In his first year at the helm of Geisinger Health System, David Feinberg, MD, has continued to hone the longtime population health leader's intense focus on evidence-based care and improved patient experience. He's also overseen the launch of the health system's ProvenExperience program, which gives refunds to patients who were not satisfied with the service or care.
He spoke to our sister site Healthcare IT News about the program, the people who make Geisinger work, the evolution of population health and the promise of what he calls "anticipatory medicine."
Q. It's been about a year since you took over as CEO at Geisinger, following eight years as CEO of UCLA Health. What have you learned so far? Any surprises?
A. From my perspective, it's been fantastic. It was a big move for me. I didn't really need to make a move, and I had a lot of anxiety about whether it was the right thing to do. And I come home from work every day saying, 'Boy, we sure made the right decision.'
The thing that drew me to Geisinger is not the thing I'm most surprised or excited about. The thing that drew me here is what I think most people know about it: It's really been innovative in different care models, and in making sure there's evidence-based care.
I keep saying I came from a place that invented the PET scan, and I'm now at a place that knows when to use the PET scan. Or, from a place where the doctor is the star to a place where the system is the star.
That systematic care is what I was so excited about at Geisinger. What I was surprised about – and I guess this might show my naïveté – was the people. The people of central and northeastern Pennsylvania are incredible people. These folks, particularly in our core market, are multi-generational. And they love Geisinger. Their whole family has worked there – grandpa maybe poured the cement for the building, the uncles and brothers worked in IT, mom is a nurse, there's a doctor.
And they're incredibly stable – the population doesn't move. And what that plays into is what's happening with us around genomics. One of the key parts of our success in a population-based genomics approach is we ask people, 'Can we look at your whole genome?' Ninety percent of the time, they say yes to this.
There's people in other areas where a 15 percent response rate is not unusual, and about 50 percent is really good. These people all say yes to us, essentially. And then, because they all still live there and haven't moved around, it allows us to do things in very different way that we couldn't do anywhere else in the United States.
So the people have been the best pleasant surprise, in a lot of ways.
Q. You're still seeing patients occasionally, correct?
A. I try to see patients every day. I'm seeing some of my own patients, but I would say they're all my patients. So I make the rounds every day: in clinics, in cath labs, in the ER. I knock on the door and make sure everything is going the right way. My first concern is if there's anything I could do to assist the patient or the family with the care they're receiving. They all get my card and a cell phone number and a message to call me if there's ever anything going on. So that direct patient care I do every day.
Q. That's not something every health system CEO can say. How does that day-to-day connection affect your strategic thinking about Geisinger's direction?
A. It drives everything. I don't know how you could run a restaurant and not try the food. We're a service industry. If you strip it down, we're people caring for people. I want to focus every day on our people, our caretakers and the people we're caring for. My whole schedule is built around making sure that's taking place.
Q. You made a lot of headlines this past fall when Geisinger unveiled ProvenExperience, which offers refunds to patients who don't think they've experienced "kindness and compassion" in their care. How has it been going since the pilot was launched in November?
A. A little bit of history is important here. Geisinger has had this portfolio around 'Proven' for quite some time, and that started about a decade ago, for our Proven Heart program – basically saying there will be one price for heart surgery. We'll make sure you really need it. And then if you get the surgery, we're going to do all the steps, on everybody. And we're so sure about it that if you were readmitted or had an infection or a complication, we could stand behind it and we won't charge you. The New York Times called that the first warranty in healthcare.
So then Proven Heart went to a number of other proven acute conditions, whether it be Proven Hip or Proven Lung. It was around surgical procedures, making sure everything got done, and for a period of time, post-op, that would be covered under a package billing.
That Proven Acute went to what I could call Proven Chronic – what I would call our medical homes and transitions of care for people with chronic conditions, and making sure, again, that there are no gaps in their care, that all diabetics get their feet checked and eyes looked at every year, etc.
It was really, really impressive. And when I got to Geisinger and see this discipline around evidence-based care, there are really great outcomes. The observed-to-expected mortality rate the month I got there was 0.5. Our anticoagulation, a month or two after I got there went from best in the United States to best in the world. System wide, our door to balloon time was 42 minutes for patient with heart disease to get to the cath lab where you're supposed to be under 90 minutes, and 95th percentile is 49 minutes.
So this focus on proven – let's get all the right steps in place and make sure they happen efficiently – was playing out really nicely, whether it was in the chronic setting or in the acute setting.
But I felt we had room – and our patients in my rounding, and our scores, would show that, while were providing what I would say is probably the best care as far as quality and safety, it wasn't particularly or consistently compassionate and kind. I think a lot of it had to do with the fact that the organization is 100 years old and in the last three years doubled in size. There was a lot of focus – you could say distraction – on our growth. We had lost our way around that, connecting with patients in a very intimate and privileged way.
So we rolled out what we think is an extension of all that proven, ProvenExperience. We'll answer the phone. We'll offer you a same-day appointment for any specialty, regardless of acuity. We'll treat you as if we've been expecting you, so you'll be treated in a particular way every time. The handoffs in care will be remarkably smooth. Of course there will be high quality. Your transition will be smooth, you'll come home from a surgery, and everything you need at home – because we know it – will be there in a box waiting for you. You'll even get a bill you understand.
And in the end, if you don't think the care was to your standards, we're happy to refund the co-pay, the coinsurance, your self-pay, your out-of-pocket, everything. We're basically saying, the same way we guaranteed the heart surgery 10 years ago, we're guaranteeing, putting a warranty, that your entire care experience will be outstanding.
If it's not, let us know. And in the process of letting us know, we'll make it very easy for you to ask for a refund, and that refund can be partial or complete. And that's based on patient preference. Even we don't think we did anything wrong, we still give that refund. There's no jury or judge. The same thing as with Starbucks. If you don't like the cappuccino, they don't sip it and say, 'We made it right, we're not giving you a new one.'
Q. Have you had to give many refunds?
A. We see refunds as more of an opportunity than as a bad thing. I don't know the exact number, but I think we've given about $80,000 in money back. Some of that is $20 copays. I saw one that was $14. Some are a few thousand dollars.
Most of the responses we've gotten – we have a nice slick app you can download from the App Store, although you don't need to use the app to get the refund – but from the app, which is an easy way to see how it's going, the vast majority of the responses have been positive: People were really happy with their care, nurse so-and-so was fantastic, this doctor was great, or the lady at the front desk or the guy in valet parking went above and beyond. With those positives, we can connect with those staff people and make sure they get acknowledged appropriately.
With the negatives, I guess a little bit of the surprise has been that there's been very few negatives that are just negative. On the app you can log positive and negative feedback, and most negatives do click both. The negatives, by and large, if you read them you'd say, 'Oh, we messed up.' It's usually messing up around coordination of care, or communication around care.
And then this part has also been pretty surprising: If you had a $2,000 out-of-pocket, and we say to you, 'How was the care?' on the app, and you say, 'Well, this doc was great,' or 'This person was fantastic,' but your negative might be, 'It was loud in the hospital, they messed up with my IV, one staff member was rude.' But when you get to the refund page, you could ask for anywhere on a sliding scale between zero and $2,000. With most of the negatives, the people are only asking for a fraction of their money back.
So one woman came in for bariatric surgery. A lot of positives. The negatives were that the IV didn't work, the noise from the construction work went until 10 at night instead of 9 at night, and there was one particular nurse who was not kind, just sort of neutral. This woman asked for $150 when she could have slid her finger over and asked for $2,000 back.
So it's pretty amazing that I think the majority of the feedback is not that people want their money back. People want to make sure we listen to them, and that we're going to fix it for the next guy. When they do ask for money back, almost universally they don't ask for it all back.
The people we care for, generally, love Geisinger. Geisinger is their community. In most of our settings it's the largest employers. For many patients, their family members or they themselves worked there. It's been good to the community for so long, that nobody is taking advantage of us. Rather, we could say, over the past six months, we've spent $80,000 on the best secret shopper program ever.
Q. There are many definitions of "population health." What's yours?
A. I think that's a great question. It's one of those buzz phrases that no one really knows how to define. Let me tell you how it's playing out for us.
To me, is it the population of our patients, is it the population that surrounds us? Who's the population, and how do you define health. I'm a guy who's obsessed with my own personal health; I eat right, exercise, don't smoke. And a lot of people think as a health system we should have no smoking anywhere in the community, or things like that. But those are really public health measures.
If you want to decrease teenage substance abuse, which is my clinical expertise, the pop health people do that better than the healthcare providers. Now, because things are kind of going to a pre-paid thing, we think, 'Wow, if we could keep people healthier, that will help us long-term.' If everyone got healthier and we were pre-paid, we could make some money.
So I think there's some confusion in the industry about who should be doing this. We really haven't had the discussion for the organization, but for me, population health is taking better care of our patients and, in our case, oftentimes the patients are the population because we're the only provider. Better care for the patients means answering the phone, taking care of people with kindness and respect. All that patient satisfaction stuff.
But it also means anticipating the other needs that they have. In a very simplistic way we've seen that in our town of Shamokin. Fifty percent of the town, all of which comes to us for healthcare, by and large, are diabetic. And 30 percent are food insecure – they don't know where their next meal is coming from. It's a really post-industrial coal-mining town that has seen better days.
That's our population. What do we do for them? There's been food banks. Obviously people are more skilled than us at getting people to eat right and exercise. That's not what we're trained to do. So what we're doing in that community is, when you get your insulin, or your prescription down in the pharmacy, we're going to start delivering, to patients, a week's worth of food that is diabetic-safe – and tasty.
We're going to treat it the way we treat people: You see your doctor, you get your medicine – in this case the medicine is food – and it won't have the stigma associated with going to the food bank. We're going to take it from one patient at a time and try to improve things for the whole population.
And then in a much more high-tech way, look at what we're doing around genomics. We think we're the only organization that's taking a population-approach to genomics. Right now there are definitely some great cancer treatment centers that are looking at the sub-type of your oncogene and determining medication based on what type of cancer you have. There are definitely tests out there that can look at your genetic profile and determine what medication you should be put on or should be avoided: pharmacogenetics.
Ours is population genetics. What we're doing – and saying to our friends and neighbors who are our patients – is, 'Would you allow us to look at your genome?' With that 90 percent response rate, and with eople not leaving our community, we just did our 100,000th full genome and we think we'll hit 250,000 pretty soon. We have this genetic information, along with clinical information, along with entire families' radiologic information, and of course we also have claims data so if you get care somewhere else we know about it.
We're now returning those results to our patients – what people would say is precision medicine. But I would say precision medicine is taking care of someone who is sick; this is any of our patients, so it's really anticipatory medicine. It's coming up with about 70 what we're describing as medically actionable conditions. I think we're up to about 76. 'You have something in your genetic profile that has a very high chance, 90 percent, of developing in you. And there's something we can do about it.'
We're giving that information now back to our patients. So that could be that you have Lynch Syndrome, which is associated with significantly higher rates of colon cancer, or you have familial hypercholesterolemia, the kind of cholesterol problem that would mean that at age 8 you should be on medication or you're going to face mortality from stroke or heart disease; or you're BRCA positive and you and your family need to make some decisions about what to do right now because of that.
And all of these, which Geisinger is really great at, are built right into the electronic health record, so the ongoing maintenance happens automatically and you don't fall through the cracks.
No one else is doing that. The precision medicine that President Obama spoke about at the State of the Union in 2015, came out with the NIH precision medicine grant we've applied for and we think we'll hear this month. They're going to give seven institutions $50 million. To qualify, you have to o 10,000 genomes and combine it with the 10,000 medical records of those people. We can sign a thousand people up in a week, so we're way, way ahead.
To me, thats population health. We're going to prevent heart disease. I think we can say today that if you're a young woman in central or northeast Pennsylvania, your chances of getting breast cancer are lower than anywhere in the world. Because no one – well, almost no one – is checking entire populations for BRCA and then acting on it.
Iceland, which has the same type of population as we do, where no one moves, is doing that genetic information, but there it's not linked to a health system so they're not getting the feedback to patients. We're the only people doing it. To me, that's population health – anticipatory care for our patients.
Q. Are there lessons smaller hospitals can learn from a world-class leader like Geisinger about using analytics to make some tangible improvements in patient outcomes?
A. My first bit of advice is to get it right with the patient in front of you. Being present in this crazy, changing industry we're in, with so much workflow disruption and the electronic health records that make it hard, is a challenge. But today there's someone coming to your ER because he's suicidal. There's someone getting a diagnosis of breast cancer. There's an elderly person who fell and has been lying in the bathroom for six hours and the family just discovered them.
And so to be present with our patients, and really stay focused on your reasons for caring for people, I think builds trust and allows you to succeed in the future – to not worry so much about what's coming when you have a patient in front of you.
And then the other part is I think our industry is ripe to be disrupted. And it's going to be disrupted because there's so much we do that doesn't add value. Waiting rooms have never cured anybody. Phone trees are not very fun when you're trying to order a pair of shoes. They're really not fun when your wife has had a stroke. People that treat you like a number, it's fine at the DMV because you don't have to go there all the time. It's not right in the healthcare system.
We need to make it the year of the patient. And I think that has to be every year.
But around analytics, I think the answer is, again, the people. It's bringing folks together: front line people – clinicians, nurses – with IT and data people, and really trying to solve problems together. And I would add to that, I think it's helpful to bring in people from other industries that have been through this before. It's happened in telecom, it's happened in a lot of retail, it's not unusual what's happening to us. These other people who've had experience where they've gone to a more retail, data-driven customization.
Those smaller (providers) that might not be so well capitalized, I think that's not a problem. We run an information exchange in our region and have other partners. Many of them are using the HIE as their health record platform. They're not even putting in EHRs. I think electronic health records are going to get easier and cheaper. But the real thing is getting people together: figuring how we can solve the access issues, the health literacy issues, making it easier for our docs to know which patients they can see, when and how. Data can help us make those decisions.
Feinberg will keynote Healthcare IT News' inaugural Pop Health Forum 2016 in Boston on May 20, where he'll discuss how data analytics and coordinated care can drive improvements in patient outcomes and offer his perspective on Geisinger's renowned ProvenCare program.