Dr. John Bulger is the Chief Medical Officer of Geisinger Health Plan and the CMO for Population Health for the Geisinger Health System. In these roles, he has been tasked with improving care quality and adding value for the populations that Geisinger serves. At Convergence, Dr. Bulger will discuss how Geisinger’s strategy supports closer provider-payer alignment to better serve its community of patients and physicians.
Why is it important for the healthcare industry to take the emergence of payer-provider convergence seriously? What do you see in your work that makes this important to you?
What it comes down to is, if you’re taking care of patients, and you’re a provider, whether a physician or hospital or post-acute provider, it’s really difficult for you to serve two masters. Historically, at Geisinger, we’ve had a payer and provider, but over the years the convergence was that, even though health system is at risk for the Geisinger health plan patients being taken of by Geisinger providers, we paid our own health care system fee for service (FFS). To me, that was a form of convergence, as everyone else was paying FFS.
The change has been the new world of value; providers can only live in one world. Providers bring a competency to that value world that lets them look in a different way, understand how the dollars flow, make decisions about the best care to provide, view a population at a higher level, decide what’s the right care to provide. The challenge is to provide what’s needed so that the provider’s doing one thing – but it’s not FFS, its being able to understand the tactics to take care of patients in a value-type world.
Which stakeholders need to be at the table when strategic conversations about convergence take place?
Ideally, you have doctors as well as nurse practitioners; hospitals, including post-acute; and payers, which includes the population health apparatus, such as care managers. Those to me are the primary stakeholders. It’s thinking of those three things – physicians, hospitals, and payers – as inclusionary pillars
The other primary stakeholder who has input in all of this is the patients. They may not be in every discussion about how you’re doing things, but you need to understand what the patients need to get them the right care at the right time. The value you’re trying to generate in all this is the value to the patient, and that’s an important starting point. It’s not value for the physicians, the hospitals, the payers. It doesn’t mean those pillars can’t win if you provide value to the patients, but you have to start by providing value to the patient.
You can have all kinds of tools in your toolbox, but if you don’t know how to apply the right tools to patients, you won’t bring value to patients. In a perfect world, you’re only applying the tools to the patients who need it, as they would be extraneous tools for other people.
How is your organization focused on convergence?
Even though we have had all three of those prongs as part of the organization since the 1970s, there hasn’t always been convergence. People make the assumption that Geisinger is like Kaiser Permanente, but that isn’t necessarily the case. There has been an arm’s length relationship between the health plan and the clinical enterprise – the use of pronouns us and them within the organization.
What started 10-15 year ago, and has accelerated in last 2-5 years, is how you bring these things together, the clinical enterprise and the health plan, to talk in the same language and make decisions together.
I’ve been here 19 years and on clinical enterprise side for the first 17. When you move to the health plan side, you realize there’s a different language. If you don’t get people in the same room, you may think you’re talking same language, but you’re not; you’re talking past each other. It’s the classic example of the blind man touching the elephant. You need to be on the same page about what your goals are.
If you’re just trying to slam a clinical enterprise and a health plan together, that won’t make it work. You have to work on the culture of the organization, get the people in the same room, and make sure you’re talking the same language.
Are you prioritizing convergence of data ingestion, analytics, care management, or patient engagement? Which of these key area(s) are you focused on?
There are so many people involved, and you need one source of data. We’ve looked at tools that can amalgamate data from different types of sources as being very important. You don’t need to worry about that if you’re a completely integrated system, but since we’re at 30% to 40%, there’s a lot of other people taking care of our patients.
Being able to apply risk stratification tools that are meaningful to patients is important, too. You can have all kinds of tools in your toolbox, but if you don’t know how to apply the right tools to patients, you won’t bring value to patients. In a perfect world, you’re only applying the tools to the patients who need it, as they would be extraneous tools for other people.
Whether it’s a case manager, a mobile health paramedic, a doctor, or a care coordinator – all of these things have a cost, and you want to proactively get the right pieces in the right place. You need a funnel to bring all the right data in, then analyze and risk stratify, do determinations up front, output a risk score or patient list, and then make decisions, based on that information, to apply whatever tools we have in toolbox.
Do you think the roadblocks to broader acceptance of convergence are more strategic, tactical, operational, or cultural in nature? What are some of the roadblocks you’re encountering?
Most of the roadblocks are internal. It’s changing culture to understand the fundamental difference of the way you do things in value-driven world. It’s a huge cultural change – and that’s in an organization that’s already integrated.
Instead of saying that you have one foot on the dock and one foot in the boat, I like to say that you need to get in the boat, sail across the sea, set the boat on fire, and start over. If you were going to create a new organization, such as CareMore, to some extent some of that stuff would be easier – you start from the ground up and build something instead trying to change ingrained history.
The internal part can be difficult. You have doctors who are used to cranking through things in FFS world. Lot of what we’ve done is a good case study, such as our work with the patient-centered medical home – but we did that artificially, with the health plan driving it, and that’s not sustainable over time if you don’t change the whole culture of how you do business. And if you get external pressures, be they access or change in payment models, that stresses your system, because you never really change the way you did business; instead, you create this model to help people do things in that changed way.
Now we’re looking at, how do you fundamentally change business? We’ve lived in a FFS world, we’ve done things through the health plan and PHM, and we’ve made it work to do value in FFS world. And that worked for a while, because 30% of the world was value and 70% was FFS. The new world, it’s the other way around – there’s still going be FFS out there, but we need to flip to the thought that we’re in a value world and still find success where we do the right thing for patients. Where we need to, we’ll finagle for the things we need to do for FFS, not the other way around.
What is driving this more: public or private payers? How much interest do you see in this as a mandatory vs voluntary process?
My personal view is that the public payers are going to be the ones that ultimately push this. There will be innovators and early adopters who do it on their own, either way – but if you want to get deep into the early and late majority, then the pubic payers are going to have to drive that. A large number of doctors will keep their head in the sand until that happens. We’re seeing that with MACRA. When MACRA says it wouldn’t use efficiency measures in 2017 for payment year 2019, doctors aren’t going to begin to look at this.
What we’re looking at internally is, how do we do that ourselves? Right now, 30% to 40% of value is with our own health plan. Another 30% is Medicare – how do we get with an ACO – and then we will have 60% to 70% is in value. The next step is to get value contracts with other partners in the market, to try to be more aggressive than MACRA.
Does that scare the daylights out of doctors? Yes. But they’ll figure it out. This is a pretty smart bunch of people. Doctors and hospitals bemoaned DRGs, but they figured it out pretty quickly. That’s just change management.
What organizations other than your own do you consider to be leaders in convergence?
Along with CareMore, there are a number of payers: Aetna, Humana, UPMC, Highmark with the Allegheny Health Network, and various Blues plans. There are a whole bunch of people thinking about this.
There are also markets such as Southern California that been aligned and working together for some time to create value in the system. Other places have done a lot in Medicare Advantage but not in the commercial space. That’s because they don’t necessarily match up; some providers doing a lot in MA are creating value because they were able to support it on FFS side in the commercial space.
How is Geisinger supporting closer alignment with payers in order to better serve your community of physicians and patients?
Lot of it’s around agreeing on the data and aligning the metrics in the data that you’re going to follow. It’s the total cost of care. How do we impact that, not the total number of widgets you make, and make it transparent to the clinical world?
Also, it’s innovating to PHM and care management. How do you wrap your arms around the patients who need it – the right care for the right patients at the right time? Use analytics to figure out who needs the care and then what tools to wrap around them. The clinical enterprise has the tools but needs to know where to apply them, and that’s where the analytics sense from the health plan comes in.