America: how a health system is transforming in response to Covid-19

The Covid-19 virus has transformed healthcare in the United States. At our facility, Geisinger Health System, we quickly activate emergency response plans and cancel all non-urgent procedures and clinic visits. Our non-clinical workforce has been diverted to work from home and virtual contact with patients has exploded. For the first time, we are addressing the shortage of personal protective equipment and vital medical equipment. Geisinger, like almost all major healthcare systems, is suffering negative financial impacts from the pandemic that could ultimately run into the hundreds of millions of dollars. The profound disruption that occurred in just 12 weeks of an industry in a century was staggering.

Many in our industry have a natural desire to get back to the way they were before. But we believe there is a better approach for our patients, employees, and our communities. Many aspects of how healthcare historically worked in the United States, including some elements of the fee-for-service business model, are the same ones that have left us vulnerable to the devastating impact of the Covid-19 virus on our systems of care. We must not return to normal. Instead, we must focus on creating a new normal. Building this new reality requires accelerating the positive transformations we have already undertaken, carrying out some fundamentally new transformations, and identifying the activities that we have stopped and must not resume.

Now is the time to boldly transform our health care systems in ways we couldn't before. We must seize this unprecedented opportunity to fix what has not worked and turn our full attention to new and more important goals focused on creating value for patients.

Many healthcare systems focus on mitigating the impact of Covid-19 on their patients, employees, and their businesses. Others have become interested in what is coming next, sometimes in disjointed and interactive ways. At Geisinger, we officially began post-crisis planning a few days after the pandemic started and assembled a steering group comprised of leaders from all parts of the organization. (By the way, we are not intentionally thinking in terms of a "post-Covid", but rather a "post-crisis" as much of the important work that needs to be done will happen while COVID-19 or its effects are still there).

We have recognized that this important work should be viewed and implemented as a strategic and operational innovation initiative, not as a damage mitigation exercise or with a focus solely on revenue recovery. We knew that executive approval, in our case from CEO Jaewon Ryu, would be necessary to provide the "air cover" necessary to carry out such sabotage and ensure a lasting transformation.

The steering group has identified 11 core areas of our business (including the clinical organization, our health insurance company, human resources, finance, information technology, pharmacy, and five other broad areas) and has established working groups in each. of these areas in charge of defining our study plans. Each task force includes leaders outside the focus of the task force; This is especially important because stopping some activities is necessary for the transition, but those close to them may resist. Outsiders can provide an honest perspective for a discussion.

The groups were asked to examine four stages of the transition: 1) the non-urgent return from work, 2) the onset of the "new normal", 3) the post-crisis activity, the expansion of the "new normal" and the response to the second possible wave of Covid-19, and 4) Operational and economic recovery in a system in transformation. Members were instructed to think carefully about the impacts at each stage on patients and front-line staff, focusing on their needs, what has changed (and will change) for them, and what will make them truly safe. Each group was also assigned the task of categorizing the activities of each of its functions as 'initiation', 'follow-up' or 'stop'.

The groups used a scenario planning approach to their work, as it cannot be assumed that the future will look like the pre-Covid-19 world. In the planning exercises, the groups developed plausible scenarios (for example, a permanent reduction in elective procedures or a higher payment for telehealth visits) and discussed the implications for the patient's care and business. In the process, the groups have made common assumptions about our new normal and how the organization should respond.

Most healthcare organizations are now working to reboot their systems. Stages 2-4, where transformation and innovation are most important, are the main focus of this article. At each stage, we put together some illustrative examples of the dozens of topics covered by each of our working groups.

The safety of our patients and staff has been our focus during the crisis, and will continue to be as we continue to resume non-urgent clinical work. Testing for SARS-CoV-2 is critical to preventing transmission, and Geisinger was one of the first healthcare systems in the United States to validate and conduct internal testing for both groups. As of early June 2020, Geisinger has conducted 21,343 internal tests of which 2,455 have tested positive. These account for 3-4% of all positive tests and results in the Commonwealth of Pennsylvania, although Geisinger does not cover major population center areas.

Contact tracing is also essential to contain any epidemic. While this has traditionally been under the auspices of state and local health departments, many of these resources have been poorly distributed during this national emergency. We believe that health systems that have the resources to do so should support contact tracing for public health departments as a public-private partnership. The United States is well short of the 300,000 contact trackers needed. Many hospital systems already have experience administering tests, communicating results, and treating those who test positive. Expanding these capabilities to include contact tracing would be a natural extension of many systems, go a long way towards the public good, and could help reduce your Covid burden.

Geisinger now has 24 employees who dedicate much of their work week to contact tracing, a new organizational capacity with immediate benefits but also valuable if we face a second wave of Covid. To date, this team has made more than 2,700 phone calls to follow up on 1,600 positive patients and those identified in contact with them. Live contact tracing benefits patients, service providers and communities

During the pandemic, Geisinger saw an acceleration of strategies that had previously been slow to gain acceptance. For example, before Covid-19, the average number of telehealth visits was 40 per day in our system. As with many hospital systems, a variety of factors, including patient and provider reluctance, and reimbursement restrictions, prevented widespread adoption. Now, due to the crisis, we provide an average of 4,000 to 5,000 telehealth visits per day (40% of which are video visits). Like most state and private health coverage, our health insurance plan now compensates for telehealth visits at the same price as in-person visits. We have also waived the copayments associated with these visits to our members. Perhaps the change in the perception of patients about telehealth is the most important in increasing adoption, since attitudes change from, this provider should not think that my problem is important because they serve me through telehealth, to this provider who cares about me and therefore sees through telehealth. . Several of our service providers have noted the remarkable benefits of telehealth visits, including that patients with chronic conditions can now avoid going to healthcare facilities, and that service providers now often have valuable information about settings. patients' homes. We plan to build on this momentum and continue to expand our use of telehealth services and all forms of virtual encounters even after this pandemic subsides.

Another program that has supported our ability to promote and maintain the health of our patients remotely is our pharmacy organization. More than two years ago, Geisinger launched its own mail order pharmacy. This feature provides market efficiencies for our patients and members. We found that patients who received prescriptions through this channel had approximately 40% drug adherence rates. For the institution, it is a more efficient way to provide prescriptions to our patients, due to the lower costs to fill them. These savings can then be passed on to our patients in the form of drastically lower costs, as patients often see cost reductions of more than 50%, making it easier for them to continue to adhere to their medication regimens. While Geisinger was increasing the use of mail order prior to Covid-19, the pandemic demonstrated its benefits for patients and service providers. Patients save money, avoid travel and physical contact, and as a result, mail order use has increased by 20% per month in the three months since the pandemic began. As with telehealth, we plan to build on this momentum to encourage continued or increased use of postal pharmacies after the pandemic.

Some of the drastic changes healthcare systems have made in response to Covid-19 will likely remain with us. For example, many have allowed a large portion of their workforce to work from home. Geisinger acted quickly to empower 7,000 WFH employees during the crisis. The benefits of this transformation include increased employee safety and access to an expanded talent pool where WFH employees can live and work from anywhere in the world. To the extent that employees continue to operate effectively from a distance after the pandemic, we expect potential cost savings by canceling leases, selling our own properties, and converting existing administrative space to medical space. A recent analysis revealed that up to 30% of our workforce can work permanently, with an additional 30% working in mixed WFH and clerical roles. In addition to the possibility that much of our clinical activity will continue in telehealth services, we are reviewing our flagship facility plan for the next few years. Health systems that have been successful with the WFH during Covid-19 should consider assessing the proportion of their workforce that may be permanently served by the WFH; We anticipate a significant reduction in operating costs and the conversion of administrative areas into clinical space using this approach.

The pandemic has also revealed that we need to step up vigilance. For example, many experts predict a second wave of Covid-19 in late fall or early winter 2020. Currently, both patients and caregivers are extremely wary of possible infections. But as current cases decline and routine work resumes, an increase in new cases may not initially be detected. To increase the likelihood of seeing a new wave as it evolves, we need new early warning surveillance systems to complement existing methods that failed to capture the original emergence of Covid-19 cases. To this end, Geisinger has partnered with Stanson Health to develop and implement an AI-enabled solution that navigates through emergency volumes, emergencies, and other vendor documents in real time for unstructured phrases indicating Covid symptoms. -19 like, 'Loss of taste'. "Shortness of breath" and hundreds of other phrases that can go unnoticed in the course of a return to busy clinical practice.

The pay-for-service business model of healthcare in the United States, a design whose skewed incentives hampered innovation and transformation of care even before Covid-19, was destined to fail under pressure, and it really happened. Covid-19 has exacerbated the already existing shortcomings of this approach, in particular its deep reliance on maximizing elective measures and overall scale. The crisis required a rapid acceleration of virtual care and home care, as patient and hospital systems intentionally reduced inpatient admissions and avoidable use of the emergency room. Virtual care and home care can reduce costs and improve patient participation. But these same efforts have led to a significant decrease in income under the current rate payment system in our country.

Geisinger has always encouraged the need to move to value-based payment models that reward prevention and good results rather than increasing actions. Covid-19 emphasizes that this transition should be significant far beyond the modest and pioneering efforts we've seen thus far. Postpaid reform should create funding mechanisms that make prevention and population health, rather than maximizing reimbursement within ECAs, the true focus of care. This will require substantial financial incentives to drive the alignment between value (better health outcomes at lower cost) and reimbursement. These incentives should be sufficient to encourage the investments necessary to fundamentally transform the care delivery model. For example, we strongly advocate for the adoption of "risk" models such as global full-payment budgets that determine in the future how much hospitals will pay to care for specific residents over the next year. Models like these will improve quality and lower costs as more patients receive the right care in the right places. Without such a change, US systems will continue to suffer from the effects of prioritizing volume over value and will be financially vulnerable in the next pandemic just as they were in this pandemic.

Covid-19 has caused extraordinary morbidity, loss of life, and devastating economic burdens, and has put tremendous pressure on the national health care system that we thought was indestructible. We must harness the lessons learned during this crisis to transform the way we care for patients. Public and private taxpayers must work vigorously with health systems to accelerate the transition to value-based payment approaches that support new models of care. If we could transform our nation's payment and care delivery systems in ways that fundamentally improve healthcare for our patients, our providers, and our communities, we would have found the silver lining of Covid-19.