Larry Brubaker suffered a massive stroke in March and was hospitalized for nearly a month before being moved to an acute rehabilitation facility, then to a nursing home and finally to his own home near Sunbury, Pennsylvania.
A former warehouse worker, Brubaker, 64, cannot walk, has little movement in any of his limbs, and has lost some powers of speech and hearing. He is being cared for by his wife Kay, who worked as a maid before retiring.
What's unusual is who is instructing Kay on how to administer medications and other routine care for her husband, as well as helping her navigate the maze of local agencies that provide social services like nursing and physical therapy -- her insurance company, Geisinger Health Plan, which is part of Geisinger Health System.
In his healthcare speech to Congress on September 9, President Barack Obama cited Geisinger as a possible model for national reform. Based in central Pennsylvania, a rural region once dominated by coal mining, the system has recently earned a reputation for high-quality care at a lower-than-average cost. The White House refers to it as an island of excellence in the nation's murky healthcare waters.
And unlike other highly touted health care providers, such as the Mayo Clinic, Geisinger isn't helped by well-heeled patients flying in from, say, Dubai. In fact, Geisinger serves 2.6 million people in 42 largely rural counties.
Yet for all its success, the Geisinger formula won't easily catch on nationally. One of the main obstacles, according to numerous experts, are doctors themselves. Most physicians prefer or at least are accustomed to the longstanding fee-for-service model -- and likely would blanch at Geisinger's salary-based compensation.
Even so, Geisinger Health System shows just how much can be done at a local level to curb runaway U.S. health costs.
Kay Brubaker, 65, finds caring for her husband a daunting challenge. She has to watch for signs of the aspiration or pneumonia that are typical with bedridden patients. Kay also has to take his blood pressure and administer the right doses of medications -- 13 of them.
But she has lots of help. Geisinger's Medical Home program works to keep patients like her husband out of hospitals and nursing homes, and in their own homes, where they can be cared for by relatives or visiting nurses at far lower costs.
The program's results are clear. Hospital admissions fell from 375 per 1,000 Medicare patients in 2006 to less than 350 the following year, saving 7 percent in medical costs, while patients outside the program rose to more than 400 admissions per 1,000 patients.
To make the system work, Geisinger employs case managers like Jennifer Chikotas, a nurse who coordinates Brubaker's care. She is available by telephone 24/7 for advice or support -- and even arranges transportation to doctors' offices.
There's a lot of room for error or confusion, Chikotas said during a visit to the health plan's office in Selinsgrove, Pa. Social Security, for example, wouldn't speak to Kay without the paperwork.
Keeping a patient like Brubaker at home, most agree, does more than just lower costs.
The last place he needs to go back to is a hospital, Chikotas said. It would open him up to more infection.
Established in 1915, Geisinger now has about 13,000 employees at 36 community practice sites and three hospitals. A private nonprofit organization, it reported revenue of $2.1 billion -- and an excess of revenue over expenses of $34.6 million -- for the fiscal year ended June 30, 2009.
Medical authorities inside and outside Geisinger credit the system's performance to three factors: its salary-based compensation for physicians; an electronic medical records system that reduces the likelihood of treatment duplication by integrating the services of doctors, nurses and administrators; and best-practice protocols that require doctors to follow accepted standards for certain kinds of treatment.
To cite one example: for a coronary artery bypass graft operation without a valve, Geisinger's average cost with a 5.3-day hospital stay was $88,055 in 2007. That compares with $370,502 over 8.1 days at Hahnemann University in Philadelphia, and $108,667 over 4.6 days at Lehigh Valley Health Network in Allentown, Pa., according to the Pennsylvania Health Care Containment Council.
The ProvenCare best-practice protocol not only lowers costs but produces better health outcomes. For coronary artery bypass graft operations, for example, hospital readmissions fell 44 percent in the first year of the ProvenCare operation. The complication rate dropped by 21 percent and the average hospital stay shrank to 5.7 days from 6.2 days.
In the field of perinatal care, the proportion of births by caesarian section has decreased to 23.5 percent from a baseline of 36.6 percent since the protocol was introduced for that specialty in October 2008, reducing the likelihood of a mother having subsequent C-sections.
Larry McNeely, a healthcare advocate for the U.S. Public Interest Research Group, which campaigns for citizens' rights, said national health reform should and could follow the Geisinger example.
I think it's a model that makes a lot of sense all over the country, he said.
Like others, McNeely argues that the key to reforming the U.S. health system is to change the way doctors are paid. The point would be to reward the quality of care, as Geisinger does, rather than the quantity of procedures, drugs or consultations.
The real barrier is the current payment system, McNeely said. If you do what Geisinger does -- provide better quality -- you are not rewarded, you are punished. The reward goes to the doctors who order the most care.
Geisinger's approximately 680 physicians are compensated with salaries and performance-related bonuses, rather than the traditional fee-for-service model. And they are rewarded for meeting ProvenCare standards.
Winging it is not an option. In treating diabetes, for example, physicians are required to follow a nine-step checklist that is designed to ensure the best outcome for the patient -- and reduce future treatment costs.
We tell our doctors, 'If you do these nine things well, your patients' complications are diminished,' said Dr. Howard Grant, Geisinger's chief medical officer.
The protocols have allowed Geisinger to meet best-practice standards more often than most other systems, according to a study by the Pennsylvania Health Care Quality Alliance, a group of healthcare providers and insurers that seek to establish uniform standards.
For heart-attack care, Geisinger performs recommended treatments 98 percent of the time, compared with 81 percent in Pennsylvania hospitals overall, and 79 percent nationwide, the organization found.
Geisinger is not without its critics, some of whom lambaste the ProvenCare system as cookbook medicine that marginalizes a doctor's professional judgment -- a claim Geisinger dismisses.
It's not set in stone, Grant said. But the presumption is that you will follow the pathway unless there is a compelling reason not to.
Another potential barrier to widespread adoption of the Geisinger model is the expense of setting up an electronic medical records system. At Geisinger, all parties -- patients, physicians, nurses, administrators, and the internal insurance plan -- have timely access to each patient's medical history. The system, which has cost about $100 million since it was installed in the mid-1990s, is designed to prevent duplication of procedures and improve the coordination of care.
For example, the electronic system allows emergency-room doctors to peruse a patient's history, allowing them to make a better-educated judgment about whether to admit that person. By contrast, paper records are typically not available to ER staff, so they are more likely to err on the side of caution and admit a patient, adding unnecessary costs.
At Geisinger, inappropriate hospital admissions have fallen by 40 percent since the system was introduced, Grant said.
The electronic system also promises better care and lower costs in future by allowing doctors to be more proactive, Grant said. A rheumatologist, for example, can use the system to identify women who are at risk of osteoporosis, and then initiate preventive treatment.
We think that over time, we will see a significant reduction in the number of people who have hip fractures, Grant said.
Part of the system is a facility called My Geisinger, which allows patients to email doctors, access their own medical records and make appointments.
It also allows nurses like Erin Hubbert to deal with minor complaints that probably don't need the attention of a doctor or an office visit. At a Geisinger clinic, Hubbert was working at a computer terminal, instructing a patient who had used the system to notify the clinic of a case of diarrhea to drink clear fluids for 24 to 48 hours.
It's up to us to determine whether to recommend a home remedy or refer the patient to a doctor, she said.
In cutting costs and raising standards of care, Geisinger stresses the role of its primary-care physicians, who traditionally earn less than medical specialists and are in short-supply nationally.
Geisinger offers those doctors an above-market base salary, a performance bonus that can account for 20 percent of total compensation and an opportunity to focus on patients rather than the insurance companies that add significantly to the workload of many family doctors.
They get to practice medicine the way they want to, said Dr. Thomas Graf, chairman of Geisinger's Community Practice.
To help keep young primary-care doctors from fleeing to more lucrative jobs as medical specialists, Geisinger also pays up to $90,000 over five years in medical-school debt.
Word is evidently getting out -- this year, Geisinger has filled all 20 of its primary-care openings, compared with only six out of 20 three years ago.
Politics may also be an impediment to taking the Geisinger formula national. The passionate opposition to healthcare reform expressed at many town hall meetings this year, along with strong resistance by Republican members of Congress, suggests that any attempt to replicate this model could face formidable resistance, said Uwe Reinhardt, a professor of economics at Princeton University.
Many doctors have prospered from the fee-for-service system, and are resistant to the uniform standards that would be imposed by a corporate model such as Geisinger's because they enjoy the autonomy and prestige of their positions, argued Reinhardt, who is also an adviser on health care economics to government, nonprofit organizations and industry.
Physicians still view themselves as the last frontier of free enterprise, he said. Once a physician becomes an MD, he is God.
The very idea of what Geisinger is doing would be viewed as fascism in this country, he said.
But for Janet Tomcavage, vice president of health services for Geisinger Health Plan, results are more important than ideology.
She cited the example of a patient who was brought in to a clinic on a Friday afternoon, complaining of swelling and redness in her calf. A hospital scan detected a blood clot, and the patient was given a clot-busting medication and then sent home where she was visited by a nurse that evening. The clot was successfully treated at home.
The episode showed a successful coordination between the clinic, the hospital and the home-care nurse while avoiding a costly hospital admission, she said.
The old M.O. would have been to send her to the emergency room, Tomcavage said. It's really not rocket science.