Geisinger: 'The Most Progressive Health System on the Planet'

Geisinger CEO David Feinberg Talks Genetics and Refunds With Eric Topol

; David T. Feinberg, MD, MBA


October 05, 2018

Eric J. Topol, MD: Hello, I'm Eric Topol, editor-in-chief of Medscape, and I'm really delighted today to talk with Dr David Feinberg, who heads up the Geisinger Health System. David, it's great to have you with us.

David T. Feinberg, MD, MBA: Thanks so much, Eric. I'm excited for our conversation.

Topol: I'd first like to give a little background. Make sure I've got it right: You went to UC Berkeley, [then] Chicago Medical School; you got an MBA from Pepperdine University, and eventually became the CEO of the UCLA Health System. Then you made a big switch moving from UCLA to Geisinger about 3.5 years ago. What was that like to make this big move from Los Angeles to Danville, Pennsylvania?

Feinberg: Well, first of all, UCLA is an amazing organization. I did my residency and fellowship there. I didn't think I was ever leaving UCLA, but I'd sent a team of guys [to Danville] a couple of years before because everyone was talking about "Geisinger, Geisinger." And when that team came back, it really changed how we provide neurosurgical services at UCLA. Then, a couple of years later, Geisinger calls and says, hey, we're looking for a chief executive.

I thought I would just go to learn more about Geisinger so I could bring it back to UCLA. What I found during that exploration phase was that I could get all the "stuff" that Geisinger had over to UCLA, but it would take 10 or 15 years, and then it would be the end of my career. Or, I could go to a place that already had all the tools and see what could happen. So, my wife and I probably did 10,000 steps every night, talking about why are we moving, why should we do this, should we do it or not do it? I had never had another job other than UCLA!

And then I came to Geisinger. I made that decision and I've got to tell you, it's amazing.

First of all, I feel liberated in that Geisinger has only one mission, unlike an academic medical center that's worried about research and academics and teaching and clinical care. At Geisinger, our only focus is the community; it's the people that we serve, so you have the freedom from that academic medical center piece. We now have a medical school, an insurance company, and a very strong clinical delivery system, and we have 33,000 people who get up every morning and try to make it better for our friends and neighbors.

It's been incredible also from a personal standpoint. After being in the echo chamber of West Los Angeles—we were living in Beverly Hills—we now live in "the other America." It's very rural and it's very poor, and things that are happening in our country make much more sense to me now than had I not had this opportunity. So it's been a privilege to move to the middle of Pennsylvania.

Topol: That's fantastic. We're going to talk about some of the things you're doing there that are truly unique on the planet, at the most progressive health system I know, so that is a real credit to what you've been doing. But before we do that, I want to read a quote I have of yours that I love:

"I think our industry is so screwed up and is ripe to be disrupted; either we do it or some Stanford drop-out in a black turtleneck is going to." That one really hit me as being from a person who truly gets it.

Let's talk about your extraordinary effort with genomics, not just the collaboration that you did with Regeneron, but also your announcement of expanding it to all patients at Geisinger who are interested.

Our doctors said to us, 'I want to do this on all my patients!'

Feinberg: There are some organizations that are way ahead of us in sequencing a cancer gene and understanding what medicine to use, or are looking at genetics and saying to patients, "You should be on this medicine or on that medicine."

Our approach is based on asking, "What if we did whole-exome sequencing on our entire population?" We started this to see whether we could find medically actionable genetic conditions that we could do something about. We are 200,000 patients into it—or I should say, research subjects, because we started with research—and we have found that 3.5%-4% of those people have something actionable: BRCA, malignant hyperthermia, Lynch syndrome, genes associated with cardiac arrhythmia.

We saw a 16-year-old girl in our emergency department who came in dehydrated from soccer. We gave her some fluids, and she participates in the MyCode study. It turns out she has two genes associated with fatal cardiac arrhythmias in young athletes. Because of where we are and the fact that most people don't move, there are 30 people in her family whom we care for that we have in our electronic records. We get all the genetics, and it turns out 15 of that 30 have the gene. Now, many of them have pacemakers or are on beta-blockers, or both, that are literally saving their lives.

We did that for our research enterprise, and Regeneron helped fund this to use that information in a deidentified way for their drug discovery. But we felt we couldn't wait to turn this on [more broadly]. It was actually our doctors saying to us, "I want to do this on all my patients!"

I think it's now been about 2 months since we said that for any of our patients, we'll do whole-exome sequencing for free. We get the results in about 2 weeks. When we get a positive result, the first thing we do is notify your primary care doctor, who then gets a 30-minute continuing medical education course on BRCA or Lynch [syndrome] or whatever the disorder their patient has—essentially, a refresher course.

Five days later, the patient is notified that they have a genetic mutation and is asked to come in to see the doctor. That way, the doc is prepared for the visit, the patient is prepared, and they have a discussion—because all it is, is a genetic mutation. The real thing is, should we go to the breast clinic? What do we need to do differently on the basis of this information? We've built it into our electronic health record, so it's very easy to have the ongoing surveillance.

Topol: Have you noticed that the doctors are getting "genomified"? That is, are they really getting more up to speed because of this program?

Feinberg: No question! There are certain health systems where doctors say, "I won't meet with you if you come in with 23andMe results." Ours is the opposite. Our doctors said, "We want this now in routine clinical care." They didn't buy in until they had their first patient with return results, and we prepped them with the right information and they had a positive experience. Then they became ambassadors for the program.

The other thing we saw that we didn't anticipate was, when we give somebody a genetic result back, that doctor the next day gets calls from six brand-new patients who want to see that doctor. The patient went home and told their friends, "I have a genetic mutation," and now their friends want to go see that doctor.

Topol: Amazing. As you know, David, there was a recent review in the New England Journal of Medicine[1] that basically pointed out that everyone with colon cancer should be screened for Lynch syndrome. Very few actually get that screening. But you're proactively doing this in patients, and not just in patients—I saw that you were the first one to enroll in the program.

Feinberg: I've had my genome done so many times now because I'm interested in the user interface. It always comes back with the same things: I've got male pattern baldness, but Rogaine® is working, and I'm actually protected against celiac disease, so I could practically bathe in wheat. But yes, it's actually the fifth time I've done my genome.

We see it as [leading to] a cost decrease. In routine clinical care today, if your parents had colon cancer at an early age, the gastroenterologist would say that all offspring should start colonoscopies at age 30 because of the family history. We know, though, that only one half of those offspring actually have the Lynch syndrome mutation, and the others shouldn't get their colon screen until age 50 or so.

It's the same with BRCA; 50% of people who have BRCA-positive breast cancer have no family history. We know it's a genetic disorder, but maybe mom died of something else or there's no sister and they don't have the family tree in their mind, so if they went to a doctor, no one would order a BRCA test.

We're finding those 50% BRCA-positive people without the family history, so we think if you live in central Pennsylvania and you're a young woman, your chances of getting breast cancer are lower here than anywhere in the United States because we know who's BRCA-positive.

The same way that we sequence your DNA, we sequence your ZIP code. We know everything about where you're living.

Topol: For people who are not as familiar with your health system, you have mentioned some 33,000 employees, but how many patients are you serving in the whole region?

Feinberg: We take care of about 3 million folks; it's about a $7.5 billion organization. We have 12 or 13 hospitals, helicopters, clinics, an insurance company, a medical school, and research focused on genetics.

Topol: Now I want to go from genetics to another topic that you've been pioneering, and that's the food pharmacy. Can you enlighten us about that program?

Feinberg: We think that the most important thing for you to live a long life, and to have a lot of life in your years, is not what takes place in the hospital, not what takes place in the clinic; medical care probably accounts for only about 20% of health outcomes. We think it's your genetic code, and we also think it's your ZIP code. So the same way that we've sequenced your DNA, we sequence your ZIP code. We know everything about where you're living.

One of the big issues is around food, so we have screened every one of our patients for food insecurity. You just have to say "yes" to one of two questions: Am I going to run out of food this month? Or, Do I think I don't have enough money for food? And then we looked at those patients who had food insecurity and also had type 2 diabetes, because if you're poor, you buy high-calorie, non-nutritious food. If you get type 2 diabetes, you miss on average 17 days of work per year, and you become poorer, so it's this negative cycle.

We said, What if we went in—and you may call this innovative, but this guy Hippocrates said this a long time ago—and did diabetes education and gave people healthy food? So we found patients who were food insecure and who had type 2 diabetes, we bring them in and provide diabetes education, and then we're really the grocery store. We give them every week seven fresh fruits, seven fresh vegetables, whole-wheat grains, and lean meat, with recipes. If they're living in a motel, they get a hot plate and a spatula and a microwave. We give them all the tools necessary to take care of themselves.

What we found was amazing. To get US Food and Drug Administration (FDA) approval [for a diabetes medication], you must decrease hemoglobin A1c by 1 percentage point; we would say that kale and quinoa decrease it 2.5 points, because that's what we've seen on average.

Now, we picked some of the sickest patients to start with, and medical costs were around $200,000 a year per patient. After a few months in the program, their medical costs dropped down to about $40,000. We save $160,000, and it costs us about $1200 to feed them.

The other thing that we're doing is we provide food to everyone in their family. That way, we're breaking the cycle, so that you're not going to get type 2 diabetes as the kid or the sister or the husband or the wife in that family.

While other places are building new towers in hospitals, all we talk about is how much produce we can get into certain buildings and use food as medicine.

Next year, in 2019, we will be on pace to serve 1.5 million meals to our patients, and we're expanding the fresh-food pharmacy to address pediatric obesity and people with type 2 diabetes who aren't food insecure (we don't know whether it will work with people of means), congestive heart failure, and end-stage renal disease. While other places are building new towers in hospitals, all we talk about is how much produce we can get into certain buildings and use food as medicine.

Topol: That's extraordinary. What I love here is you've taken a high-tech approach with getting exomes of hundreds of thousands of your patients, and now what you would consider a low-tech approach, which is fixing the food problem.

I don't know any other system that is doing that. I mean, this is really an amazing range. Those two programs are enough to set you apart from any other health system on the planet, but there are other things you're doing as well. There was a program where if you were unhappy, you could get your money back. What other things are you up to?

Feinberg: Let me stick with the social determinants, and then I'll tell you about our refund program.

So I'm here in Danville, and within 50 miles we have a bunch of hospitals and clinics. If you are basically in our catchment area and you need a ride, to church, to home, to the doctor's office, to your friend's, we provide it for free. We will transport you wherever you need to go, because we think that loneliness and isolation is probably as big a killer as heart disease. So we eliminate the transportation issue.

We're in a rural part of America with a lot of Lyme disease. We know from an environmental standpoint, based on how close you live to the forest, your rates of Lyme disease, and we feed that information into our primary care doctors' offices so you get a Lyme score when they see you. It's hard to make that diagnosis sometimes, so we're using predictive analytics around that.

The death rate from opiate overdose here is four times higher than in New York City, so we've done a lot of work to decrease our use of opiates. Starting next month, all elective surgery at Geisinger will be done opiate-free. When I was trained, we told surgical patients not to eat anything after midnight. We [now] do the opposite: We feed you a high-protein amino-acid drink 2 hours before surgery—surgery without opiates, so your gut isn't slowed up—and then we feed you 2 hours after surgery.

If there's any part of your care that you're not satisfied with, we offer a no-questions-asked, money-back guarantee.

Our refund program, though, really builds on the history of Geisinger's focus on eliminating unnecessary variations in care. It started with hearts, and we're so good with hearts now that such places as Walmart, JetBlue, McKesson, and Lowe's say, if you need heart surgery, spine surgery, or bariatric surgery and you live in basically the eastern part of the country, you can pay 50% of the cost to have it done in an Arkansas hospital if you're a Walmart person or wherever they are, or you can go to Geisinger and have it done free. They send the patients to us, with a companion.

The crazy thing is that 40% of the time, we don't operate, and these are people who were scheduled for surgery in their home town. We're really good at that.

We're really good at acute care. We're really good at chronic care. Our anticoagulation management was the best in the United States, and now it's become the best in the world. But I felt that we had to do more: How can we answer the phone every time on the first ring? How can we offer everybody same-day appointments? How do we make sure everybody treats you with compassion? How do we make sure that the bill we send you is totally understandable?

So we added what we call "proven experience": If there's any part of your care that you're not satisfied with, we offer a no-questions-asked, money-back guarantee. You can have all or some or whatever you want of what you paid back.

And then we have a little bit of fine print. We do ask questions. We ask for your name and address so we can send you the money, but that's the only question we ask. We have returned millions of dollars to our patients, and they have been the best secret shopper program ever. They tell us what's working and what's not working.

For example, just the other day a woman had surgery and left all kinds of positive comments about the doctor and the nurses, but she had three complaints: the IV infiltrated; there was construction on the floor above that we said would end at 9:00 but it lasted until 10:00; and one of the nurses wasn't very kind about helping her to the commode.

This woman had paid $2000 out of pocket for the surgery, and she asked for $150 back. To me, it's worth $150 to find out how we can get better and whom we need to compliment for doing well.

Topol: Wow, that's amazing. You are so far removed from what other health systems are doing. You are an outlier in the positive sense, but there must be some downsides. Is there anything holding you back in a uniquely negative way?

Feinberg: The thing that worries me the most is our location. We are in a place where the economy is not robust. Young people don't have a lot of opportunities. If we become exclusively a provider to government payers, Medicare and Medicaid, because that's all that's left in our communities, it will be hard for us to make these types of investments.

That's why we said, we want to make Scranton, Pennsylvania, the healthiest place to live in America. We're bringing all of our programs there—our genetics, our food, all of that stuff, and a lot of community partners. We think if we can make it the healthiest place to live, it will actually bring business into the Scranton area.

For example, one of our patients told me his blood sugars were in the 300s. After 3 months in our fresh-fruit pharmacy program, his blood sugars got better, and he was able to get his commercial driver's license back. He is now driving again.

Bad health and poverty are so linked. We think if we can promote health, it will create economic stimulus. People will go back to work, and that's what we need.

That's the issue. It's different from New York City, or Los Angeles, or San Diego for that matter. We're just not doing well from an economic standpoint.

Topol: For people at Medscape who are watching, this is not just talk. I've read the papers[2,3]; there are papers in Science,[4,5] in the American Journal of Human Genetics[6] recently about your programs. It isn't like you're just talking about this. You've got the data. It's extraordinary, and you're really contributing to the academic side, too.

One last thing I wanted to ask you about: If you do this in Danville and in Scranton, what about the rest of the country? Can this be the model for America?

Feinberg: Atlantic City has the diversity that exactly matches America, and we're doing it there. I often think the criticism or the questioning of a place like Geisinger is that "yeah, it works up there, where no one moves, and you've had electronic health records, and you've got all the pieces."

But we're doing it in a city that has had its ups and downs. When the casinos were closing a few years ago, [our program] said to all the casino workers, we'll provide you healthcare for the year for free. It's been that same kind of engagement with the community. Hopefully, the community comes back, and we're seeing it come back in Atlantic City. That's a place that does not look like Danville, Pennsylvania. It looks like America.

Topol: It's amazing. I think everyone who is listening or reading this transcript will actually be stunned, because so many are not familiar with the pioneering efforts that you're doing. Congratulations on that. We're going to continue to be watching what's going on there and hoping that it expands geographically. I don't know what more you can do innovatively, but you are as disruptive in a positive way as anyone there is in all of healthcare at Geisinger. With great admiration, David, to you and all your colleagues there, we're cheering for you.

Thanks so much for joining us today at Medscape. I know that this will be enlightening for everyone who is learning more about what's going on at Geisinger. Thanks, David.

Feinberg: Thank you so much, Eric. It's been a real pleasure.


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