Geisinger Health System's Plan to Fix America's Health Care

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Patient no. 86: Geisinger CEO Glenn Steele, who initiated the ProvenCare guarantee, became one of its early beneficiaries. As a patient, the process "was totally opaque to me," he says. "And that's exactly the way I wanted it to be." | photograph by Kyoko Hamada

There's a financial component to ProvenCare -- doctors receive bonuses based in part on following the protocol -- but Geisinger insists it's not trying to force its staff to practice what is pejoratively known in the industry as "cookbook medicine." A doctor who concludes there are good reasons not to do one of the 40 steps simply documents that decision in the patient's record. "What we're trying to do," Casale says, "is avoid the moment of smacking yourself on the head at the end of a procedure and saying, 'Jeez, I should have used antibiotics!' "

The results have been promising. A paper published in the fall of 2007 in the journal Annals of Surgery studied 181 CABG patients subject to the ProvenCare protocol between February 2006 and February 2007. Compared to nonchecklist patients, the ProvenCare group had 16% shorter hospital stays. Their bills were about 5% lower. While Casale admits that the study was small, he insists the results are still significant: "We've seen a 45% decrease in readmission rates, 60% decrease in neurologic complications -- meaningful changes that you'd certainly be happy to get even if they don't meet a statistician's level for ringing a bell." He says surgeons opted to skip a step in only three cases.

The breakthrough so far hasn't revolutionized Geisinger's business; the company's sales force hasn't yet been able to attract new employers or insurance customers on the basis of ProvenCare, although it's in discussions with insurance giant Aetna. "The idea of mistake-proofing specific problems is at the center of the patient-safety movement and care improvement," says Dr. Troyen Brennan, Aetna's chief medical officer. "I give them great credit."

What Geisinger would really like, of course, is Brennan's business. Chief innovation officer Paulus is optimistic, predicting that new customers will come as the company expands the number of procedures and diseases covered, which now include total hip replacement, cataract surgery, and programs for managing diabetes.

In the meantime, Geisinger continues to compile success stories, including that of CEO Steele, who became patient No. 86 in the ProvenCare CABG program. "I was in and out of the hospital in two-and-a-half days," he says. Casale, who was Steele's surgeon, says the case opened his eyes to how complex a routine operation really is: "Two weeks after, the head of our IT group called me and said, 'Al, I just looked through [Steele's] chart, and I want to send you a list of everybody that accessed the medical record from the time he was seen in the clinic to two weeks post-op.' There were 113 people listed -- and every one had an appropriate reason to be in that chart. It shocked all of us. We all knew this was a team sport, but to recognize it was that big a team, every one of whom is empowered to screw it up -- that makes me toss and turn in my sleep."

Which makes the value of that 40-step checklist very clear indeed.