Health-care cure or anomaly?

DANVILLE, Pa. - President Obama's and Nancy Pelosi's people have made the pilgrimage to this little town in middle-of-nowhere north-central Pennsylvania to see the Geisinger Health System.

So have staffers from the Mayo Clinic, Kaiser Permanente, and the Cedars-Sinai Medical Center.

In fact, Geisinger, touted by Obama as a health system that offers "high-quality care at costs below average," has gotten so popular that it started offering group tours. It expects more than 70 visitors from insurance companies and health systems this week.

"We were consuming ourselves with entertaining," said Howard Grant, a former Temple University Health System chief medical officer who became Geisinger's chief medical officer in 2008.

"People from all reaches of the country are trying to understand how what we do translates to their world."

What visitors find in the wooded hills of Danville, population 4,450, is a seriously wired health system that has made saving money and improving quality a priority. It has been aided by a relative lack of competition, its stable patient base, and the fact that its 800 doctors are on salary. It owns its own health-insurance plan and pharmacy.

That's a rare combination of factors that makes outsiders question how much of Geisinger's success can apply to the rest of the country.

"I really wish President Obama would stop holding them up as a model, because it's just not readily, broadly applicable," said David Nash, dean of the Jefferson School of Population Health at Thomas Jefferson University and a longtime proponent of basing medical care on proven science.

Nash said Washington reformers should focus on ideas that would work for the vast majority of hospitals, not unusual systems like Geisinger. "We don't have time for Penn and Jefferson and Temple to turn into Geisinger," he said. "We just don't."

Others say that Philadelphia's poorer patients need more care and support, that the city's focus on medical research is more expensive, and that Geisinger's cooperative approach draws doctors with a mind-set different from that of doctors attracted to the rarefied research at Philadelphia's top hospitals.

Medical care is more fragmented in most hospitals, with many doctors self-employed or working for independent groups, and insurance provided by separate companies. That pits those groups against one another economically. In a fully integrated system, like Geisinger's, everyone benefits more easily from holding costs down and improving care, experts said.

"Because we are completely integrated, it doesn't matter to us which component of our organization sees the revenue or sees the expense," Grant said.

The Obama administration did not respond to a reporter's request for elaboration on why the president used Geisinger as a positive example, but it's likely that the health system's strong performance in the Dartmouth Atlas played a role.

For more than 20 years, the Dartmouth Atlas Project has analyzed Medicare spending, producing maps that show huge regional variation in spending that it attributes primarily to differences in the amount of care. Though it has not evaluated Geisinger's quality, its researchers have consistently found that higher spending does not correlate with higher quality.

Elliott Fisher, director of the Center for Health Policy Research at Dartmouth College, said the nation could cut health spending by 20 percent to 30 percent by making everyone behave like low-cost regions.

Medicare costs in Geisinger's region averaged $6,790 per patient in 2006, placing it in the nation's lowest fifth. At $9,665 per patient, Philadelphia's spending was in the top fifth. Geisinger leaders say pay for their medical staff is comparable to pay here.

Fisher is impressed with Geisinger. "They have made a very firm commitment to both improving care and reducing costs," he said.

Geisinger Medical Center opened in 1915 as a 70-bed hospital funded by Abigail Geisinger, daughter of a wagon-maker. Its first surgeon and leader had trained at Mayo, another center lauded for its integrated practice and salaried physicians.

The system now includes three hospitals, serves 2.6 million people, and spans 43 counties. In its core, 31-county market, it captures 30 percent of patients. Thirty percent of its patients belong to the Geisinger Health Plan, its own insurance company, but it also treats patients with other plans. Its doctors provide care in 15 hospitals not owned by Geisinger.

Glenn Steele, a colorectal surgeon who held leadership positions at the University of Chicago and a Harvard University-affiliated hospital, came to Geisinger nine years ago after the breakup of its merger with the Penn State Hershey Health System.

When the dust cleared, the new chief executive officer decided to focus his system's mission not on creating medical knowledge, as Philadelphia's big-name academic medical centers do, but on "radically reengineering care" to add new science into medical treatment more quickly and effectively. Studies show it takes 17 years for a breakthrough to be disseminated throughout a health system, Steele said.

Geisinger was an early adopter of systemwide electronic medical records. The records make it easier for hospitals and doctors to share and collect information and make sure that patients get tests and medications they need. More than 2,000 non-Geisinger physicians have access to the records, which helps reduce duplication of tests for patients who use more than one hospital.

The system is using Web programs that allow patients to calculate their heart-disease risk and estimate the impact of different treatments. They are asked whether they prefer taking medications, changing their lifestyles, or doing nothing, a change that system leaders hope will improve compliance with doctors' orders. Starting in January, patients will be able to see not only their medical records online but also their doctors' notes.

Nationally, many doctors and hospitals make more money if they see patients more often or perform more procedures. That's how most insurance reimbursement works. Lest Geisinger's salaried doctors scrimp on care, 20 percent of their pay is linked to performance. Forty percent of that bonus is tied to quality, said Grant, the chief medical officer.

"You can save all the money in the world. If you don't hit these quality metrics, you're not getting anything," said Ronald Paulus, Geisinger's chief innovation officer.

One of the programs Geisinger sees as a big success, the primary-care, medical-home program, was conceived in 2006 in the Geisinger Health Plan. Nurses stationed in primary-care offices keep a close eye on the most costly patients for Medicare and the health plan, members with multiple conditions such as lung disease and heart trouble that can lead to frequent, expensive treatment.

The nurses' job is to deal with problems before they get serious enough to require a hospital. High-tech scales, for example, let them monitor the weight of heart patients every day. Weight gain is a sign of dangerous fluid buildup. They make sure these patients see a doctor almost immediately when they feel bad, reducing the chances they'll go to an emergency room. Patients newly discharged from the hospital get extra attention.

The program has reduced hospital admissions and readmissions between 15 percent and 20 percent. The system invested $2 million to $3 million in the case managers. It has earned $2.7 million in government payments for quality and efficiency.

Anna Rice is only 62, but she has the medical problems of an older woman, including congestive heart failure, chronic obstructive pulmonary disease, arthritis, and back pain. She takes 29 medications and uses an oxygen tank at night. Nurse Pam Berns monitors her care at Geisinger's Knapper Clinic in Danville. She makes sure that Rice gets preventive care and takes her drugs correctly.

Rice said Berns keeps her healthier. "I'd be lost without her, honestly," she said. "We talk at least once a month, unless I'm having problems, and then she calls me three or four times a week."

ProvenCare, another experiment, has attracted national publicity because it offers the equivalent of a surgical warranty: one price for pre-op workups, the procedure, and postsurgical care, no matter what happens. Usually insurance companies pay more if a patient has complications or needs surgery again because of a mistake.

So far, only the Geisinger Health Plan offers the warranty price. Alfred Casale, a heart surgeon who directs the Geisinger Heart Institute, said that Geisinger had offered the deal to other companies but that they had yet to accept.

The program started with heart surgery and has expanded to cataract, bariatric, and hip-replacement surgery. In a heart bypass, everyone involved in a patient's care works to ensure that 40 standards are met. There was some concern about "cookbook medicine" initially, Casale said, but that is largely gone. Readmission rates for the first batch of patients fell 43 percent.

The program saves the Geisinger Health Plan about $2,000 per heart patient, Casale said.

He said surgeons had remarkable freedom to practice their own way when he arrived eight years ago. They had different information sheets for discharged patients. Some even changed the position of equipment in the operating rooms, which he said was like a husband and wife moving furniture in the living room every time they entered it.

When a patient had heart-rhythm problems, Casale said, the first question a physician assistant asked was, "Whose patient is this?" That, not the patient's condition, determined what came next.

"The outcomes were really good, but we were getting those with incredible forbearance for physician idiosyncrasy," Casale said.

Not everyone is on the Geisinger bandwagon. One man moved to Geisinger's service area from a major city where he had relied on doctors at academic medical centers. He went to a Geisinger doctor when a chronic gastrointestinal condition flared up. The man, who asked to remain anonymous because he feared repercussions for his employer, said he was unhappy with the care from his primary doctor and a Geisinger hospital. Doctors refused to collaborate with his longtime specialists, he said.

He made the long drive to a city academic hospital where, he said, he had received better, more personalized care.

Even people who like Geisinger's style say it would be hard to transplant to Philadelphia. Hospitals here also use checklists of evidence-based care. Some, like the Hospital of the University of Pennsylvania, have most doctors on salary. But the fact that many are paid by outside insurance companies and get referrals from distant primary-care doctors makes package pricing and extensive-care coordination difficult.

"It is much harder to do it when you're not in the same corporation," said Ralph Muller, CEO of Penn's health system. HUP, Penn's flagship hospital, has among the lowest costs in the Philadelphia region, according to the Dartmouth Atlas.

Muller said Geisinger also benefited from its rural patient base. There is "clear evidence all around the country," he said, that poverty and race contribute to high costs in urban areas. Many poor people have less social support and worse access to doctors before they hit Medicare age.

Muller added that Geisinger could act "more like a factory" when it came to medical procedures. Clinical innovation, a key part of the mission of hospitals like HUP, is more expensive.

"We do a lot of things over and over again," he said, "but we also do a lot of things for the first time."

Alan Zuckerman, president of Health Strategies & Solutions in Philadelphia, said Geisinger's most important feature is a culture that would feel alien in Philadelphia hospitals.

"It's a group-practice mentality. People go to Geisinger because they want to participate in a team-oriented delivery system as opposed to a me-oriented system," he said.

Doctors in many top city hospitals, he said, are stars who are less inclined to treat primary-care colleagues well. "It's a completely different culture. It's anathema. It's like asking Republicans if they want to be socialists," Zuckerman said. "The overwhelming majority of people who aren't working at places like [Geisinger] don't want to work there."