Geisinger Health Plan

I. General information three companies comprise what is known as Geisinger Health Plan (ghp): Geisinger Health Plan, a traditional Health maintenance organization (hmo); Geisinger quality options, inc., preferred provider organization (ppo) plans; and Geisinger indemnity insurance company (giic), which operates as a third-party administrator (tpa) and offers administrative-only services. Together the three companies had more than 544,600 members at the end of fiscal year 2020. All three companies are based in danville, Pennsylvania. Geisinger Health Plan (ghp), a not-for-profit organization, provides pre- paid managed healthcare to its members. At the end of the 2020 fiscal year, ghp was predominately providing managed healthcare to government programs including 194,200 medicaid members, 69,100 medicare advantage members and 14,600 chip members. In addition, ghp provided managed healthcare to 54,000 commercial members. Founded in 1972, incorporated in 1984, and initially licensed by the department of insurance in 1985, ghp currently operates in 48 contiguous counties of predominately rural central and northeastern Pennsylvania. In addition, ghp contracts with more than 58,600 providers and 135 hospitals. Ghp is consistently recognized for quality. Geisinger Health Plan has been accredited for quality by the national committee for quality assurance (ncqa) since 1993. Our commercial and medicare hmos are both rated one of the top Health plans in the nation in the 2020-2021 national committee for quality assurance Health insurance Plan ratings. New facilities and more services because ghp is a 501(c)(4) nonprofit organization, revenues in excess of the cost of the healthcare provided to members are used to improve facilities and services, increase benefits and provide affordable rates. Ghp typically makes annual contributions to Geisinger Health, it's 501(c) (3) parent organization, to enhance teaching, education and research projects that benefit all pennsylvanians. These contributions are used to fund the development of new facilities and to add more services to our existing hospitals and physician clinics. This directly supports the charitable mission of Geisinger Health and its charitable affiliates by making it possible to enhance healthcare programs and services throughout the region while improving the availability of care for patients in our service area. Providing affordable, high quality, comprehensive healthcare and benefits increases the access of care to those who might not otherwise be able to afford healthcare and contributes to the quality of life in all of the communities we serve. Ghp provides comprehensive healthcare services on a prepaid basis through an integrated healthcare delivery system, which provides healthcare to the community as a whole. As part of an integrated Health system, ghp is able to channel experience, knowledge and funds to pursue unique projects with Geisinger. No other organization in this region has both provider and payer joined together to create synergies that improve the Health of the communities that we serve. Provenhealth navigator (phn) ghp's provenhealth navigator (phn) is a partnership between patients, primary care providers and ghp to improve members' Health. Also known as a "medical home," phn provides a case manager who works closely with the member's healthcare providers, the member and the member's family by coordinating care with hospitals, specialists, pharmacists and skilled nursing facilities. The model Geisinger employs blends aspects of a chronic care model, a medical home model and a patient-centered primary care model. Additional functional components are included, creating a new healthcare delivery vehicle: Health navigator. Acting as the first-line caregiver and guide, Geisinger Health Plan nurse case managers help members navigate the health-care system. The key strategy of Health navigator is to offer members access to a Health navigator case manager 24 hours a day, 7 days a week. The primary care practice team and ghp, working with the member at the center of the system, accept responsibility to optimize Health status for every individual and to meet pre-established quality, efficiency, and member satisfaction outcome targets for the practice population. The cost of providing phn to non-members was 3.9m during the fiscal year ended june 30, 2020. Provencare - chronic disease Geisinger identified common chronic diseases (diabetes, coronary artery disease, congestive heart failure) and adult prevention measures (immunizations, colonoscopies, etc.). Using evidence-based best practices, care was "bundled" to include the most effective treatment. Success is measured by meeting 100% of the bundle requirements, as tracked over time. Geisinger has made significant improvement in meeting the bundle requirements for diabetes and preventive care for adults. Provencare - acute episodic care (the "warranty") beginning with coronary artery bypass grafts (cabg), the process includes identifying high-volume diagnosis-related groups (drgs), determining best practice techniques and delivering evidence-based care. Working with ghp, the Geisinger clinical enterprise established a global fee that includes pre-operative care, hospitalization, physician fees, rehabilitation and any care (admissions due to complications) related to the surgery within 90 days. This additional care is not charged (if they are seen at a Geisinger facility). This "warranted" care has been very successful and featured in the new york times and published in the annals of surgery. In addition to cabg, Geisinger now has programs for angioplasty with an acute myocardial infarction (heart attack), hip replacement, cataracts, erythropoietin (a drug used for kidney patients), perinatal care, low back pain and bariatric surgery. Transitions of care helping individuals transition from one level of care to another, such as transitioning from the hospital to home, is an important component of ensuring comprehensive and high quality healthcare services. Geisinger has aligned resources and implemented new strategies within the hospital as well as within primary and specialty settings to anticipate patient needs and coordinate services to assure timely and safe transitions. These new strategies have incorporated more timely communication from the hospital to primary care providers, leveraged data from the electronic Health record & claims to identify risk and used case managers to provide early follow up services. Geisinger's efforts around transitions have demonstrated reductions in readmissions as well as more coordinated follow through after discharge. Electronic Health record (ehr) Geisinger is on the forefront in the development and use of the ehr. Ghp helped support the 100 million invested in the ehr over the last several years. The possibilities for improving the quality of care with the ehr are endless. Currently, ghp uses the ehr to communicate with members who are involved in medical or disease management programs and their physicians. Geisinger also allows community hospitals and physicians to access patient information. Disease and case management services to improve the Health of members, ghp provides disease and case management programs and services to coordinate care for those with chronic conditions. The programs are focused on congestive heart failure, hypertension, diabetes, coronary artery disease, osteoporosis, chronic obstructive pulmonary disease, chronic kidney disease, asthma, tobacco cessation and weight management. These in-depth programs were the result of a collaboration of expertise between ghp and providers in Geisinger and have attained national recognition by Health management organizations & industry groups. The success of this collaboration is one example of how this unique relationship can benefit the community. Community Health, education and outreach ghp employees provide the public with information on topics such as insurance education, advance directives, dental and hand hygiene, asthma care, the importance of screenings & immunizations and wellness. In all, ghp provided information to 549,564 individuals at 2,419 events including Health fairs, school-based presentations, seminars and organizational meetings. This education includes: more than 200 Health education events for children were held that covered dental, nutrition & physical activity, hand hygiene and sun safety topics. More than 3,730 children attended the events. Nearly 500 events were held that supported evidence-based chronic disease programming, reaching a total participation of over 1,550 individuals. Almost 2,500 wellness activities were held at employer groups and community events. All of our programs are available to our commercial members which represent approximately 245,185 individuals. 234 employer group and community flu events were held, providing 11,534 flu shots. Due to covid-19, all wellness in-person com