Accelerating the Transformation of Healthcare Making higher quality, more affordable healthcare a reality for all Americans requires dedicated leadership and a deep understanding of U.S. healthcare. The team at the Peterson Center on Healthcare, the Peter G. Peterson Foundation, and the Center’s advisory board guide our overall strategy and ensure work is well-informed, substantive, and effective. Peterson Center on Healthcare Leadership

OBJECTIVES:To estimate long-term cost savings associated with patients' exposure to an all-or-none bundle of measures for primary care management of diabetes. STUDY DESIGN:In 2006, Geisinger's primary care clinics implemented an all-or-none diabetes system of care (DSC). Claims data from Geisinger Health Plan were used to identify those who met Healthcare Effectiveness Data and Information Set criteria for diabetes and had 2 or more diabetes-related encounters on different dates before 2006. A cohort of 1875 members exposed to the DSC was then compared against a propensity score matched non-DSC comparison cohort from January 1, 2006, through December 31, 2013. METHODS:A set of generalized linear models with log link and gamma distribution was estimated. The key explanatory variable was each member's bundle exposure measured in months. The dependent variables were inpatient and outpatient facility costs, professional cost, and total medical cost excluding prescription drugs measured on a per-member-per-month basis. RESULTS:Over the study period, the total medical cost saving associated with DSC exposure was approximately 6.9% (P < .05). The main source of the saving was reductions in inpatient facility cost, which showed approximately 28.7% savings (P < .01) over the study period. During the first year of the DSC exposure, however, there were significant increases in outpatient (13%; P < .05) and professional (9.7%; P < .05) costs. CONCLUSIONS:A system of care with an all-or-none bundled measure used in primary care for patients with diabetes may reduce long-term cost of care while improving health outcomes.

Early evidence suggests that the patient-centered medical home has the potential to improve patient outcomes while reducing the cost of care. However, it is unclear how this care model achieves such desirable results, particularly its impact on cost. We estimated cost savings associated with Geisinger Health System's patient-centered medical home clinics by examining longitudinal clinic-level claims data from elderly Medicare patients attending the clinics over a ninety-month period (2006 through the first half of 2013). We also used these data to deconstruct savings into its main components (inpatient, outpatient, professional, and prescription drugs). During this period, total costs associated with patient-centered medical home exposure declined by approximately 7.9 percent; the largest source of this savings was acute inpatient care ($34, or 19 percent savings per member per month), which accounts for about 64 percent of the total estimated savings. This finding is further supported by the fact that longer exposure was also associated with lower acute inpatient admission rates. The results of this study suggest that patient-centered medical homes can lead to sustainable, long-term improvements in patient health outcomes and the cost of care.

*The views expressed in this discussion paper are those of the authors and not necessarily those of the authors’ organizations, the Institute of Medicine, or the National Academies. The paper is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine or National Academies and is not a report of the Institute of Medicine, the National Academies, or the National Research Council.

The Geisinger Health System (GHS) is a well-established, not-for-profit enterprise that delivers health care and provides health insurance. Having started reengineering the way it delivers care nearly two decades ago, GHS is one of a handful of entities that is well prepared for a shift from fee-for-service to value-based payment. In 2009, GHS' Board of Directors added to GHS' mission the "scaling and generalizing" of the approaches GHS has employed to distinguish itself as a model for how health care should be delivered. This expanded mission was based in part on a desire to become a leader in helping other health care providers improve their clinical and financial performance. Given the increasingly challenging health care payment environment, a decision was made to try, in the course of pursuing this goal, to create a financial return for GHS on the substantial investments GHS had made in innovations over the past two decades. Because of a belief that generalizing, scaling, and commercializing products and services are fundamentally different from delivering health care, and a recognition that GHS employees lacked the time and resources to scale and generalize, GHS created a free-standing, for-profit entity - xG Health Solutions - funded in large part by a venture capital firm, to commercialize GHS intellectual property. This entrepreneurial venture has proven that the tools and methods used at GHS can be adapted and used to help other health care delivery systems reduce the cost and improve the quality of the care they deliver. Although it is too soon to know how successful xG Health Solutions will be, it has grown substantially during its first 2 years, and appears to have confirmed that GHS' judgment that a separate, but related, entrepreneurial entity was a good way to "scale and generalize" GHS' health care performance improvement intellectual property.

*The views expressed in this discussion paper are those of the authors and not necessarily those of the authors’ organizations, the Institute of Medicine, or the National Academies. The paper is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine or National Academies and is not a report of the Institute of Medicine, the National Academies, or the National Research Council.

Coronary artery disease is complex chronic disease best managed by a team empowered by actionable data and a comprehensive approach, the ability to improve intermediate outcomes was dramatically enhanced after Geisinger created a system of care to do so. Continuous measurement of critical data elements of process and intermediate outcome measures allows the delivery of actionable information to the most appropriate team member, including the patients and family as team members. Continuous monitoring of the overall program looking for trends and opportunities across sites and regions allows for program enhancements. The comprehensive "all-or-none" bundled approach to care, which has already realized a 300% improvement, will be further enhanced by incorporating additional "Big Data" flows.

Geisinger Health System, Danville, PA *Correspondence address: Glenn D Steele, Jr, MD, PhD, FACS, Geisinger Health System, 100 North Academy Ave, Danville, PA 17822-2201. E-mail: [email protected] Received November 18, 2013; accepted November 18, 2013. Disclosure Information: Nothing to disclose. Presented at the American College of Surgeons 99th Annual Clinical Congress, Washington DC, October 2013.

OBJECTIVES:To determine whether a system of care with an all-or-none bundled measure for primary-care management of diabetes mellitus reduced the risk of microvascular and macrovascular complications compared with usual care.STUDY DESIGN:A parallel pre-post observational design was used. In 2006, a system of care for diabetes was implemented for some members of the Geisinger Health Plan. A total of 4095 primary-care patients were in the Diabetes System of Care group (DS) and compared with a propensity score-matched cohort of 4095 primary care patients not in the system of care (non-Diabetes System of Care [NDS]).METHODS:Cumulative hazard rate was measured over a 3-year period for retinopathy, amputation, stroke, and myocardial infarction (MI).RESULTS:The adjusted hazard ratios (HRs) for MI (HR, 0.77; 95% CI, 0.65- 0.90), stroke (HR, 0.79; CI, 0.65-0.97), and retinopathy (HR, 0.81; CI, 0.68-0.97) were all significantly lower among DS patients. The adjusted HR for major amputations (HR, 1.32; CI, 0.45-3.85) did not differ between groups, but only 17 major amputations occurred during the follow-up period. The necessary number of patients to treat in order to prevent 1 event over 3 years was 82 for MI, 178 for stroke, and 151 for retinopathy.CONCLUSIONS:A system of care with an all-or-none bundled measure used in primary care for patients with diabetes may reduce the risk of MI, stroke, and retinopathy over a 3-year period.

Patient-centeredness-the idea that care should be designed around patients' needs, preferences, circumstances, and well-being-is a central tenet of health care delivery. For CEOs of health care organizations, patient-centered care is also quickly becoming a business imperative, with payments tied to performance on measures of patient satisfaction and engagement. In A CEO Checklist for High-Value Health Care, we, as executives of eleven leading health care delivery institutions, outlined ten key strategies for reducing costs and waste while improving outcomes. In this article we describe how implementation of these strategies benefits both health care organizations and patients. For example, Kaiser Permanente's Healthy Bones Program resulted in a 30 percent reduction in hip fracture rates for at-risk patients. And at Virginia Mason Health System in Seattle, nurses reorganized care patterns and increased the time they spent on direct patient care to 90 percent. Our experiences show that patient-engaged care can be delivered in ways that simultaneously improve quality and reduce costs.

Diabetes mellitus (DM) and associated complications are increasing in the United States, with prevalence up 40 percent from 2002 to 2010. [1] Randomized controlled studies have shown reductions in the increased cardiovascular disease risk associated with diabetes when glucose, cholesterol, and blood pressure are better controlled and there are standards of care for improving patient […]

The movement of US physicians toward working as employees rather than working as private practitioners is increasing interest in compensation systems that drive improved quality and efficiency without compromising the productivity of existing fee-for-service payment systems. We describe the approach of Geisinger Health System, an integrated delivery system in Pennsylvania that assigns about 20 percent of total expected physician compensation to incentives that support improvements in quality and efficiency along with growth in clinical volume. We believe that dedicating a moderate portion of physician compensation to achieving strategic goals, such as maximizing quality and efficiency, is improving the value of care provided at Geisinger. At the same time, because most of Geisinger's clinical care is still delivered and paid for on a fee-for-service basis, the incentives for clinical volume are enabling Geisinger to achieve the financial viability to pursue its mission.

OBJECTIVES To estimate cost savings associated with ProvenHealth Navigator (PHN), which is an advanced model of patient-centered medical homes (PCMHs) developed by Geisinger Health System, and determine whether those savings increase over time. STUDY DESIGN A retrospective claims data analysis of 43 primary care clinics that were converted into PHN sites between 2006 and 2010. The study population included Geisinger Health Plan's Medicare Advantage plan enrollees who were 65 years or older treated in these clinics (26,303 unique members). METHODS Two patient-level multivariate regression models (with and without interaction effects between prescription drug coverage and PHN exposure) with member fixed effects were used to estimate the effect of members' exposure to PHN on per-member per-month total cost, controlling for member risk, seasonality, yearly trend, and a set of baseline clinic characteristics. RESULTS In both models, a longer period of PHN exposure was significantly associated with a lower total cost. The total cumulative cost savings over the study period was 7.1% (95% confi dence interval [CI] 2.6-11.6) using the model with the prescription drug coverage interaction effects and 4.3% (95% CI 0.4-8.3) using the model without the interaction effects. Corresponding return on investment was 1.7 (95% CI 0.3-3.0) and 1.0 (95% Cl -0.1 to 2.0), respectively. CONCLUSIONS Our finding suggests that PCMHs can lead to significant and sustainable cost savings over time.

Comparative effectiveness research (CER) represents an evolution in clinical decision-making research that allows for the study of heterogeneous groups of patients with complex diseases processes. It has foundations in decision science, reliability science, and health care policy research. Health care finance will increasingly rely on CER for guidance in the coming years. There is increasing awareness of the importance of decreasing unwarranted variation in health care delivery. In the past 7 years, Geisinger Health System has performed broad reengineering of its acute episodic and chronic care delivery models utilizing macrosystem-level application of CER principles. These provider-driven process initiatives have resulted in significant improvement across all segments of care delivery, improved patient outcomes, and notable cost containment. These programs have led to the creation of novel pricing models, and when "hardwired" throughout a care delivery system, they can lead to correct medical decision making by 100% of providers in all patient encounters. Neurosurgery as a specialty faces unique challenges and opportunities with respect to broad adoption and application of CER techniques.

Geisinger's ProvenCareTM Program (for elective coronary artery bypass surgery, total hip replacement, and others) has shown that the principles of reliability science, facilitated by a robust electronic health record and institutional commitment, allow the re‐engineering of complicated clinical processes. This eliminates unwarranted variation and promotes the completion of evidence‐based elements of care. It has not been established that ProvenCare can be generalized to other institutions. Now, under the auspices of the American College of Surgeons Commission on Cancer, ProvenCare has been adapted to a multi‐institutional collaborative for the care of the patient with resectable lung cancer. CA Cancer J Clin 2011. © 2011 American Cancer Society, Inc.