum—is paid at the 50th per­centile or above. So we don’t pay any­one be­low av­er­age. In ex­change, we ask our docs to do five things: take great care of pa­tients; treat pa­tients like they are your fam­ily; help us with same­day ac­cess, so oc­ca­sion­ally that means stay­ing late, oc­ca­sion­ally that means com­ing in on a Satur­day;

help us with re­cruit­ment and re­ten­tion, be­cause we want to make it a great place to work; be en­gaged in our teach­ing and research, talk to pa­tients about the genome study; and fi­nally, be a good ci­ti­zen—run on time, don’t use foul lan­guage, vol­un­teer for com­mit­tees, that kind of stuff. If you do those five things, we’re go­ing to pay you.

It doesn’t say how many surg­eries you do, how many pa­tients you see. It’s not vol­ume-based. If one of our docs needs to spend an en­tire morn­ing with one pa­tient or­ga­niz­ing ev­ery­thing, that meets what we’re look­ing for. Those are the docs we’re look­ing for. We want peo­ple who know how to take care of pa­tients the right way.

MH: What have been the re­sults so far?

Fein­berg: The re­sults have been fan­tas­tic. We’ve seen a bet­ter re­ten­tion than we think any­where in the coun­try. Our re­ten­tion last year was just un­der 5%. I go over ev­ery sin­gle doc who leaves Geisinger. I want to know why. And I would tell you now ev­ery one of those is, “I’m a hos­pi­tal­ist and I want to do a fel­low­ship,” and we don’t of­fer it. Or, “My fam­ily is mov­ing,” or, “We have kids now, and the grand­par­ents are in Florida, so we are go­ing to move there.” We don’t have any­one leav­ing be­cause they’re burned out. We’ve re­ally elim­i­nated that.

Our re­cruit­ment has been phe­nom­e­nal. We brought in hun­dreds of new doc­tors, and they’re fan­tas­tic. Geisinger has a pretty good brand name.

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