Next Things First

Getting It Right the First Time, Warranty Included by charlottegee
April 1, 2009, 6:40 am
Filed under: hospitals, innovation | Tags: , ,

Yesterday the Washington Post ran a piece on Geisinger Health System’s ProvenCare program, which the health system began three years ago:

Mimicking the [Maytag] appliance company that advertised its products’ reliability, the health system devised a 90-day warranty on elective heart surgery, promising to get it right the first time, for a flat fee. If complications arise or the patient returns to the hospital, Geisinger bears the additional cost. The venture has paid off. Heart patients have fared measurably better, and the health system has cut its bypass surgery costs by 15 percent. Today, Geisinger has extended the program to half a dozen other procedures, and initiatives such as the counterintuitive experiment in Pennsylvania coal country are now at the heart of efforts in Washington to refashion how care is delivered across the United States.

How’d they do it?

Geisinger … achieves those goals through standardization. Science-based protocols are “hard-wired” into the process, in much the same way that high-end manufacturing works, said Alfred S. Casale, Geisinger’s associate chief medical officer and a driving force behind the program. For heart bypass surgery, Geisinger guarantees that every patient will receive 40 action items it has identified as best practices. The list includes, for example, properly administering antibiotics within 30 minutes of the operation. The wrong dose increases the likelihood of infection, and infection can lead to a second surgery, prolonged hospitalization and greater risk of death. Surgeons can opt out of doing any element if they give a reason, and an operation is canceled if a single step is missed in the preparations. Electronic medical records contain built-in reminders for the surgical team and track the results.

Of course, not all is well (and many of the reader comments point out that the writer focused only on the good things, leaving out some of the negative effects, and didn’t cover the systematic problems with replicating this program):

But its success has been limited. Geisinger also treats patients who are insured by other companies, and those insurers are not convinced that the savings would be large enough to make it worthwhile for them to renegotiate contracts with the health system. Many still feel more comfortable with the traditional pay-per-procedure approach, even though they run the risk of having to pay thousands of dollars to fix surgeries that go wrong.

Most hospitals are also skeptical of Geisinger’s innovation, saying they would lose money by being unable to bill for treatment of patients who must return. “If they do the right thing and keep patients out of the hospital, it costs them,” said Glenn Steele Jr., Geisinger’s president and chief executive. … Geisinger doctors initially recoiled at the idea of “cookbook medicine,” believing they already followed best practices, Casale said.

PBS’ “NewsHour with Jim Lehrer” also reported on the ProvenCare system:

DR. ALFRED CASALE: We’re saying that we’re so sure that by doing these things right, we’re going to lower complication rates that we’re willing to share the risk of that with the payers, rather than, in the past, there was this perverse mechanism where, if I forgot to give an antibiotic and the patient developed a wound infection after that, and if that patient had to come back in and have another operation to fix the wound, I’d send you another bill, and your insurance company would happily pay it. We think this ProvenCare process has shifted from paying for individual items to paying for value delivered by a high-quality, high-performing system.

MedInnovationBlog had something to say about systems in health care:

Geisinger’s 90 day warranty is an example of “systems engineering” in health care. A number of large integrated multipspecialty groups – Kaiser, Virginia Mason, Intermountain Healthcare, Partners Health, and various academic centers – are following this approach. Systems engineering advocates say, in essence, if you get enough health care people within a health system working together in an organized and systematic way to achieve specific goals, you will reduce errors and improve performance. This requires data, commitment, infrastructure, computer monitoring, electronic records, and physicians in intergrated large multispecialty groups. In American medicine , systems engineering is not common since only 4% of doctors belong to groups of 50 or more.

Posted by CharlotteGee