Health provider offers hospital care with a 90-day warranty

May 20, 2007|By New York Times News Service

What if medical care came with a 90-day warranty?

That is what a hospital group in central Pennsylvania is trying to learn in an experiment that some experts say is a radically new way to encourage hospitals and doctors to provide high-quality care that can avoid costly mistakes. The group, Geisinger Health System, has overhauled its approach to surgery. And taking a cue from the makers of television sets, washing machines and other consumer products, Geisinger essentially guarantees its workmanship, charging a flat fee that includes 90 days of follow-up treatment.

Even if a patient suffers complications or has to come back to the hospital, Geisinger promises not to bill the insurer extra.

Geisinger is by no means the only hospital system currently rethinking ways to better deliver care that might also reduce costs. But Geisinger's effort is noteworthy as a distinct departure from the typical medical reimbursement system in the U.S., under which doctors and hospitals are paid mainly for delivering more care.

Since Geisinger began its experiment in February 2006, focusing on elective heart bypass surgery, it says patients have been less likely to return to intensive care, have spent fewer days in the hospital, and are more likely to return directly to their own homes instead of a nursing home.

Geisinger presented the first-year results of its experimental program at a meeting last month of the American Surgical Association.

Geisinger stands out as a group that has transformed the way it delivers care, said Dr. Donald M. Berwick, the chief executive of Institute for Healthcare Improvement, a national nonprofit organization whose goal is better patient care. In almost no other field would consumers tolerate the frequency of error that is common in medicine, Berwick said, and Geisinger has managed to reduce the rate significantly.

"Getting everything right is really, really hard," Berwick said.

It is still too early to know whether the approach, called ProvenCare, will catch on elsewhere.

So far, the only insurer that Geisinger has contracted with under the new arrangement is its own insurance unit, which covers about 210,000 people in Pennsylvania.

Eventually, though, Geisinger hopes to attract other insurers and employers that provide health benefits by expanding the approach into other lines of care provided by the nearly 660 doctors it employs at its three hospitals and 55 offices in the region.

Geisinger is trying to address what it views as a fundamental flaw in the typical reimbursement system.

Under the typical system, missing an antibiotic or giving poor instructions when a patient is released from the hospital results in a perverse reward: the chance to bill the patient for extra treatment.

As a result, doctors and hospitals have little incentive to make sure they consistently provide treatments that medical research has shown to produce the best results.

Researchers estimate that roughly half of American patients never get the most basic recommended treatments - such as an aspirin after a heart attack, or antibiotics before hip surgery.

The wide variation in treatments can translate to big differences in death rates and surgical complications.

In Pennsylvania alone, the mortality rate during a hospital stay for heart surgery varies from zero in the best-performing hospital to nearly 5 percent at the worst performer, according to the Pennsylvania Health Care Cost Containment Council, an agency of the commonwealth.

Around the world, other modern industries - whether car manufacturing or computer chip making - have long understood the importance of improving each piece of the production process to tamp down costs and improve overall quality.

But hospitals have been slow to focus their attention on standardizing the way they deliver care.

Geisinger doctors identified 40 essential steps for bypass surgery, then devised procedures to ensure that those steps would always be followed, regardless of which surgeon or which one of its three hospitals was involved.

From screening a patient for the risk of a stroke before surgery to making sure the patient has started on a daily aspirin regimen upon discharge, Geisinger's 40-step system makes sure every patient gets the recommended treatment.

David Dunsmuir, 65, was impressed by the cardiac surgery he received - and the doctors' and staff's efforts to explain things during the four days he spent in December at Geisinger's hospital in Wilkes-Barre. The care, which included a few weeks of rehabilitation, was delivered "like clockwork," Dunsmuir said.

For Geisinger, as with any hospital, the challenge is often in persuading the doctors to get on board. Before the ProvenCare program began, Geisinger's seven cardiac surgeons each delivered the care they believed was best for patients. And that care varied.

"We realized there were seven ways to do something," said Dr. Alfred S. Casale, the director of cardiothoracic surgery at Geisinger.

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