Home Clinical Medicine that comes with a “warranty”

Medicine that comes with a “warranty”

October 2009

Published in the October 2009 issue of Today’s Hospitalist

GEISINGER HEALTH SYSTEM has grabbed its share of headlines by offering what many have called “surgery with a warranty.” Now the health system is working to replicate the methodology behind that successful program and apply it to hospitalists.

While Geisinger doesn’t offer a warranty on all surgical procedures, many high volume surgeries and episodes of care fall under a so-called “warranty” through a program called ProvenCare. For certain elective surgeries like CABG, the health system promises that if any patients come back within 90 days with a preventable complication, it will take care of the problem at no extra charge.

Geisinger makes the ProvenCare program work by encouraging its physicians to follow best practices when caring for these patients. “If you do everything right up front,” explains John Bulger, DO, director of the hospital medicine service line at Geisinger Health System in Danville, Pa., “you’ll decrease your complications and costs.”

The idea is that insurers pay a slightly higher flat fee for surgeries or episodes of care that fall under the program, knowing that they’re off the hook for readmissions for the first 90 days. Some of those fees go to a bonus pool for physicians who make the program a success.

Getting physicians’ attention
Since ProvenCare was launched for CABG patients in 2006, average length of stay fell from 6.2 days to 5.7, and 30-day readmission rates dropped 44%.

A critical part of the program has been identifying the quality measures that improve care and reduce readmissions. Physicians help decide which care processes have the strongest evidence.

The group puts those benchmark measures into one bundle. The CABG bundle, for instance, includes 40 processes, such as making sure patients receive appropriate beta-blockade before discharge. Physicians must complete those to be eligible for an incentive.

Because most of Geisinger’s physicians are health system employees, they receive a base salary plus an incentive plan. With 40% of that incentive tied to quality measures, ProvenCare gets physicians’ attention, particularly in specialties like cardiothoracic surgery where the incentive is linked to ProvenCare performance.

While all Geisinger patients benefit from the Proven- Care program, only one payer “Geisinger Health Plan ” has formally participated in the program to date. Geisinger is currently inviting other payers to sign on.

Expanding the program
While the initial ProvenCare program applied only to elective CABG surgery, Geisinger has rolled it out for conditions like hip replacement, cataract surgery, PCI/angioplasty, bariatrics, low back pain and perinatal care, with more programs in the works.

Geisinger is also expanding the program to target specialties like hospital medicine. While Geisinger hospitalists will have some exposure to ProvenCare measures in areas like hip and knee surgery, particularly as they take on a greater role in surgical comanagement, Dr. Bulger says the real impact will be in other areas.

The health system has already begun identifying best practices in hospital medicine. But instead of targeting patients undergoing a particular procedure, Geisinger plans to apply ProvenCare to all patients admitted to and discharged from the hospital.

“We’re going to come up with the evidence-based interventions that patients need as they transition from outpatient to inpatient, and then to outpatient again,” Dr. Bulger says. “We’ll agree that we’re going to do that for every patient.”

There is one major challenge in retrofitting the Proven- Care methodology to tackle care transitions, however. The evidence isn’t nearly so clear for improving discharge as it is for procedures like CABG.

“There’s not a lot of research that’s been done on a longitudinal basis,” says Dr. Bulger. Individual studies may give data on how a hospitalist program has fixed a single problem on a single floor, for instance, but not on more systemic strategies to reduce readmissions.

Discharge measures
Geisinger has already begun pilot-testing measures culled from transitions-of-care research. The plan is to see what works, then create quality measures that can be implemented at the health system’s two hospital sites.

The goal is to decrease all readmissions by one-third by packaging a number of quality measures into a Proven- Care program for hospitalists, which may launch next summer. To reach that ambitious goal, Geisinger is implementing a series of more targeted measures.

One measure requires that 90% of discharge summaries be delivered within 24 hours of discharge. Dr. Bulger says success on that particular measure is possible in large part because Geisinger has built a system to create electronic discharge summaries.

“You have to put a process in place to make discharge summaries available electronically and to send them at discharge,” he explains. “You can’t make physicians wait for a transcription service.”

Another measure being implemented is making sure every patient has a primary care appointment set up before discharge. That goal is made somewhat easier because 60% of patients who come through Geisinger’s two hospitals have a primary care physician within the Geisinger network.

Transferable results?
ProvenCare may sound like it’s ahead of its time, but Dr. Bulger says that it’s actually very timely because payers like Medicare are determined to reduce the financial impact of readmissions. While no formal plans have been released, he thinks Medicare will pick a group of DRGs, create a national average for readmissions and then penalize hospitals that see more.

Geisinger’s success with ProvenCare has been impressive, but it raises a question: Can similar programs be implemented at facilities that don’t have Geisinger’s resources?

Dr. Bulger says that while certain transition measures might be difficult for smaller health systems and stand-alone hospitals to implement, large portions are transferable, regardless of an organization’s resources or size.

“You may not be able to extrapolate what we’re doing to the letter,” he explains, “but a lot of the methodology can be spread.”

Edward Doyle is Editor of Today’s Hospitalist.