How One Health System Is Transforming in Response to Covid-19

by Jonathan R. Slotkin , Karen Murphy and Jaewon Ryu - June 11, 2020

Covid-19 has upended U.S. health care. At our institution, Geisinger Health System, we rapidly activated emergency response plans and cancelled all non-urgent procedures and clinic visits. Our nonclinical workforce has been shifted to work-from-home and virtual communication with patients has exploded. We have dealt with shortages of personal protective and vital medical equipment for the first time. Geisinger, like nearly all major health care systems, is experiencing negative financial impacts from the pandemic that might ultimately amount to hundreds of millions of dollars. The profound disruption in just 12 weeks of an industry a century in the making is astounding.

Many in our industry feel a natural desire to get back to how things were. But we think there is a better approach for our patients, employees, and communities. Many aspects of how U.S. health care has historically operated, including some elements of the fee-for-service business model, were the very things that left us vulnerable to the crippling impact of Covid-19 on our systems of care. We should not return to business as usual. We need to instead focus on creating a new normal. Building this new reality requires accelerating the positive transformations we have already made, undertaking some fundamentally new ones, and determining which of the activities we have stopped that we should not resume.

Now is the time to boldly transform our health care systems in ways we have previously been unable to. We should use this unprecedented opportunity to fix what hasn’t worked and direct our full attention to new and greater goals centered on creating value for patients.

How we are doing it

Many health systems are focusing on mitigating the impact of Covid-19 on their patients, staff, and business. Others have started paying attention to what comes next, sometimes in disjointed and reactive ways. At Geisinger, we formally initiated post-crisis planning just days into the pandemic, convening a steering group comprised of leaders from all parts of the organization. (Incidentally, we deliberately think not in terms of “post-Covid,” but rather “post-crisis” since much of the important work to be done will take place while Covid or its effects are still present.)

We realized that this critical work should be viewed and executed as a strategic and operational innovation initiative, not as a damage-mitigation exercise or with the focus solely on restoring revenues. We knew that executive endorsement, in our case from CEO Jaewon Ryu, would be needed to provide the “air cover” required to perform such disruptive work and assure an enduring transformation.

The steering group defined 11 core areas of our business (including the clinical enterprise, our health insurance company, HR, finance, IT, pharmacy, and five other broad areas) and created workgroups across each of these tasked with defining our approaches. Each workgroup includes leaders from outside of the workgroup’s focus; this is particularly important since stopping certain activities is essential to transformation but may be resisted by those closest to them. Outsiders can bring a dispassionate perspective to the discussion.

The groups were asked to examine four stages in the transformation: 1) Return of non-urgent work, 2) Start of the “new normal,” 3) Post-crisis activity, expanding the “new normal,” and responding to potential second wave of Covid-19, and 4) Operational and economic recovery in a transformed system. Members were instructed that they must carefully consider the impacts at each stage on patients and front-line employees, focusing on their needs, what has changed for them (and will change), and what will make them feel truly safe. Each group was also tasked with categorizing the activities of each of their functions as work to “Start,” “Continue,” or “Stop.”

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

Stage 1: Reopening, resumption of non-urgent work, and test and trace

Most health care organizations are now well into restarting their systems. Stages 2 to 4, where transformation and innovation are most critical, are the main focus of this article. In each stage, we call out a few illustrative examples of the scores of topics that each of our workgroups have tackled.

Our patients’ and employees’ safety has been at the center of our attention during the crisis, and will remain so as we continue to resume non-urgent clinical work. SARS-CoV-2 testing is critical in preventing transmission, and Geisinger was one of the first health systems in the U.S. to validate and perform in-house testing for both groups. As of early June 2020, Geisinger has performed 21,343  in-house tests, of which 2,455 were positive. These represent between 3% and 4% of all tests and positive results in the Commonwealth of Pennsylvania despite Geisinger not covering any of the major population center areas.

Contact tracing is also essential for containing any epidemic. While this has traditionally fallen under the auspices of local and state health departments, many of those resources have been spread extremely thin during this national emergency. We believe that health systems with the resources to do so should support public health departments’ contact tracing as a public-private partnership. The U.S. is falling well short of the estimated 300,000 contact tracers needed. Many hospital systems are already expert in managing testing, communicating results, and treating those who test positive. Extending those capabilities to include contact tracing would be a natural extension for many systems, would contribute substantially to the public good, and could help reduce their own Covid caseloads.

Geisinger now has 24 employees dedicating significant parts of their workweek to contact tracing, a new organizational capability with immediate benefits but that will also be valuable should we experience a second Covid wave. To date, this team has made over 2,700 phone calls to follow up on 1,600 positive patients and those identified to have come into contact with them. Contact tracing directly benefits patients, providers, and communities

Stage 2: Start of the “new normal”

During the pandemic, Geisinger has witnessed an acceleration of strategies that had been previously slow to gain acceptance. For example, before Covid-19, we averaged about 40 telehealth visits per day across our system. As with many hospital systems, a variety of factors including patient and provider reluctance and reimbursement constraints inhibited wide adoption. Now, because of the crisis, we are averaging 4,000 to 5,000 telehealth visits daily (40% of which are video visits). Like most private and government health coverage, our health insurance plan is now reimbursing telehealth visits at the same rate as in-person visits. We have also waived co-payments associated with these visits for our members. A shift in patients’ perception of telehealth has perhaps been the most important in increasing adoption, with attitudes moving from, This provider must not think my problem is important since they are seeing me via telehealth, to This provider cares about me and therefore is seeing me via telehealth. Many of our providers have observed notable benefits of telehealth visits including that patients who suffer from chronic conditions can now avoid coming to health care facilities, and that providers now often have a valuable view into patients’ home environments. We plan to build on this momentum and to continue to expand our use of telehealth and all forms of virtual encounters even after this pandemic abates.

Another program that has powered our ability to remotely promote and maintain our patients’ health is our pharmacy organization. More than two years ago, Geisinger launched its own mail-order pharmacy. This benefit provides market efficiencies to our patients and members. We have found that patients who receive prescriptions through this channel have nearly 40% higher rates of medication adherence. For the organization, it is a more efficient way to deliver prescriptions to our patients, given lower costs to fulfill. These savings can then be passed along to our patients in the form of substantially lower costs, with patients often seeing cost reductions of greater than 50%, which makes it easier for them to continue to adhere to their medication regimens. While Geisinger had been working to increase mail-order utilization before Covid-19, the pandemic has made its advantages clearer to patients and providers. Patients save money and avoid travel and physical contact and, as a result, have increased mail-order utilization by 20% per month during the three months since the start of the pandemic. As with telehealth, we are planning to leverage this momentum to encourage sustained or increased mail-in pharmacy use post-pandemic.

Stage 3: Post-crisis, and potential second wave

Some of the acute changes health systems have made in response to Covid-19 are likely to stay with us.  Many, for example, have allowed a sizable portion of their workforce to work from home. Geisinger moved quickly to enable 7,000 employees to WFH during the crisis. The benefits of this shift include increased employee safety and access to an expanded talent pool since WFH employees can live and work from anywhere in the world. To the extent that staff continues to effectively work from remote after the pandemic, we anticipate potential cost savings from elimination of leases, sale of owned real estate, and conversion of existing administrative space to clinical space. A recent analysis revealed that up to 30% of our workforce could WFH permanently, with an additional 30% working in hybrid WFH and office-based roles. Coupled with the likelihood that sizable parts of our clinical activity will continue as telehealth, we are revising our master facility plan for the years to come. Health systems that have had success with WFH during Covid-19 should consider assessing what proportion of their workforce could WFH permanently; we project markedly decreased operational costs and conversion of administrative areas to clinical space with this approach.

The pandemic has also revealed that we need to strengthen surveillance. For example, many experts are predicting that a second wave of Covid-19 will occur in the late Fall or early Winter of 2020. Right now, patients and providers alike are highly vigilant about possible infection. But as current cases subside and routine work restarts, a surge in new cases may initially go undetected. To increase the likelihood that we’ll see a new wave as it develops, we need novel early-warning surveillance systems to supplement the existing approaches that failed to capture the original emergence of Covid-19 cases. To this end, Geisinger has partnered with Stanson Health in the development and deployment of an AI-enabled solution that sifts through volumes of ambulatory, ER, and other provider documentation in real time for unstructured phrases that suggest Covid-19 symptoms such as, “loss of taste,” “trouble breathing,” and hundreds of other phrases that in the course of a return to busy clinical practice might initially go unnoticed.

Stage 4: Economic recovery

The fee-for-service business model of U.S. health care, a design whose misaligned incentives stunted care innovation and transformation even before Covid-19, was destined to fail under strain - and it has. Covid-19 aggravated the already present shortcomings of this approach, in particular its deep reliance on maximizing elective procedures and volume in general. The crisis necessitated the rapid acceleration of virtual care and care at home as hospital systems and patients deliberately decreased inpatient hospital admissions and avoidable ER utilization. Virtual care and home care can lower costs and improve patient engagement. But these same efforts lead to dramatically reduced revenue under our nation’s prevailing fee-for-service reimbursement scheme.

Geisinger has long promoted the need to transition to value-based payment models, which reward prevention and good outcomes rather than increased procedures. Covid-19 underscores that this transition must be meaningful, well beyond the modest-scale and pilot efforts we have seen to date. Consequential payment reform must create funding mechanisms that make prevention and population health - rather than maximizing reimbursement under FFS - the true focus of care. This will require substantial financial incentives to drive alignment between value (better health outcomes at lower cost) and reimbursement. These incentives must be sufficient to encourage the investments necessary to fundamentally transform the care delivery model. For example we strongly advocate the adoption of “risk” models such as all-payer global budgets that prospectively set a payment amount for hospitals to care for a given population over the coming year. Models like this will lead to improved quality and reduced costs as more patients get the right care in the appropriate settings. Without such a change, U.S. systems will continue to suffer from the effects of prioritizing volume over value and will be financially exposed in the next pandemic exactly as they were in this one.

Conclusion

Covid-19 has resulted in extraordinary morbidity and loss of life and devastating economic burden, and has placed tremendous strain on a national health care system we thought was indestructible. We must leverage the lessons learned throughout this crisis to transform the way we care for patients. Public and private payers must vigorously work with health systems to accelerate the move to value-based payment approaches that support new care models. If we are able to transform our nation’s care delivery and payment systems in ways that fundamentally improve health care for our patients, providers, and communities, we will have found the silver lining of Covid-19.

Jonathan R. Slotkin, MD, is vice chair of neurosurgery and associate chief medical informatics officer at Geisinger. He is chief medical officer of Contigo Health, a Premier, Inc. company.

Karen Murphy, RN is executive vice president, chief innovation officer and founding director of the Steele Institute for Health Innovation at Geisinger. She was formerly Secretary of Health for the Commonwealth of Pennsylvania.

Jaewon Ryu, MD, is president and chief executive officer of Geisinger.