Q: Talk a bit about Geisinger's ProvenCare program, which puts evidence-based standards and patient engagement to work in the service of fixed-price procedures. How does data play into it?

A: We have come to believe that a huge amount of our value reengineering, whether it's hospital-based care episodes or whether it's taking care of patients with multiple chronic diseases, does two things. Number one, it gives better outcomes, both near-term as well as long-term. Number two, it decreases a lot of the cost.

There's a lot of things that realization has allowed us to do. One of them is it allows us to look at cost as a surrogate for bad outcome, so if on the insurance company side you see a cohort of high-cost patients, we pinpoint and target, and have both payer and provider engaging in a discussion of how can we improve those outcomes for that cohort of patients.

A good example would be use of erythropoietin in patients who have anemia that's associated with chronic renal disease. This is really a paradigm; it's the result of lots of high-price but very effective biologicals. And the questions we asked when we looked at this group of patients with anemia secondary to chronic renal disease, is are they getting the best outcomes in terms of alleviation of their anemia?

What we found, in looking at the data and analyzing the data – and then looking at every step along the way at how this care was given to this group of patients throughout our system – we found that about 20 percent of those patients actually didn't need to be receiving the high-cost biological that is EPO. That by standard, off-the-shelf indications, they could just as well have been treated with iron, at about one one-hundredth of the cost.

And, by the way, EPO has side-effects, and those are cardiovascular toxicities, so stripping out the use of that high-expense biological was not only a cost-savings but a savings in terms of avoiding toxicity for a huge number of these patients.

So that's about a 20 percent benefit right there in extracting that value by doing away either with ambiguous indications or essentially no indications for the use.

The second thing we noticed in looking at how these patients were cared for was the efficiency. Inpatients that actually had hard indications for the particular biologic EPO, what was the efficiency of the actual treatment protocol, and how often did the patients have optimized red blood cell levels that were maintained and sustained. And what could we do in terms of changing the information that went back to the places that were giving that EPO treatment that could optimize their red blood cell levels and sustainability?

The long and the short of it is, we changed the venues where they were treated. We changed the expertise of the people who were essentially doing the treatment so that they were people who were much more attuned to doing that treatment as a focus of their job – as opposed to only one out of 100 or 150 things. And we supported them with best-practice algorithms that can be very dynamic.

Now, I think that's a perfect example of how data – both in terms of analytics and in terms of fundamentally effecting a change in the behavior of how these folks were treated on the provider side – really is to be married.

Q: And what about Geisinger's Center for Clinical Innovation – one whose main goals is to "leverage IT and advanced analytics to support population health." What are some gratifying things that have come out of there, recently?

A: We have changed expectations with regard to how we treat patients with serious chronic disease. Type 2 diabetes was just the first one in a list. We've now expanded it to coronary artery disease, to COPD, to hypertension.

But probably our longest-lived commitment was to treat type 2 diabetes patients – there were probably 27,000 or so that we started with, almost eight years ago – to create a set of aspirations, a set of data feedback loops and to change our incentives, in terms of how we pay our primary care physicians. And really commit to a bundle of nine best-practice goals being achieved in all of these type 2 diabetics that we took off the shelf from all of these endocrinologists and diabetologists but had never previously been engineered into the expectations for trying to achieve 100 percent of those goals in 100 percent of the diabetic patients.

We have an article coming out in May in the American Journal of Managed Care that shows that after three years of improvement in these 27,000 patients, getting all of them up to and optimal for all nine of these expectations, it took only three years before we saw a significant diminution in their risk for heart attacks, for strokes, for amputations or for diabetic retinopathy.

For me as a clinician, someone who actually used to take care of patients, I mean, that's amazing. To actually see, after only three years, a beneficial effect on diabetes-related secondary disease.

Now we haven't even done the economic analysis of that, but presumably, if you're avoiding heart attacks and strokes, you're probably avoiding a lot of hospitalization – high-cost and high aggravation treatment.