Geisinger would export innovation, resources to Holy Spirit, but it wouldn’t import patients [The Patriot-News, Harrisburg, Pa.]

Sept. 29--DANVILLE -- Nurses and doctors needn't be in the same room to monitor the very sickest Geisinger Medical Center patients.

Or in the same building. Or ZIP code.

Moreover, intensive care patients cared for in this way getter better care, and are less likely to die, Geisinger leaders say.

It's an example of the groundbreaking tactics that have drawn national attention to Geisinger.

And it's something Geisinger might transplant to the Harrisburg region, if it joins with Cumberland County-based Holy Spirit Health System.

Geisinger touts itself as a national leader in the effort to raise the quality and lower the cost of health care. President Obama raised Geisinger's national profile a few years ago by holding it up as a model during a speech about reforming the health care system.

Still, Geisinger says it needs to prove that its methods can apply to other organizations. That's a major goal of the possible affiliation with Holy Spirit, Geisinger leaders say. Moreover, they say they plan to export expertise and resources to the Harrisburg area, rather than import patients in need of specialized care to Geisinger

Seventy miles north of Harrisburg, in a room on Geisinger's main campus, nurses sit at clusters of computer screens while monitoring intensive care patients. From this nerve center, they access patients' vital signs and medical histories and watch them live via video.

Some patients are in a nearby building, but some are miles away at other Geisinger hospitals.

If a bedside nurse in one of those intensive care rooms needs to leave, that nurse can push a button, and someone at the remote location will begin watching live video of the patient.

But Geisinger leaders are quick to note this involves no intensive care unit staff reductions. Rather, it provides a "secondary" layer of attention, giving remote staff the ability to, for example, notice trends in a patient's condition that might not be immediately obvious to bedside staff.

The remote location staff includes an "intensivist" -- a doctor who specializes in intensive care patients. The iECU concept allows one intensivist to service multiple hospitals.

Beyond that, computers merge the records of the patients with the latest research on their condition and treatment. This can highlight problems in how an intensive care unit is caring for patients, and point the way to better treatments for individual patients.

Geisinger promises to export rather than import

From the outskirts of Harrisburg, Geisinger can easily be Views of the Susquehanna River and farmland dominate the trip. In Danville, Geisinger's main campus occupies a hill rising from the town of about 5,500.

Geisinger claims to be the largest rural health system in the United States. But it might have a higher profile nationally than it does in the Harrisburg region.

Geisinger, with six campuses and a 44-county service area, is bigger than Holy Spirit and even Penn State Milton S. Hershey Medical Center. It bills itself as a hospital that offers the most advanced services, making it unnecessary for patients to travel to big city hospitals.

But so do Holy Spirit neighbors Penn State-Hershey and PinnacleHealth System.

So a possible Geisinger-Holy Spirit affiliation raises questions: Will Geisinger use Holy Spirit as a pipeline for patients needing specialized care? Does the future involve sick people from the Harrisburg area making 70-mile trips to Danville?

Frank Trembulak, Geisinger's longtime chief operating officer, said that's not the plan.

He said Geisinger would not expect sick patients to travel to Danville. Rather, Holy Spirit doctors could refer patients to the closest hospital that provides the needed care --with the patient's preference being a key factor.

But he also expects Holy Spirit's need to refer patients to other hospitals would decrease. That's because Geisinger is willing to invest in Holy Spirit and increase the level of specialized care, said Trembulak.

So rather than patients traveling north to Geisinger, the traffic is more likely to involve Geisinger exporting medical innovations and new services south to Holy Spirit, he said.

Geisinger was founded in 1915, when Danville was a little bigger than today.

Given its location, it seems improbable that Geisinger would grow so big. The most prominent nearby towns are Sunbury, Lewisburg and Bloomsburg. The closest "big" town is Wilkes-Barre, 57 miles away.

Geisinger has perhaps one geographical advantage -- Interstate 80, which passes just north of town.

Long ago, Danville prospered because of iron ore and production of railroad rails. In the early 1900s, Abigail Geisinger, widow of a man who earned a fortune from iron, decided Danville needed a hospital.

Rather than replicate the care available at nearby small-town hospitals, she wanted local working people to have access to medical specialists.

She recruited a young surgeon, Dr. Harold L. Floss, who had spent time at the newly established Mayo Clinic in Rochester, Minn. The Mayo founder had created a system that consisted of a group of doctors receiving a salary rather than being paid for volume.

Floss oversaw Geisinger for 43 years, fulfilling Abigail Geisinger's vision for a regional medical center.

By the 1990s, Geisinger employed hundreds of doctors, had nearly 550 beds in Danville and 230 in Wilkes-Barre and LifeFlight helicopter service.

A monumental development took place in 1997, when Geisinger and Penn State-Hershey decided to merge.

But another startling development came within three years, when the two realized they had underestimated the differences in their cultures, and decided to divorce. Both weathered a few years of financial losses following the split.

Dr. Glenn Steel Jr. became Geisinger's CEO in 2000. Once finances stabilized following the split with Penn State-Hershey, he challenged Geisinger doctors to tap Geisinger's unique qualities to improve the quality and lower the cost of health care. Among Geisinger's unique qualities is its health insurance plan, Geisinger Health Plan, which gives insight into providing and paying for health care.

That's the nutshell version delivered by Dr. Alfred Casale, who directs Geisinger's Heart Institute.

Casale freely lists the dirty secrets of health care: About 35 percent of medical care does no good. Doctors often do things, even surgeries, according to personal "idiosyncrasies."

On top of that, a "perverse incentive" has long pervaded health care: When a hospital does a bad job, and the patient needs more care or time in the hospital, the hospital gets paid more.

Geisinger proposes not to charge for faulty care

Steele posed the idea that if Geisinger doesn't correctly perform an operation, the customer shouldn't have to pay, said Casale.

That led to an examination of heart bypass surgery, a common and expensive operation that often results in complications, which require the patient to be readmitted, resulting in additional expenses.

Geisinger identified 40 essential steps to a successful bypass operation and turned this into an electronic checklist, which had to be filled out.

Casale stressed it doesn't amount to "cookbook" medicine. Variations are allowed when there is a sound reason, such as an allergy to a medication, for doing otherwise.

"If it's evidence based, then we're going to do that every time," Casale said. "It's the exact same thing that industrial engineers have been doing for generations."

Geisinger used data from its health plan to calculate the average cost of the operation and follow-up care, including complications.

Then it subtracted half the cost of the complications. That became the price tag Geisinger would charge for a bypass and 90 days of follow-up care.

This formula meant that Geisinger would profit if it reduced complications by more than half, and lose money if it didn't.

The effort received national attention, with the New York Times crediting Geisinger for offering a "warranty."

But to Geisinger's surprise, health insurers wouldn't agree to the fixed price, instead sticking to their old payment methods.

Undeterred, Geisinger has expanded the approach to about 10 other procedures. It trademarked the name, "ProvenCare."

One of Geisinger's goals it so demonstrate that ProvenCare and similar Geisinger innovations are transferrable to other organizations -- health systems, intdependent physician practices, health insurers -- which are different than Geisinger in terms of geography, size and organization.

That's one of the reasons Geisinger wants to partner with Holy Spirit, said Trembulak.

Health insurer Highmark Inc. contends Geisinger costs more than most other hospitals, and that costs rise at hospitals Geisinger acquires. Highmark recently launched a new insurance plan that puts Geisinger on a more expensive tier, meaning Highmark members have a higher level of cost sharing if they choose Geisinger services.

Trembulak responded that Geisinger cares for the sickest patients, conducts research and is a teaching hospital, and therefore has higher operating costs then some hospitals, and needs to be reimbursed accordingly.

He added that as Geisinger has acquired "financially distressed" community hospitals, it must negotiate "more reasonable payer contract rates, so reasonable operating costs and needed margin for reinvestment is achieved."

He also said many payers focus on lower per unit costs, creating an incentive for hospitals to perform more procedures. He said Geisinger believes it's better to focus on removing the 35 percent of excess care and costs that add no value.

"That is our value proposition at Geisinger and, as a result of our innovative care models, we create healthier populations of patients and real value for all," he said.

Geisinger leaders say they hope to grow Geisinger Health Plan, which has about 450,000 members, in the Harrisburg region. At the same time, they insist they're willing to collaborate with non-Geisinger health systems and insurers, including those in the Harrisburg area, interested in adopting Geisinger methods.

Geisinger and Holy Spirit plan to spend up to nine months sharing information and deciding whether to formally affiliate.

Sister Romaine Niemeyer, Holy Spirit's CEO, said Holy Spirit will remain a Catholic hospital, and its continuation of Catholic policies are "non-negotiable." She also said Holy Spirit won't be sold to Geisinger.

Trembulak said Holy Spirit would become "part of the Geisinger Health System." Items such as patient volumes and financial results would be reported separately, but also included in Geisinger Health System results, he said.

Trembulak also has stressed that, unlike other community hospitals Geisinger recently acquired, Holy Spirit isn't financially stressed and unable to continue independently. Unlike those hospitals, Holy Spirit would retain local control after joining with Geisinger.

Casale said Holy Spirit and its doctors have much to offer Geisinger. Discussing the potential affiliation, he said "You can't do this with organizations that are fixer-uppers."

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