Gregg Masters 00:10
You’re listening to PopHealth Week on HealthcareNOW Radio. I’m Gregg Masters, Managing Director at Health Innovation Media, publisher of ACOwatch.com and your co host with my colleague and partner Fred Goldstein, President of Accountable Health, LLC, a Jacksonville, Florida based consulting firm. On today’s broadcast our guest is Stephen Jay Scheinman, MD, the President and Dean of the Geisinger Commonwealth School of Medicine, and Geisinger’s Chief Academic Officer and Executive Vice President. Dr. Scheinman was formerly Professor of Medicine and Pharmacology at SUNY, the State University of New York upstate Medical University, where he served for eight years as Senior Vice President and Dean of the College of Medicine. Board Certified in internal medicine and nephrology. Dr. Scheinman has earned international prominence for his research into the genetics of inherited kidney diseases, and kidney stones and has published more than 90 peer reviewed articles, reviews and book chapters on topics related to kidney disease and genetics. On today’s show, we get a unique perspective from a national leader stewarding the assets of an integrated delivery system nested academic medical center iterating on a new vision of community rooted training of physicians and other allied health care practitioners. This is our first conversation with Dr. Scheinman but no doubt will not be our last. So Fred, over to you help us get to know Dr. Scheinman and the unique footprint. He’s leading at the Geisinger Commonwealth School of Medicine.
Fred Goldstein 02:00
Thanks so much, Greg. And, Steve, welcome to pop Health Week.
Steven Scheinman 02:03
Thank you very much. Glad to be here.
02:05
Yeah, it’s a pleasure to have you look forward to this discussion, fascinating, you know, between Geisinger, the medical school. So could you give us a little background on the founding of Geisinger and the school itself?
Steven Scheinman 02:17
Well, Geisinger, was founded over 100 years ago. And it’s a an inspiring story. But the medical school was founded only 10 years ago. This summer, we’re celebrating our 10th anniversary of the arrival of our very first students, and uniquely among American medical schools. We were founded, not by a university looking for the prestige of a medical school and not by a clinical system looking to feed its workforce. We were founded by the community of northeastern Pennsylvania, it was almost the smallest metropolitan area to aspire to having a medical school and very economically depressed. And in the first years of the school’s founding, it was it survived a major recession. But the community was committed to the success of the school because they saw that having a school in the region would not only help develop the careers of young doctors, and attract physicians to come to the area to be affiliated with the school, but also that the school itself would create programs that would improve care in the region. It was really a very ambitious goal. And many people thought it would be completely unrealistic. And yet it succeeded. And it succeeded because of the strong support of the community, which has manifested in philanthropic support, which made it possible for the charter class to have fully half of their tuition covered for all four years. It was manifested in the support by the state of Pennsylvania, and remarkably by Blue Cross of northeastern Pennsylvania, so the major insurer in the region supported financially very substantially the founding of the school.
Fred Goldstein 04:01
That’s, that’s really fantastic. And so, you talked about the community sort of being so heavily involved in this, and how is that sort of reflected in the school itself and and the work that the students there do?
Steven Scheinman 04:13
Well, certainly it’s in our culture because of the founding myth of the school, which is the truth, which is that it was founded by the community, and it’s built into the curriculum. So all of our students perform are required to perform community based research, a project that that is a quality improvement project with a community partner, all students are required to do 100 hours of community service. I’m aware of several other medical schools that require as much as 20 hours. I’m not aware of any other school that requires 100 hours. They typically do this community service with a not for profit agency, often providing behavioral health care or they might work in a food bank or they might teach health in the public schools a variety of opportunities to do their community service. But it’s also baked into the content of the curriculum and their clinical experiences, much more than most other medical schools are ambulatory and community based. So it’s really part of our DNA.
Fred Goldstein 05:18
So if you think about that, from a population health perspective, and I know that David and others, Nash and others have talked about, hey, we’ve got to get more of this population health curriculum into the schools, in essence, you sort of bake some of that in because they’re seeing real world out there. Is that the case?
Steven Scheinman 05:33
Yes, that’s right. And of course, we pay conscious attention to population health, in the content of the curriculum, not just experiential, it’s, it’s also formal didactics in population health. And, in fact, we’ve recently formed a partnership with David Nash’s, a school of population health health at Thomas Jefferson University, whereby the two schools are sharing the cost of tuition for medical students from our medical school, who want to take a year off after the third year of medical school, to go to Philadelphia and get a Master’s in Public Health degree. So we’re excited about that. We’re doing it as a pilot for three classes. And the first class is doing that right now.
Fred Goldstein 06:19
So that’s great they get in some didactic work, as well as some real world field work. And when you look at what you’re doing with those, you’d mentioned the hundred hours versus 20. And the other community work, are other medical schools or academic medical centers are trained doing similar things, are they moving in that direction? Now?
Steven Scheinman 06:38
I think that many medical schools are paying much more attention. In fact, I think it’s it’s been a something that has been discussed quite a bit among the leadership of academic medicine, that medical schools are paying more attention to the obligation they have to the community in which they are located whether that be a rural community like ours, or an urban community, the double AMC gives out an award every year for schools that have engaged substantially with their communities. So a school wins that award every year. And there are particular schools that have paid conscious attention to their community in in a range of ways. And so some of them do this through the projects whereby the students engage with the community to on a community improvement activity. There is the Herbert Wertheim School of Florida International University in Miami, in which Dr. Joe Greer leads a program whereby the students adopt a portion of the community, several, it may be several blocks of a community whereby their goal during their time in medical school is to improve a particular aspect of care in that portion of the community. And so they pay very serious attention to the community that they live in. One very good example,
08:02
Geisinger is also an integrated delivery system well known around the country for doing innovative things. How does Geisinger work with the with the with the medical school itself, the integrated delivery network?
Steven Scheinman 08:14
Well, I’ll answer that from several levels. First of all, as I mentioned, the school was founded as an independent medical school 10 years ago. But two and a half years ago, we became Geisinger and it was a match made in heaven, the mission of the school and the mission of Geisinger were really quite congruent with each other. The medical school, as I’ve said, embraces a mission to the community. Geisinger has always had a mission to this region of Pennsylvania, and, and has been developing over the years programs that serve that community in in unique ways. And so we have the opportunity now, to train our students to experience directly some of these programs that both serve the community and create new models of care. And I’ll give you a couple of examples of that. One is a program called Geisinger at home, whereby Geisinger has identified patients who require an inordinate amount of inpatient services. They’re in the emergency room frequently, they get admitted much of the time from the emergency room, and they have a complex set of medical problems. So what Geisinger does and this is now they’re doing this now for about 1200 patients is they send the medical team at regular intervals to the patient’s home, so they can pick up on problems well before they get to the point where they require emergency attention. And they have on this team everybody the patient needs including the doctors and the nurses, the respiratory therapist or the nutritionist, dietician, wound care specialist, whatever the patient’s problems are, they make sure that there’s someone on the team going out to the home to address that. And things in this way are addressed much more proactively. It may sound like a very expensive proposition. But in fact, when you think of the unnecessary expense of, and the unfortunate situation of letting things get to the point of needing to go to the emergency room and needing to be admitted for a problem that could have been averted, it turns out that sending a team to the home is a bargain. And it’s particularly workable, because Geisinger has an integrated care delivery system, whereby the health plan and the clinical system are part of the same organization. And so, whereas a clinical system in isolation, might look at filling the hospital beds and keeping the emergency room busy as ways to improve the bottom line. In an integrated care delivery system, the goal is to keep total costs down. So the amount of the health plan saves is much greater than the amount that the clinical system loses. So you save money, and the patients do much better. That’s one example that’s Geisinger at home,
Fred Goldstein 11:05
as you’re considering that and I know you know, everyone’s now looking to these alternative payment models, as ways to kind of take the value that’s created by doing these unique things and convert it to a value to the organization you already have that set up as a health plan and have integrated and look more broadly at the patients. Do you sense that the other hospitals are beginning to recognize they need to move that direction, it’s certainly not been something we’ve seen rapid change in
Steven Scheinman 11:32
No, the change has been much the the move to value based care and risk based contracting has been much slower than people had hoped. But it is something that I think is generally acknowledged as the right direction. And we are particularly excited that our students will experience their clinical experiences in a setting of value based care. But organizations that don’t have their own health plan are still able to do this contractually with the payers more complicated when that happens. But there certainly are many examples of that.
Fred Goldstein 12:11
And the second example, you were going to bring up
Steven Scheinman 12:13
so another thing that Geisinger is doing is called the fresh food pharmacy, pharmacy spelled with an F is based on the concept that healthcare is only a portion of the full set of determinants that determine your health outcomes and self care, including diet is tremendously important. And so Geisinger has identified patients, particularly those with diabetes, obesity, and hypertension, and particularly when they have a combination of this that they will provide the patient with all the meals they need for that week in healthy ingredients, and will give them the training to cook those ingredients in healthy ways and will provide the food not just for that patient, but for the entire family since it’s hard to maintain good eating habits when other people at the table are eating unhealthily. And so this also, like the previous example might sound expensive to feed entire families for long term. And yet, what Geisinger is finding is that in diabetics, the hemoglobin A1c levels fall significantly, the blood pressures come down, that weight comes down that patients are more active and do better, and therefore consume less in the way of clinical services. And so once again, this is a way that Geisinger health plan is spending money to achieve this. And yet saving much more than they’re spending in the better outcomes. And the patients are doing much better. And once again, our students have the experience to train in the setting where they’re experiencing proactive care that just responds to illness after it occurs, but is improving health before illness gets bad.
Fred Goldstein 14:04
So you’ve discussed two interesting models, one of them directly to social return to health, which is the eating I guess it you guys and yours actually created the system to identify the individuals and then figure out all the logistics to get the food to them,and then monitor that. Wow.
Steven Scheinman 14:20
Yes, that’s right. And they’ve done this they’ve just opened a second site for the fresh food pharmacy. And the plans are to to span this throughout the entire footprint of Geisinger, which covers most of northeastern and central Pennsylvania and also South New Jersey through the Atlantic care system, which is part of Geisinger
Fred Goldstein 14:42
Are there other issues that Geisinger now looking at for the next phases in the social determinants areas?
14:48
Yes. Geisinger is very interested in exploring additional opportunities to address social determinants. Another example I can give you is a program whereby Geisinger provides free transportation to patients not just to come to their doctor’s appointments, but to take their kids to daycare or to get to the grocery store, all of which allows them to take better care of themselves.
Fred Goldstein 15:14
Wow, that’s I think that’s the first one I’ve heard that goes beyond just bringing them in, obviously, to see their primary care doctor. So that’s really an interesting approach to broaden it out that far, as you look at, you know, these efforts to improve the health of communities. And obviously, you’re the major player up in those communities. How have you structured that to work with the various organizations and the and the social with the social work groups and the rest of not for profits? Is there a formal association or is it just kind of been linked up over time to create that
Steven Scheinman 15:44
when the school was founded 10 years ago, as an independent entity, we were tremendously dependent on partnerships throughout the community of various sorts, to be able to deliver our educational product, and also to provide this these community experiences for the students. And so the school engaged very substantially with the community physicians throughout the region, and ultimately established a network of over 1200 physicians who volunteered their time to teach the students at the school not only didn’t have a hospital of its own, but it also didn’t have a practice plan. It was completely dependent on community volunteers to do the clinical teaching until it became Geisinger. And those community volunteers, many of whom still teach our students have done it out of the pride and excitement of having medical students, I will tell you that there’s something we’ve got some secret sauce that attracts a remarkable quality of medical students who are committed, engaged, articulate, and smart. And so the community preceptors were thrilled to have them and if they didn’t have a student in a particular semester, they would complain where’s my student? So that’s one aspect of the community outreach that was very important was the strong partnerships that we’ve forged in the early days with community physicians. The other is strong partnerships with community organizations. And so from the first, the school became very engaged with all the community agencies, the schools, the not for profits, the other practices and added up over time, to a very substantial network of service agencies. In fact, in an area where rivalries among various entities are known to occur, the school was one of the entities that was viewed as a neutral third party was, we were we were viewed with trust by everybody. And we had great relations. And that was largely due to the large benefit that people saw in having students come out and deliver these services and participate in their programs. A third respect in which we reached out to the community is that the year after the school was founded, we obtained through our Vice President for Community eEngagement, a position that doesn’t exist at every school. Her name is Dr. Rita Castro, we obtained a two and a half million dollar federal award from HRSA to establish a program called Reach High, which created STEM opportunities for underprivileged students in the high schools throughout the region. And what this amounted to was a summer experiences at the medical school, as well as a one Saturday every month throughout the school year. And this paid huge dividends in the outcomes of these students educational experiences. So when a student comes from an underprivileged background, they’re predicted to underperform in standardized tests. And these students, on average performed above the national mean for SAT. Very high percentage of them ended up going to college. And a portion of this program was devoted to college students from underprivileged backgrounds, over half of whom have gone to medical school. So school offered these sorts of enhancements throughout the community that enhanced our stature within the community and strengthened our relationships with with all of these entities.
Fred Goldstein 19:22
Steve, that’s just wonderful to hear that story about STEM and schools. So it’s a question I’m not sure you can answer. But everybody’s looking to move the health of their communities up. You’re obviously got a highly integrated, at least compared to many places, maybe not all but highly integrated approach doing a lot of really unique and different things. Have you been able to see if that’s impacted the community’s health status on a larger basis,
Steven Scheinman 19:50
we that is our aspiration. It’s too early to be able to do this but as as we roll out these programs, they are linked with with metrics, and so our goal over time, and I think it will be many years, but our goal over time is to see a measurable improvement in the community. So Geisinger’s goal with with these programs is not confined to Geisinger, members or Geisinger patients. Some of the programs like Geisinger at home are at least for now. But But Geisinger as well as the school sees a mission to the community at large.
Fred Goldstein 20:28
Yeah, and like you said, it’s early these these changes are really big. And we tend to see communities unfortunately, in many ways, going the wrong direction over time. So just being able to stabilize that and begin to move it in the other direction will be fantastic. Where do you see these medical schools in the future, say, five to 10 years from now? What sort of changes do you see and what might be done around population health?
Steven Scheinman 20:52
I think all medical schools are taking a close look at their curriculum. It’s something that schools do on a regular basis and curriculum renewal is, in many schools an ongoing process, but the in many ways that the curriculum at most medical schools still follows the basic structure that Abraham Flexner prescribed for medical schools in 1910. But many schools now are taking a fresh look at that. And it’s not just the new schools, I mean, schools like Harvard and Vanderbilt are also doing very creative things with curriculum. And among the things that schools in general are looking at is the new content areas that may not have even been around when the senior faculty at these schools were in medical school. And these include areas like informatics, and genomics, and population health and value based care and payment models, the economics of health care. And I think many schools are taking a look at how they can work these topic areas into their curriculum. And what we’re doing with a curriculum, it’s only 10 years old, is taking the view that it’s not possible and certainly not good to try to wedge all of this new content into corners of a curriculum that’s well established. So we are doing and we were starting on this process now is rewriting our curriculum completely with the goal to incorporate these the themes that I’ve been listing and other themes as well, including medical humanities, and healthcare, finance, and bioethics, organically across all four years of medical school, in which the curriculum would be horizontally integrated with very significant clinical experiences from the very first, which would be linked with community experiences, and with the science not occurring exclusively in the first two years, but also persisting through all four years of medical school. So that so that these topic areas are not concentrated in small boluses at a one single point in the curriculum, but in fact, woven across all four years. So that’s the concept, exciting curricular innovations, at other medical schools. And so I think that over the next several years, we’re going to see population health and community engagement at more and more medical schools, the social determinants of health being incorporated in a substantial way, as schools recognize that health care itself is only a small portion of health outcomes.
23:41
I’ve got just a quick question for you. For those academic medical centers. Obviously, you are showing a way to survive through new innovations in this new world order. But what would you tell those academic medical centers, simple things to maybe consider and not be so worried about this change coming
Steven Scheinman 23:58
if you’re notcomfortable with change and prepared to deal with change when you shouldn’t be in healthcare, because few industries are changing as rapidly as healthcare. And for example, the fee for service model is one that is not geared towards towards outcomes, is structurally designed to drive costs and needs to disappear. I think what I would say is that to survive in the in the current climate, you need to be innovative, you need to be thinking about value and outcomes, rather than heads and beds. And to the extent you’re able to innovate in that direction, you stand, a much better chance of surviving.
Fred Goldstein 24:42
Well, thank you so much. Steve, that’s a great close to the session. It was fantastic talking with you, and I’d love to get you back on sometime in the future.
Steven Scheinman 24:48
I’ll be happy to do it.
Gregg Masters 24:49
And that’ll be the last word on today’s broadcast. I want to thank Stephen Jay Scheinman, MD, the President and Dean of the Geisinger Commonwealth School of Medicine and Geisinger Chief Academic Officer and Executive Vice President. For more information on the Geisinger Commonwealth School of Medicine go to www.Geisinger. That’s G E I S I N G E R.edu. forward slash education and follow their work on Twitter via @Geisingercwlth Geisinger Commonwealth abbreviated for PopHealth Week. My colleague Fred Goldstein and HealthcareNOW Radio. This is Gregg Masters saying bye now.