Where Surgery Comes With a 90-Day Guarantee

The Pennsylvania health group that's betting on standardizing practices to improve care, and winning  

HfAMexteriormain.jpgGeisinger

No frequent buyer card or Foursquare mayorship can make up for the distress of having to return to the hospital to treat chains of complications after what was supposed to be a one-time medical procedure. It's not that hospitals actually offer such perks, but it's an acknowledged problem that medical errors and complications make it easy for patients with acute diagnoses to become returning customers.

In February 2006, Geisinger Health Group of central Pennsylvania launched ProvenCare, an experiment that gave its three hospitals an incentive to get it right the first time. Patients admitted for elective heart bypass surgery were charged -- via their Geisinger insurers -- one flat rate, which covered the costs of up to 90 days of follow-up admissions and procedures.

As The New York Times reported a year in, it was "noteworthy as a distinct departure from the typical medical reimbursement system in this country, under which doctors and hospitals are paid mainly for delivering more care -- not necessarily better care."

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Geisinger was placing a bet that they could provide care for cheaper than the amount for which they billed the insurance company, calculated as the initial cost of the procedure plus 50 percent of the historical cost of follow-up for the three month period. It meant the hospitals would be taking on all of the uncertainty; to justify such considerable risk, they needed to be reasonably sure that they could get their patients in and out for less than the cost they were charging. And so while the idea of attaching a warranty to heart surgery was certainly new, the real innovation was in their overhaul of the surgical procedure itself, which had to bring about enough of an improvement to translate into reduced costs through reduced errors and complications.

Here's how they've done: as of 2011, a 67 percent reduction in in-hospital mortality for the 554 patients who underwent a coronary artery bypass graft (CABG). A 76 percent reduction in deep sternal wound infections. A 10 percent reduction in any and all complications. And patients' odds of needing blood products during surgery dropped by almost half.

Here's how they've done it: standardization. Geisinger strengthened their odds by overriding their cardiac surgeons' individual operating styles with 40 set best-care guidelines that everyone, every time, had to follow. Even dissent is strictly formulated -- doctors who veer from the guidelines have to justify their reason for doing so, selected from a previously agreed-upon list of acceptable justifications.

"The dig against it sometimes is that this is cookbook medicine," said Dr. John Bulger, the Chief Quality Officer for Geisinger. But the real purpose of ProvenCare was to make accountability a priority: "In each of these cases, the patient's going to get everything done." Bulger and his colleagues closely monitor feedback from their surgeons, technology has since caught up to allow for a real-time feedback loop. If something that should be happening on the exam table or in the operating room isn't, they know about it, and they can rework the system to make sure that next time it does.

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Lindsay Abrams is an assistant editor at Salon and a former writer and producer for The Atlantic's Health Channel.

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