Dr. Glenn Steele on the Path Forward Towards Care Delivery Transformation

May 21, 2018
Healthcare Informatics caught up recently with Glenn D. Steele, Jr., M.D., Ph.D., who has been busy spreading the gospel of the Geisinger approach to healthcare delivery innovation, U.S. healthcare system-wide

During his 14 years as president and CEO of Geisinger Health, Glenn D. Steele, Jr., M.D., Ph.D. led the Danville, Pa.-based integrated health system forward to become one of the most respected and admired health systems in the United States, as he pursued a path of quality, transparency, and accountability that won the organization many awards, and created innovations—including Geisinger’s pioneering ProvenCare program—that are being replicated nationwide.

Then, in April 2016, Dr. Steele announced his retirement from Geisinger, along with announcing his being named chairman of xG Health, a Geisinger-affiliated consultancy designed to spread the organization’s principles across the U.S. healthcare system. He also announced at the same time that he had been named vice chairman of the Health Transformation Alliance (HTA), a group comprised at that time of 25 leading U.S. corporations seeking to help change the healthcare delivery system nationwide HTA now counts 47 members).

Dr. Steele recently spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding all the activities he’s been involved in, and the ongoing evolution of the value-based healthcare delivery and payment concept within U.S. healthcare. Below are excerpts from their interview.

How are things going at xG, in terms of spreading the gospel of what you and your colleagues had achieved at Geisinger?

In fact, I’m at an XG innovations conference at Baltimore right now. What’s involved in all this is a scaling effort, an attempt to generalize the innovations we worked on at Geisinger. I’m always gratified by being around committed providers and payers, and now, through the Health Transformation Alliance, committed purchasers, as well. And it’s important to understand that whatever environment you’re in, you’ve got to fundamentally change how care is given. And you can’t do that without lots of trial and error, without lots of commitment, without trying a lot of different things, similar to what we were trying to do, with some peculiar advantages, at Geisinger. So I enjoy the challenge; it’s not an easy aspiration to generalize. But I think it’s a worthy effort. And I get juiced doing what I do.

Glenn Steele, M.D., Ph.D.

Congratulations on all these successes. In looking at the overall U.S. healthcare system, and the proverbial one-thousand-mile journey that the system is moving through on its way to becoming a truly value-based system, it seems to me that we’ve reached an inflection point, where we’ve moved beyond the very early experimental phase, and are somewhere beyond that, with ample examples of success in innovation to point to, even as we have a long way yet to go. Your thoughts?

I agree completely with you on that. There are four or five reasons we can’t go backwards. Number one, the expectations of consumers are changing—what they can do in other industries, is what they’ll expect in healthcare. And if we continue to be hospital-centric and physician-centric, organizations that continue to engineer away from that will win market share.

Number two, we’ve got physician issues, and if we continue to ask physicians to do the same things over and over and faster and faster, we’ll have burnout. So that’s a compelling issue—physician life satisfaction; and that has to be linked to changes in how care is given. Number three, whether you’re in a fee-for-service environment and getting pounded by payers that want to reduce pay per unit of work, or in a shared-risk environment, you have to change how care is given and what it costs—that’s fundamental.

And fourth, most organizations are fundamentally driven by the potential for change, to better serve their communities. Back in the 1990s, when we were arguing about “Hillarycare,” there was this idea that you could choose between cutting costs or improving quality; but that’s a false choice. When you rework care delivery, you get lower costs and better outcomes.

You’re the absolutely perfect healthcare leader with whom to converse about the changes needed in physician culture to accomplish transformational change. I remember 30 years ago on healthcare, how most physicians, and certainly most medical-professional associations, were dead-set against change. And yet some fundamental cultural changes are having to take place in order to allow for the clinical transformation needed to transform the overall healthcare system. Your thoughts?

I think demography solves most problems. Cicero said it eloquently in Latin, where there’s death, there’s hope, and he was referring to wars. But I think the people coming along will be much more resilient than those ending their careers. And medical practice is changing. And if you’re a primary care physician, you’re not going to be able to take care of a panel of 4,500 people, some of whom have four or five chronic diseases, some coming in for well visits—it just can’t work that way. At Geisinger, we always asked ourselves, what would allow physicians to have a more gratifying day at work, as opposed to someone forcing them to do something? And the adoption of Epic wasn’t always easy; but the combination of implementing an EHR [electronic health record] and creating care pathways, is what worked, essentially. So demography will help. What’s more, the young folks coming into medicine will have different expectations of their professional and personal lives; and technology will help them to work better. And a lot of medicine is a commodity and can be performed by PAs and nurse practitioners. And that frees up physicians to really spend their intellectual capital differently.

Do you see the 48-year-old doctors in practice changing attitudes, given that most of them will want to keep practicing, and that retirement is too far away for them to simply retire straightaway?

Oh, yes. When we at Geisinger moved into the Scranton area, most of the care was given by non-employed, non-Geisinger docs; and we got along with them extraordinarily well. They did just as well with population health and chronic care management as did our employed docs, and we were able to reward them, because 50 percent of their pay came from our Geisinger Health Plan. It will all vary depending on payer mix, etc. But the 40 to 65 and sometimes-older docs who are still extraordinarily well thought of and committed, will have to change, but a lot will change and will be very important in maintaining the credibility of the doc-patient relationship, and some will frankly go away.

Right now, CIOs and CMIOs are finding themselves overwhelmed with all the changes they’re having to help facilitate in their organizations. From your point of view, what should they be focusing the bulk of their energies on?

You need to have some sort of discipline related to patient outcomes. And there may be other ways of constructing this, but what we did is we said, for a given cohort of patients, say patients undergoing an interventional procedure, whether surgical or cardiology, what would be the ideal outcome for those patients? Another example is for the type 2 diabetic patients, what would we love to see in two to five years in terms of the improvement they should make? And only after we decided both on the payer and provider side at Geisinger, only when we decided what would the perfect outcome should be, did we decide what the technology should be to enable that. So the technology has to be the enabler of something specific. If you simply choose technology without knowing what clinical outcome you’re aiming for, you just get chaos.

What should happen, what will happen, in next two to five years, in all this?

What should happen is that payers and providers working together should produce more value. And whether it’s payer and provider in the same fiduciary, or teaming up together, those teams should win more market share, and those that don’t provide more value, should lose more market share, that’s the ideal. And the purchasers would move towards that higher value. And everyone would move towards more value and cost. 47 large employers, Health Transformation Alliance, that’s what we’re moving towards.

There will be more and more horizontal and vertical mergers. Some of the horizontal mergers, particularly among large hospital systems, won’t produce more value, they’ll produce the illusion of change, and the eye will be taken off value. In other cases—the bet CVS and Aetna are making, for example—they’re betting on transformational change. And hopefully, some of that will happen. It will be interesting no matter what.

What’s been the most satisfying thing for you about creating change?

Knowing that you could optimize outcomes for a huge population of patients, while doing that with a very robust business model. Post-Geisinger, this growing set of expectations among payers and providers. I’m enthusiastic about more and more leadership on both sides.

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