Dr. Glenn Steele, President and CEO of Geisinger Health System

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Mark Masselli: This is Conversations on Healthcare. I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret we have seen our final round of activity till Apri l 30th, t he
final deadline for uninsured Americ ans to sign up for coverage to avoid penalty at tax
time next year.

Margaret Flinter: The one last chance the federal exchange and most of the state run
exchanges offered people that extension for those who remained uninsured.

Mark Masselli: Another in teresting development Margaret is the White House is
applying some pressure to those states that have refused to expand Medicaid for their
uninsured residents living close to the poverty line. States like Texas and Florida have
millions of uninsured resid ents between them that would qualify for Medicaid expansion
guidelines and the federal government is now warning those states that they will lose
billions in hospital funds if they continue to refuse.

Margaret Flinter: Well as you can imagine that we kno w for the states who have
expanded coverage is a windfall that they badly needed so leaving that money on the
table and locking out millions of low wage Americans from gaining coverage it just
doesn’t seem to make a lot of sense.

Mark Masselli: But somet hing that does make sense today is or guest Dr. Glenn Steel
is President and CEO of Geisinger Health Systems in Pennsylvania.

Margaret Flinter: Well the work of Geisinger and of Dr. Steel both their vision and what
they have accomplished is truly ground breaking and already achieves what the
Affordable Care Act is seeking to manifest.

Mark Masselli: And we are looking forward to Lori Robertson but no matter what the
topic you can hear all of our shows by going to chcradio.com.

Margaret Flinter: And as always if you have comments please email us at
[email protected] or find us on Facebook or Twitter because we love to hear from
you. Now we will get to our interview with Dr. Glenn Steel in just a moment.
But first here is our producer Marianne O’Hare with this week’s headline news.
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Marianne O’Hare: I am Marianne O’Hare with these Healthcare Headlines. A law is advancing through the California legislature that would require all children entering kindergart en to be vaccinated. The bill blocks parents from gaining of vaccine

e xemption for personal beliefs. Under the bill only children with medical waivers would
be exempt from the vaccines. Meanwhile a recent longitudinal study of over a hundred
thousand ch ildren vaccinated for measles, mumps and rubella showed once again no
correlation between vaccination and autism. Bird flu is taking hold in the country. Avian
flu now present in 12 states. More than 7 million birds have been destroyed thus far.
The CD C says two strains have been genetically identified in this country H5N2 and
H5N8 and these particulars strains are less likely to transfer to humans than other
strains of the virus and genetic test on the stereo bacteria found in several bluebell ice
crea m products produced in Texas show the bacteria has been present in those
products for at least 5 years and number of illnesses have been reported in several
deaths that occurred from ingesting the taint to the ice cream, the third biggest brand in
the US. The genetic evidence has led the company to recall all of its products now in
the market place and living longer could quite simply come down them around. A study
of seniors 85 and older show the most pessimistic a person was the more likely they
were to die within 5 years conversely those who were more optimistic in nature were
more likely to live longer. The study conducted in Sweden show those elderly adults
who continue to find things to look forward to had a more optimistic attitude and it
directly impacted their sense of health, well - being as well as longevity. I am Marianne
O’Hare with these Healthcare Headlines.

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Mark Masselli: We are speaking today with Dr. Glenn Steel e , President and Chief
Executive Officer of Geisinger Health Systems i n Pennsylvania . Before joining
Geisigner in 2001 Dr. Steel e served as the dean of the Biological Science Division at
the University of Chicago. Apart of that he was a professor of surgery at Harvard
Medical School and chairman of the Department of Surger y at the New England
Deaconess Hospital in Boston. He has earned numerous awards and accolades
including their recent Justin Ford Kimball Innovators Award from the American Hospital
Association. He earned his MD at the NYU School of Medicine. Dr. Steel e welcome to
Conversations on Healthcare.

Dr. Glenn Steel e : It’s good to be here. Thank you very much.

Mark Masselli: Now you have been at the helm of Geisinger Health Systems for 15
years now an integrated care delivery system serving some 2.8 million patients in 44
counties throughout the rural Pennsylvania and I think when you took the helm with
Geisinger you were dealing with a demerger with another large Pennsylvania Health
System. I wonder if you could tell our listeners about your initial evasio n for how
healthcare could be re - engineered back then when you started.

Dr. Glenn Steele: Well first of all the strategy of putting an academic medical center
together with a really good doctor and clinical organization because I believe ahead of
its tim e and I think the strategy was right. I think the transaction was wrong. My coming
in at that time of the three and a half year demerger was a perfect baseline. My initial
vision was to come in and repair the damage of the three and a half year dysfunct ional

merger and then to see whether we could use this payer provider structure and this
great credibility to fundamentally work both insurance company and clinical care giving
work together to benefit the people that we served and that was and still is to a large
extent a fundamental difference in the relationship between insurance companies and
healthcare providers.

Margaret Flinter: Well Dr. Steele can you describe for our listeners Geisinger’s
approach to self insurance, affordable coverage and also t he reduction of malpractice
caused that you ushered in was just nothing that you re ally received a lot of accolades
for. How did you managed to shift the system to one that not only incentivized that
quality of care with the value of care as well?

Dr. Gl enn Steele: Well first of all we had the perfect setting here. High market share on
the provider’s side, a high market share on the insurance side and a very stable
population so if you got that setting and you are actually more or less responsible for t he
health outcomes of a population over a lifetime what you want to do is to give the most
high quality care at the lowest cost possible as total cost of care goes down that comes
directly to a firm that the business model on the insurance company side and because
we were in the same fiduciary payer and provider we could do the internal transfer of
pricing and get some of that value benefit back to the providers who changed how they
delivered the care so it was pretty logical thing to conceptualize based on our patient
population, based on our demography and bas ed on our fiduciary structure.

Mark Masselli: You have said that this self insurance approach provided a perfect
sweet spot for focusing on the quality of care delivered at Geisinger and in fact you
have been engaging in what we now refer to as care coordination before it became a
trend in recent years and in 2006 you launched a program called Proven Care which
was founded on three principles, strict reliance on evidence based standards in
medicine, transparent and fix prices for procedure and patient en gagement. I should
say that we have Steven Brill on our show and I am sure he would love this notion of
transparent and fix prices for procedures and could you tell our listeners how you
managed to ac hieve these goals and what kind of impact it’s had on the quality of care
continuum and what other systems might learn from the experience of Geisinger.

Dr. Glenn Steele: Well first of all Steven Brill has been here and I think he kind of gets
it, he foc used on hospital pricing which is completely irrational and this is symptom until
I came to Geisinger. What I believe was if you do a complex task like heart surgery or
like hip replacement or like taking care of Type II Diabetes over a period of years if there
is unjustified variation in how you accomplish that task. It was my belief tha t number
one there would be lower quality and number two there would be higher cost because
that’s in fact the case with every complex task that’s done. So at the real c ore of our so
called proven gear was to reengineer everything that was done from the time of a
diagnosis for instance of a blocked coronary artery until the therapy was through and
the inventory how much variation was even within our system and to take fro m evidence
that’s already existing all of what was felt to be best practice and make it the default,
make it the default because it would be the easiest thing to do. And that was the value

re - engineering experiment and the question was what would happen t o already good
outcome and we found that it gotten better and what would happen to cost and we
found that already lower cost got much lower. And that was really the essence of the
issue. I also found out that if you do something substantive like value re engineer it
doesn’t get lot of values LEPR unless it’s in a sexy package. And the sexy package
was a single price and it was the single price that we negotiated between us as a payer
and our providers and it amounted to about 37% to 38% of our business so we didn’t
get the whole business on this guarantee. But for the guarantee what we said was for
the Geisinger payer we would establish a single price including a discount in price for
taking care of any complications that would occur free. Now the other important thing is
that if we do any of this reengineering and we shall benefit to patients we will apply to all
patients regardless of whom the payer is. It’s just that the financial arrangement, you
know the sexy packaging, the single price was only in between us as provider and us as
payer.

Margaret Flinter: Well Dr. Steele can you tell us a little bit about the use of your
electronic health record in informing best practices and also maybe just a little bit about
some of the practice transformation t hat you have undertaken in the end were tried
setting them. I am thinking particularly things like integrated behavioral health.

Dr. Glenn Steele: I think a really important predicate to all the stuff that’s happened
over the last decade and a half was the decision in 1995 that the board at Geisinger
made to go electronic and Geisinger was spread out over 44 rural and post industrial
counties. If we haven’t started to apply EHR in the ambulatory setting we really
wouldn’t have been a system. You know I think the first goal was simply to be able to
have a single electronic signing system. Another important thing is to understand the
transactional EHRs only gets you so much, even good ones like EPIC where we could
actually get real data coming back to th e folks who are in the trenches taking care of
patients and begin to use those data to influence a change in ho w they were caring for
patients. And that of course being able to get data from both the payer side of
Geisinger and the provider side to feedba ck in order to target particular groups so that
we could focus primarily on predicting who had to have a different kind of care.

Mark Masselli: We are speaking today with Dr. Glenn Steele President and Chief
Executive Officer of Geisinger Health Systems in Pennsylvania. Before joining
Geisinger in 2001 Dr. Steele served as the dean of Pittsburgh School of Medicine at the
University of Chicago and prior to that as professor of surgery at Harvard Medical
School. Dr. Steele you obviously held a number of l eadership roles in several of the
nation’s top teaching institutes and from the advantage point you really come to the
conclusion that may not have been possible to achieve what you achieved at Geisinger
and those other large institutions. I want you to s ort of share with our listeners your
thought about the challenges other organizations face in their attempt to reengineer
their health systems as they try to meet the goals of the Affordable Care Act ?

Dr. Glenn Steele: The two major principles are an obl igation to ensure more folks who
we care for. The second major principle in the Affordable Care Act is this attempt to

move away from fee for service but you know CMS and what they are doing with
Medicare is essentially committing to getting a huge amount of payment for Medicare
switched over to something that’s population risk and away from units of work by 2018
and on the Medicaid front I mean the fact of the matter is Medicaid is going to be
expanding greater than any other payer over the next few years and most of the states
can’t afford to continue to pay Medicaid fee for service and by the way the Medicaid fee
for service leads by and large to really crappy care and so we are going to see a huge
shift to Medicaid managed care and that’s going to force us to do the same kind of value
reengineering for those folks that we have done over the last 12 years for Medicare
advantage and for our commercial HMO because if we don’t, two things will happen.
Number one those folks will continue to default to the e mergency rooms in order to have
any kind of care not just emergency care and that’s ridiculous and of course the second
consequence is it will be impossible for us economically so that’s kind of how I rapid up
around this turbulence but I think good progre ssion through ACA.

Margaret Flinter: Well Dr. Steele I would be really interested in hearing a little bit about
your recruiting strategy I have heard it described as a campaign that says something to
the fact of to come here you will have to leav e three things behind, no practice cost,
traffic jams and crime which might be pretty big incentive for people but you know all
seriousness rural communities can have a very difficult time no matter how great
institution and luring practitioners. Now you could te ll us some about the recruiting
strategies that have brought that great talent pool.

Dr. Glenn Steele: Yeah obviously we are blessed by having whole wonderful
universities. Well we are also blessed by having an interesting culture here and then
most peo ple in this area would actually prefer a nursing trajectory than an investment
banking trajectory. I think that if you have a vision which a number of us were able to
establish early on and if you can translate that vision into some early success and if y ou
can get read able some to talk about it above the fault in a font page in the New York
Times you are going to get a lot of possessed right and then people will start coming to
Shangri La. I am trying to figure out what’s going on here? I have no troub le recruiting
at all. The proof of the putting most recently is my successor. We got a guy he was our
first choice and he is coming in and he is a dancer from Hollywood for heaven sake. So
I mean you know you get your first choice from UCLA and it’s pro of positive the
recruiting is not a problem.

Mark Masselli: I was just pointing on your thought and we have shared this notion that
really it is all about the data warehouse and I believe we have about 95% of your patient
population willingly ops into ma ny major research protocols. Can you share with our
listeners what you would say is unique about your data?

Dr. Glenn Steele: So I mean we have longitudinal data that for 15% of our patients we
have two and three generations of access and that’s incredi ble. The second thing that’s
unique is the ability to combine data from the insurers side of the house I mean so there
are things within the clinical database that make it relatively advantageous but there are
also things like predictive modeling and by p utting all that together it’s extraordinarily

powerful. But if you don’t put that stuff together in a usable manner so that when it goes
out to your community practice primary care physician s they can actually look at it and
immediately with the patient a nd the patient’s family in front of them do something
different in their behavior then it doesn’t end up changing the quality or the cost
structure and again because of the incredible partnering that we have with our patients
is we have taken the next step where we are taking data and distributing it out to our
patients and their families so that they have a much more symmetrical relationship to us
as providers because it’s an activation of the human beings that we are ultimately
responsible to and responsi ble for that’s going to make the next big transition in quality
and value.

Margaret Flinter: Dr. Steele I would imagine that you are needing to work in our
healthcare communities with the behavioral health organizations, substance abuse
organizations may be you just take a moment if you will to just share with us how you
work with the other players in your healthcare community.

Dr. Glenn Steele: First of all about 15 years ago when I got here we established a
principle where we would take our health info rmation technology and we would become
as non - proprietary as possible to take it out to Non - Geisinger or non - employed
physician groups to take it out to the regulatory thresholds of what was then called stark
and I trust and we basically said we are not go ing to think about our IT as a competitive
advantage. We are going to think about how we use our IT and change healthcare as a
competitive advantage but let’s get as many people in this area with a big needy, high
disease severity, static population rolle d into our commitment to do lifetime health status
improvement regardless of whether it was just Geisinger take care of or whether it was
Non - Geisinger so that’s number one. The second thing is we really did end up with one
of the most functional HIE’s, H ealth Information Exchanges that has allowed us to reach
out to Non - Geisinger skilled nursing facilities, Non - Geisinger and community based
healthcare centers so that we can actually share information which is critical and the
third thing and this is after our big bet on the Medicaid MCO a couple of years ago. I
mean we are forced to reach out to the federally qualified healthcare centers, the
FQACs in order to function as closely as we can with them similar to how we function in
our own community practice s and without those outreach sites, without that attempt to
actually take as much of our enabling technology as possible we are just not going to
achieve our mission so that would be – now the behavioral thing, the very interesting
thing because you are pr obably aware there is still this demand that’s a regulatory
demand usually state by state to outsource all of the behavioral health budgeting and
care giving and that’s hogwash , that needs to change but we have a good partner. Our
behavioral health partne r for the Medicaid population is a part of the UPMC health plan.
It’s very well run and we work well with them. But quite frankly we are advocating to
have the responsibility for behavioral health and actually what’s called carved in to the
responsibilit y for all the other kind of health and that’s an advocacy process that is
underway.

Mark Masselli: We have been speaking with Dr. Glenn Steele, President and CEO of
Geisinger Health Systems in Pennsylvania. You can learn more about t heir work by

going t o geisinger.org or find them on Twitter at geisingerhealth. Dr. Steele thank you
so much for joining us at Conversations on Healthcare.

Dr. Glenn Steele: It’s my pleasure.

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Mark Masselli: At Conversations on Healthcare we want our audience to be truly in the
know when it comes to the facts about Healthcare Reform and Policy. Lori Robertson is
an award winning Journalist and Managing Editor of FactCheck.Org a non - partisan,
non - profit consumer advocate for voters that aim to reduce the level of de ception in US
politics. Lori what have you got for us this week?

Lori Robertson: Well Kentucky senator Rand Paul has now officially declared that he
th
will run for president. Paul’s April 7 announcement prompted us to take a look back at
claims by Paul that we have reviewed in the past and some concerned healthcare. In
2013 for instance Paul wrongly said that under the Affordable Care Act you will go to jail
if you don’t buy health insurance and refuse to pay the tax penalty. The law actually
states t hat those who don’t pay the penalty for not having insurance can’t be subject to
any criminal prosecution. Shortly after the law passed th e IRS commissioner at that
time said the law precludes jail. The law also says that the IRS can’t use lean or levies
during force payment of the penalty. What can the IRS do to enforce compliance? The
commissioner said in 2010 that violators could face offset against future tax refund.
More recently in February Paul talked about vaccinations in a TV interview wrongly
saying that many children have developed profound mental disorders after vaccination.
We found that sever reactions have occurred in extremely rare cases that there is no
evidence that any currently recommended vaccine causes mental disorders in
otherwis e healthy children. Paul later walked back his comments telling the New York
Times that he believes vaccines are safe and effective. And that’s my FactCheck for
this week. For more on past claims from Senator Rand Paul visit our website at
FactCheck.org .

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country’s
major political players and is a project of the Anna Bird Public Policy Center at the
University of Pennsylvania. If you have a fact that you would like checked Email us at
CHCradio.com. We will have FactCheck.org Lori Robertson check it out for you here on
Conversations on Healthcare.

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Each week conversations highlight a bright idea about how to make wellness a part of
our communities in everyday lives.

One in six people in the world lacks access to drinking water a basic sanitation and
statistics show that diarrhea is a leading cause of death for these populations but
access to clean and portable water continues to preset a real challenge. In Africa the

numbe rs are staggering with 46% of residents of subterranean here in Africa having no
direct access to clean water. In 2005 artist Tracy Hawkins went to Tanzania to see
what she could do about it. Clay Pot Water Filtration has been around for several
hundred years where simple Clay Pots lined in the bottom of silver oxide can remove up
to 99% of the impurities from most water sources but no one had undertaken a
dedicated program to produce and distribute these pots. Tracy founded the Sing’isi
Pottery Project with a local activist and began making the pots with local artisans in this
region of Tanzania. By 2008 she had her team were able to get a factory built so that
they could increase production. The project has served multiple communities and
continues to expand. Independent researchers have determined the system to be safe,
effective and the best part the health of entire communities has been improved
significantly once each village resident is provided with a clay filtration system. The
pots are inexpe nsive to produce, easy to handle and the factory has also created jobs
for local residents. They have since changed the name of the organization to safe
water ceramics of East Africa and have continued plans to replicate the successful
model across the re gion , a simple, easily manufactured solution that improves access to
portable water for community that previous ly had few options, one that improves health,
well - being and economic conditions at the same time. Now that’s a bright idea.

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Margaret Fl inter: This is Conversations on Healthcare. I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli. Peace in Health.

Conversations on Healthcare broadcast from the campus of WESU at Wesleyan
University.

Streaming live at wesufm.org and brought to you by the community health center.