Innovative Geisinger thrives in rural areas, excels at recruiting, retaining employees

Health care's little engine that could

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Newly minted nurse Drew Hampton could have punched his ticket for any city. Thanks to the convergence of the Baby Boom generation and longer American life expectancies, nurses are in demand here, there and everywhere. But instead of seeking bright lights, he took a job with Geisinger Health Systems, the mostly rural, mid-state hospital system headquartered in Danville, Montour County, near Bloomsburg.

His reasons for coming aboard mirror the message that Geisinger is trying to project upon the health care universe -- bigger isn't always better, especially when you can get big-city experience, compensation, innovation and research opportunities in a small-town venue, even without a major university affiliation.

It's a message that has industry observers taking notice, and for the most part, agreeing.

"The reputation is great, and getting better," said Dr. Donald Berwick, head of the nonprofit Institute for Healthcare Improvement in Massachusetts. "They're in the same league as the Mayo Clinic or the Cleveland Clinic."

You may not have heard of Geisinger, because Pittsburgh is dominated by UPMC and West Penn Allegheny. But it has a huge footprint -- three flagship hospitals, 55 rehab facilities and physician centers and even supermarket clinics, covering 41 of the state's 67 counties, many of them north of Interstate 80. (The practice closest to Pittsburgh is in Clarion.) Those who monitor the industry say Geisinger is a technological pioneer among all hospitals, not just rural ones. On many lists, it ranks among the top 100 health systems in the nation.

Now, they want the world to know. Geisinger, a nonprofit system, launched an ad campaign this year, emphasizing the rural theme -- chirping crickets, singing birds, autumn hues, waterfalls and a pan flute thrown in for good measure. Each of the TV and print ads ends with the trademarked catchphrase, "Geisinger: Redefining Boundaries."

"We're doing the big surgeries that an inner-city hospital does," said Mr. Hampton, now a cardiology nurse. After four years at Bloomsburg University, he explored other hospital systems and said Geisinger was the only one offering him a nursing "externship" -- a protracted job-shadowing session that gives an applicant a taste of the job before he or she agrees to sign on.

It's one of the many steps the system has taken to aid recruiting and boost retention among nurses (as well as doctors). Since 2002, when the nursing recruiting plan was put into place, Geisinger's nursing shortage rate has dropped from between 10 percent and 11 percent, which is standard across the industry, to just above 3 percent. The number of doctors has grown from 500 to 700 in six years. Systemwide, including the insurance arm, Geisinger now employs 12,000, up from 7,000 since 2001.

"We're always recruiting," and not just when a certain position comes open, said Roxie Shrawder, a nurse and Geisinger's chief nursing recruiter. They do the standard stuff, dispatching recruiters to job fairs and conventions. But they also reach into middle schools and high schools, offering co-op opportunities to students and encouraging nursing careers. Nursing grads, much like medical school grads in some other health systems, are eligible for loan forgiveness programs.

Geisinger's own nursing school closed in 1998, cutting off what had been a reliable supply of nursing prospects. The following year, Geisinger announced it would dissolve its brief marriage with Penn State, which saw Geisinger spend $40 million a year to subsidize Penn State's College of Medicine in Hershey. The transitional period meant losses of $25 million in 1998. (Last year, revenues exceeded $2 billion.)

"That was kind of the starting point," said Dr. Glenn Steele Jr., chief executive officer of the health system. The ugly divorce from Penn State allowed Geisinger "to go back to our basic values," Dr. Steele said.

Layered on top of those values was a growth mission. And if it hoped to meet the personnel demands of its planned expansions, including a Centre County clinic that will open in 2008, Geisinger would have to get creative about recruiting. It's not easy to get medical professionals to move to what they assume is a "cultural wasteland," as one hospital official said, and you can't simply poach nurses and doctors from neighboring hospitals, because there are none. Solutions: Doctors can get bonuses if they convince colleagues to work for Geisinger. Nurses get extra pay for weekend hours, and can be trained through an in-house degree program, designed by Philadelphia's Thomas Jefferson University.

But the biggest recruiting tool of all may be the system's technological infrastructure. For years, Geisinger has been putting the finishing touches on an electronic health record system, accessible to doctors and patients throughout the 25,000-square-mile footprint, and they were doing it before other health systems. Like other hospitals, they are trying to refine billing procedures and financial systems, to make them more customer-friendly. You even can make appointments online.

The goal is "continuity of care" at primary, hospital and specialty levels. "They certainly made some mistakes strategically," said Dr. Berwick, adding that plenty of other top-flight health systems have made merger missteps over the last decade. "But now they're in a period of innovation. [It's] really one of the pioneering efforts in the country."

That the system's comeback coincided with the arrival of a new CEO is no coincidence. Dr. Steele came to Geisinger by way of the University of Chicago and the Pritzker School of Medicine, with a reputation for research excellence and a desire to get away from academia.

"Academia is limited by discovery," he said. He wanted the challenge of seeing that the research "was applied to benefit human beings." To do that, Geisinger would have to be turned into an "engine of innovation."

Here's an innovation: Geisinger's "ProvenCare" approach to heart bypass surgery, now in place for a year. The health system, after studying hundreds of coronary artery bypass graft surgeries, arrived at an average price. On top of that price is added half of the historical cost of post-operative hospital stays.

Insurers are billed a flat rate for the procedure. They get savings right of the box, since they know that, over time, they get a 50 percent price break on the post-op care. Geisinger, then, hopes to save money by coming in under the 50 percent threshold.

If it doesn't, it eats the overrun. That eliminates the "perverse" truth that hospitals get more money for bad care, long hospital stays and thus bigger bills to insurers.

The procedure itself is carried out according to a manual of 40 standardized guidelines, compiled by the hospital. If anything goes wrong, and post-op stay is longer than usual, it won't cost the patient -- or the insurer -- another dime for 90 days.

In effect, patients have a warranty on their surgery.

"We're trying to take evidence-based practices, and make sure they get hard-wired into the care process," said Dr. Ronald Paulus, Geisinger's chief innovation and technology officer. That's easier said than done -- while best practices are more or less agreed upon by the American College of Cardiology and the American Heart Association, each surgeon is different, and each surgery varies, if only by a step or two.

"Part of [the challenge of] this is getting the buy-in that goes along with standardizing care," Dr. Paulus said. Doctors believe they, and not necessarily an instruction manual, know what's best for an individual patient.

Innovation is one thing; it's an open question as to whether all these innovations have "market legs," as Dr. Steele likes to say. If fancy technology, surgical warranties and a good nurse-to-patient ratio actually translate into better care, Geisinger can point to the outcomes and attach a dollar value to them, over a three-, five- or 10-year period.

For insurers and employers to buy into the ProvenCare warranty, Geisinger will have to show that not only is the care superior, but also offer bundled, fixed-price deals for other major surgeries. Geisinger is working on that for hip replacements, angioplasty, knee surgery and cataract procedures.

So far, there have been no takers on the flat-rate offer, other than Geisinger's own insurance unit. But Dr. Steele says that can change, especially if a major player like Medicaid moves toward outcomes-based, "pay-for-performance" reimbursement.

"Medicare is sniffing around the possibility of not paying for complications," Dr. Steele said. If that happens, an insurer might suddenly be interested in a fixed price that includes a portion, but not all of, likely post-op care.

"The real question," said Dr. Paulus, "is can it be adopted, and is it desirable by purchasers," and do consumers start picking Geisinger over other hospitals as a result? If the answers to those questions are yes, that means the prospects are better for commercial ventures -- nurse practitioner pit-stops in Weis supermarkets, for example, patterned after the health clinics in retailers such as Wal-Mart and Target, and MinuteClinic, which leases retail space across the country.

Clinics like those could become more popular in Pennsylvania, as Gov. Ed Rendell's "Prescription for Pennsylvania" aims to loosen restrictions on nurse practitioners and other non-doctors, moving care out of hospitals and emergency rooms, where it is more expensive, and into community clinics.

That fits nicely with Geisinger's growth plan, maintaining its 50 percent market share in the mid-state, and becoming a referral destination of choice in the state's competitive northeast. (The recent acquisition of a Wilkes-Barre hospital helps Geisinger serve that fast growing region, flooded by spillover from New York and New Jersey.)

The growth plan stops, for now, at southwestern Pennsylvania. Geisinger already abuts UPMC's market, and in some spots competes for customers. But in Pittsburgh, and especially in UPMC, it sees more of a collaborative relationship, not a competitive one. The two health systems have discussed joint research, clinical trials and data-sharing, though no formal deal is imminent.

Like UPMC, Geisinger is building a "biobank" of tissue and DNA samples from consenting patients, to be used for future research. Central Pennsylvania is ideal for genetic research, Geisinger says, because of the stable, homogenous population, which allows for long-term follow-up patient tracking. To that end, Geisinger has focused much of its research team on issues specific to rural health. This year, it announced the formation of its Rural Health Policy Institute.

It's all part of innovation and the belief in finding growth in parts of the state that often are overlooked.


Bill Toland can be reached at btoland@post-gazette.com or 412-263-2625.


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