CU Health & Medical Paper

Review the readings and videos linked below.

Submit a 1-1?2 page paper addressing the following three prompts related to Triple Aim:

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Define the Health Navigator role and its significance in a rural community.

Detail the three primary objectives of Triple Aim.

Describe the Health Works Model; how does expansion to contiguous communities address rural healthcare gaps?

Case Study
Organized Health Care Delivery System • July 2010
Genesys HealthWorks: Pursuing the Triple
Aim Through a Primary Care-Based Delivery
System, Integrated Self-Management
Support, and Community Partnerships
S arah K lein and D ouglas M c C arthy
I ssues R esearch , I nc .
The mission of The Commonwealth
Fund is to promote a high performance
health care system. The Fund carries
out this mandate by supporting
independent research on health care
issues and making grants to improve
health care practice and policy. Support
for this research was provided by
The Commonwealth Fund. The views
presented here are those of the authors
and not necessarily those of The
Commonwealth Fund or its directors,
officers, or staff.
Abstract: Genesys HealthWorks is a model of care developed by Genesys Health
System in metropolitan Flint, Michigan, to improve population health and the patient
experience of care while reducing or controlling increases in the per capita cost of care.
These are the objectives of the Institute for Healthcare Improvement’s Triple Aim initiative,
in which Genesys participates. Genesys is pursuing these aims by engaging communitybased primary care physicians in a physician–hospital organization that emphasizes care
coordination, preventive health, and efficient use of specialty care. It also promotes health
through the deployment of health navigators, who help patients adopt healthy behaviors,
and by partnering with a county health plan to extend access to primary care and other
services to low-income, uninsured county residents.

For more information about this study,
please contact:
Douglas McCarthy, M.B.A.
Issues Research, Inc.
To learn more about new publications
when they become available, visit the
Fund’s Web site and register to receive
Fund email alerts.
Commonwealth Fund pub. 1422
Vol. 49
Genesys Health System developed a model of care known as HealthWorks to
improve the health of the population in Flint, Michigan, and surrounding Genesee
County, while also improving patients’ experience of care and lowering (or at
least reducing the rate of increase in) the per capita cost of care. These are the
three primary objectives of the Institute for Healthcare Improvement’s Triple Aim
initiative, for which Genesys was one of 15 prototype organizations. (More than
40 organizations are participating in the program today.) The Commonwealth
Fund is studying several of these organizations to learn how they are engaging
in the Triple Aim and what lessons their experience holds for others who wish to
undertake or promote transformation in health care delivery.
The organizing principle of the Triple Aim is that simultaneously pursuing these three objectives enables health care organizations to identify and fix
problems that lead to poor coordination and inefficient delivery of care. It also
2 T he  C ommonwealth F und
helps health care organizations focus attention on and
redirect resources to those activities that will have the
greatest impact on health. In many cases, these organizations play the role of “macro-integrator”—a term
coined by IHI to describe entities and coalitions that
bring stakeholders and resources together to pursue
a shared vision of an optimized system of care for a
defined population.1
The Genesys HealthWorks model of care
embodies the Triple Aim’s unifying “macro-integrator”
function through three key elements that emphasize
the importance of primary care, health promotion, and
patient self-management support:
1. Engaging community-based primary care physicians in a physician–hospital organization
that emphasizes the importance of primary care
and makes more efficient use of specialty care;
2. Promoting health through the deployment
of health navigators, who support patients in
adopting healthy lifestyles to prevent and manage chronic disease; and
3. Partnering with community organizations to
extend the goals of the model to the entire
local population.
The model has achieved notable results in two
patient populations. Among patients who receive care
through Genesys Health System and its affiliated
physicians, the model has helped lower the use and
cost of care while improving physician performance
on quality indicators. A study by General Motors (GM)
found the automaker spent 26 percent less on health
care for enrollees who received services at Genesys
versus local competitors, according to the Genesys
PHO. Meanwhile, the use of health navigators has
improved health behaviors of patients in multiple
demonstrations. Extending the health navigator model
to serve low-income, uninsured patients enrolled in a
tax-supported county health plan has led to improved
health status and reduced use of the hospital and
emergency department.
This case study describes the circumstances
that led Genesys to develop the HealthWorks model
and then describes each of the model’s elements, the
results the model has helped achieve, and key lessons
learned.2 Chief among these is the importance of partnership between physicians, local health care systems,
and community organizations to build a strong primary
care infrastructure that can in turn support broader
efforts to improve health behaviors and health in the
Genesys Health System is a nonprofit, integrated
health care delivery system that provides a continuum
of medical care services to patients in Genesee County
and surrounding areas (Exhibit 1). It includes a 410bed acute-care teaching hospital (the Genesys Regional
Medical Center) that provides Level II trauma services,
a convalescent center, a home health agency, a durable
medical equipment supplier, resident and home hospice care, and various ancillary/diagnostic services and
sites. The Genesys Regional Medical Center is located
in the suburb of Grand Blanc on the southeastern edge
of Flint.
The health system partners with a network of
150 community-based primary care physicians affiliated with the Genesys Physician–Hospital Organization
(PHO) (Exhibit 2). The physicians practice in medical
groups in a multicounty service area and admit patients
to the hospital—Genesys Regional Medical Center—
almost exclusively. Genesys Integrated Group Practice
(GIGP) makes up the core of participating physicians
in the Genesys PHO. It includes 81 primary care physicians who operate in private practices ranging in size
from one to six physicians each. (The remaining 69 primary care physicians affiliated with the PHO work in
independent small practices.) As members of the GIGP,
the shareholder physicians agree to work together to
achieve quality and utilization goals (described below).
For specialty care, these physicians refer patients
exclusively to a closed panel of 354 contracted medical
specialists (who receive most of their referrals from the
PHO) and a few hospital-employed specialists. GIGP
G enesys H ealth W orks : P ursuing the T riple A im
Exhibit 1. Genesys Health System Service Area
Source: Genesys Health System.
also owns and operates three diagnostic centers and
three after-hours clinics.
The Genesys PHO is a physician-led organization that negotiates a mix of risk-based managed
care contracts (that may specify a fixed payment per
member) with health plans on behalf of the hospital
and the physicians. The PHO also handles a variety
of functions delegated to it by health plans including
physician credentialing and utilization management. It
is one of five Michigan physician organizations chosen
by Blue Cross Blue Shield of Michigan (BCBSM) to
participate in a pilot-test of delegated care management
responsibilities for patients covered by fee-for-service
insurance. (See Appendix A for more information on
the Genesys PHO.)
Roughly one-third of Genesys PHO physicians
use the Misys electronic health record (EHR) to track
and coordinate their patients’ care; all use some form of
electronic prescribing system for all of their prescriptions, as required by the PHO. The PHO is converting
Exhibit 2. Genesys Health System and
Genesys Physician–Hospital Organization
Health System
Genesys Regional
Medical Center
Family Health Centers
(staffed by
medical residents)
Genesys PHO*
Hospital Employed
Physicians and Faculty
Genesys Integrated
Group Practice
Physician Association
Genesys Convalescent
Center (nursing home)
Genesys Home &
Hospice Care
Ancilliary services
* The PHO is a partnership between Genesys Regional Medical Center and Genesys Integrated Group Practice.
PHO = Physician–Hospital Organization.
Source: Genesys Health System.
4 T he  C ommonwealth F und
Exhibit 3. Health Insurance Coverage Among Nonelderly Residents: 2006–2008
Flint metropolitan area
Source: Employee Benefit Research Institute analysis of Current Population Survey, March 2007–2009.
from Misys to Allscripts EHR (because of the merger
of these two vendors) and anticipates that all PHO physicians will be using the Allscripts EHR by the end of
2011. (At present, the ambulatory EHR does not link to
the hospital’s EHR system.)
The health system forges relationships with
community organizations to improve population health
and patient access. One example is its participation in
Genesee Health Plan, a tax-supported county health
plan that provides primary care and preventive health
services, limited prescriptions, and laboratory tests to
approximately 27,000 low-income uninsured residents
of Genesee County. When Genesee Health Plan formed
its provider network, the PHO helped by requiring primary care physicians who participate in its managed
care contracts to provide key components of a “medical home” and basic health services to members of the
health plan.3 As a result, Genesys PHO physicians,
along with two Genesys primary care residency clinics, serve as primary care providers for 41 percent of
Genesee Health Plan’s members as of May 2008.
(See Appendix B for more information on Genesee
Health Plan.)
Both Genesee County and Flint have undergone a substantial decline in population and employment in the last three decades, reflecting the changing fortunes of the U.S. auto industry on which the
community relies. Flint had an unemployment rate of
26.6 percent as of December 2009; Genesee County’s
rate was 16.0 percent.4 Almost one of four nonelderly
residents lacked health insurance in the Flint metropolitan area during 2005–2007 (Exhibit 3). Flint
residents, in particular, have less health insurance
coverage and greater socioeconomic disparities than
surrounding Genesee county, the state of Michigan,
and the nation. Genesee County ranks last out of 82
counties in Michigan on measures of healthy behavior,
which include smoking, adult obesity, binge drinking,
and teen birth rates. (See Exhibit 4, County Health
Genesys Health System estimates that its affiliated primary care physicians now care for 40 percent to
45 percent of the 435,000 residents in Genesee County,
which is the focus of its Triple Aim efforts. The
Genesys Regional Medical Center treats 31 percent of
hospital patients in its primary service area, and draws
patients from a secondary service area that includes
parts of six surrounding counties (Exhibit 1). It competes with two nonprofit teaching hospitals in its primary service area: the 443-bed Hurley Medical Center
and the 458-bed McLaren Regional Medical Center
(one of eight regional hospitals operated by McLaren
Health Care), both located in Flint. Genesys, Hurley,
and McLaren together care for about 90 percent of
the hospital patients in Genesee County. Hurley and
McLaren both have primary care networks that include
employed physicians.
The payer mix for patients receiving care from
the Genesys Integrated Group Practice is as follows: 31
percent Blue Cross Blue Shield of Michigan (primarily fee-for-service payment); 30 percent Medicare; 21
percent commercial health maintenance organizations
(capitated payment); 10 percent Medicaid (predominantly managed care); 4 percent other insurance; and
G enesys H ealth W orks : P ursuing the T riple A im
4 percent uninsured. (Payment mix is similar for the
PHO as a whole.)
Genesys Health System, which employs approximately 3,100 staff, is a member of Ascension Health, a
Catholic health care system that operates 69 acute care
hospitals in the United States. Its philosophy of care
reflects a promise to provide “Healthcare That Works,
Healthcare That Is Safe, and Healthcare That Leaves
No One Behind.”5
The history of Genesys Health System is intertwined
with that of the U.S. auto industry, which dominated
the economy of Genesee County for more than a
century. Local automakers including General Motors
(which was founded in Flint and at its peak employed
roughly half of the Flint population) created a stable
base of well-insured patients for local hospitals and
physicians. By the late 1970s and early 1980s, Genesee
County had some of the highest health care utilization
rates and costs in the country, yet health outcomes were
not optimal.
Unhealthy behaviors were prevalent and part
of the local culture. With excellent health insurance
benefits, many patients came to expect local providers could address any problem they developed. “I
had more than one patient say to me, ‘Well, I always
knew that after I got my second bypass surgery, that’s
when I might consider quitting smoking,’” says Trissa
Torres, M.D., M.S.P.H., medical director of Genesys
Nor was the patient experience of care ideal.
“Our [physician] offices were not coordinated and had
significant variations and practice standards,” says
Mike James, president and CEO of Genesys PHO.
“Physician relationships with the patients were inconsistent. Some were very good and some, quite frankly,
were very distant.” Moreover, the relationship between
physicians and specialists did not promote clinical collaboration. “They ran into each other in the hospital
occasionally, but it was not anything that related to care
plans or trying to improve quality,” he says.
The impetus for change came in the 1980s, with
the decline in U.S. auto industry. As General Motors
struggled to maintain market share, the company put
pressure on local health care providers to lower their
costs, which contributed to the cost of manufacturing
American cars. Around the same time, the area’s unemployment rate began rising as automakers moved manufacturing operations overseas to lower costs. General
Motors, which employed 80,000 workers in Flint in the
late 1970s, shed jobs at such a rate that by early 2010,
it employed less than 8,000 people in Flint.6
To continue to thrive, Genesys Health System
needed to change its approach to care so that it would
reduce its costs and enhance its ability to positively
influence health outcomes in the community. That
need is still pressing today. Flint is still one of the
most economically challenged cities in the country.
Indeed, the role that the economy played in Genesys
Health System’s transformation cannot be overstated. It
alarmed both the hospital and the physicians and compelled them to collaborate in ways uncommon in more
stable economic environments. Cities or regions facing
similar (or less) distress may learn from their experience.
In 1991, Genesys Health System outlined its plan to
increase the quality of its services and lower its costs
by increasing the availability and quality of primary
care. Primary care physicians would build strong relationships with their patients and guide care decisions
that promote health and prevention, while optimizing
The health system’s plan called for an increase
in the number of primary care providers in the community, the development of an integrated delivery system
that would span the continuum of care, and greater use
of care management techniques to decrease utilization
and promote cost-efficiency. The plan also called for
a reduction in hospital bed capacity. Genesys Health
System accomplished this by consolidating its four
predecessor hospitals (with a combined capacity of 908
beds) into one regional medical center, which opened
in 1997, thus reducing excess capacity in the community by about 500 beds.7
6 T he  C ommonwealth F und
The integration of physician, institutional, and
community objectives and incentives was an essential
element of the plan, according to Young S. Suh, thenpresident and CEO of the system.8 “We believe the
changes we are implementing will ultimately lead to
higher satisfaction for patients, physicians, and staff,”
Suh wrote.
Because Genesys’s plan would reduce acute and
specialty care services and thus have an adverse impact
on hospital revenues, the system needed to increase
its patient base by expanding its primary care referral
population. “It does not work if you are treating the
same number of patients,” James says. To address this,
the health system expanded its service area from one
county to five.
When it updated these goals in 2007, it sought
input from the community. The health system hosted a
three-day work session where 40 participants, including physician, community, and health system leaders, gathered to set the health system’s 25-year goals.
The statement the committee developed—known as
VisionScape—reinforced the goals outlined in 1991
and expanded upon them through several related elements. The first of these—developing the “hospital of
the future”—seeks greater engagement of the medical
staff through comanagement companies, which will
align the incentives for hospitalist and specialty care
physicians to work together more closely to improve
quality, safety, and efficiency as Genesys drives toward
becoming a high-reliability organization.9
In addition, VisionScape called for an expansion and enhancement of medical education in the area.
Genesys Health System—which already trains residents in family medicine, internal medicine, and several specialties and medical students through a longstanding affiliation with Michigan State University—is
working with community partners to develop new
models of medical education to enable team-based
training across disciplines.
VisionScape also ratified the health system’s
efforts to promote healthy behavior—rather than just
treating disease—by applying the HealthWorks model
of care (described above) to realize the Triple Aim of
“Unhealthy lifestyles relate directly to the leading
causes of death in our community and also to
high overall health care costs. The healthier our
population is, the more we can lower the need for
expensive acute care services.”
Trissa Torres, M.D., M.S.P.H.,
medical director of Genesys HealthWorks
improved population health, better care experience,
and reduced cost. “Unhealthy lifestyles relate directly
to the leading causes of death in our community and
also to high overall health care costs. The healthier
our population is, the more we can lower the need for
expensive acute care services,” Torres says.10 This case
study focuses on how Genesys Health System is applying the HealthWorks model to achieve the objectives of
the Triple Aim.
Genesys Physician–Hospital Organization has played
a pivotal role in establishing a robust primary care
infrastructure by aligning the interests of its affiliated
physicians with the hospital and by setting standards to
achieve quality and efficiency goals. (See Appendix A
for a full description of the PHO.)
The PHO was created in 1994, when health system leaders believed the country was moving toward
universal managed care. While that national plan never
came to fruition, the PHO continued to operate as if it
had—encouraging its physicians to define standards
of practice and referral protocols and apply them uniformly to patients whether they were covered by health
maintenance organizations or not.
“It took us five years to really change the culture,” James says. The PHO did so by employing
a moral argument, which emphasized that “to treat
your risk (managed care) patients one way and treat
your fee-for-service [patients] another way is wrong,”
James says. Having one model of care also made sense
because patients often move between fee-for-service
and managed care plans.
The PHO leaders believed that physiciandirected practice standardization would ultimately
G enesys H ealth W orks : P ursuing the T riple A im
lower costs by reducing unnecessary and duplicative
specialty services and ancillary tests and improve
chronic disease care, which would further reduce hospital admissions and emergency department visits.
“Our strategy from the beginning was to provide a
higher quality of care in a more efficient manner than
the market,” James says. “Key to this is a strong doctor–patient relationship.”
Key elements of the PHO’s strategy include
establishing physician-directed quality improvement,
making specialty care more efficient, promoting more
effective utilization management, improving chronic
and preventive care, and engaging patients in selfmanagement through a patient-centered medical home.
The PHO is also actively engaged in aligning payment
incentives to support its model of care. It is one of 35
Michigan physician organizations participating in Blue
Cross Blue Shield of Michigan’s Physician Group
Incentive Program (see Appendix A).
Beginning in November 2008, 11 PHO-affiliated
physicians began participating in a trial of a patientcentered medical home as part of the Blue Cross
Blue Shield of Michigan’s Physician Group Incentive
Program. The medical home trial provides incentives
to physicians to participate in performance reporting
and provide extended access, preventive health services, and links to community services. The physicians
were able to do this fairly easily because the PHO had
encouraged physicians to adopt many of these elements of patient-centered medical homes years before.
“The systemic approach to utilization and quality was
already in place,” says Ann Donnelly, senior vice president of administration and medical management for
the PHO. The PHO plans to expand the medical home
model to all affiliated physician practices by 2013.
The focus of the PHO’s work on the patient-centered medical home is on increasing patient self-management support through two mechanisms: 1) patient
health goal-setting with providers, and 2) the integration of health navigators into primary care, which is
described in the next section.
A health navigator program that supports patients in
adopting healthy behaviors that reduce health risks,
thereby helping to prevent or manage chronic diseases,
is a key component of the Genesys HealthWorks model
to improve population-based health across the system
and in the community.
The generally poor health status of Genesee
County residents (see Exhibit 4) points to the need for
promoting healthy lifestyles as a means to improving the health of the community, says Torres. “When
we review the factors that relate to overall health, our
county is last or next to last in all of these categories. It
supports the fact that we need to go above and beyond
acute care delivery . . . to focus on improving healthy
While the health navigator program focuses
on behaviors that will have the greatest impact on
health outcomes (e.g., physical activity, healthy eating, tobacco avoidance), it also encourages success by
helping patients tailor behavior change plans to their
preferences, interests, and readiness for change. For
example, a patient may wish to reduce stress before
tackling weight loss.
The health navigator model was developed and
evolved through a variety of pilot and research projects starting in 1997 and is currently being used in two
subpopulations: 1) among patients receiving care from
primary care physicians participating in the patientcentered medical home pilot program at Genesys
PHO; and 2) among low-income, uninsured residents
enrolled in Genesee Health Plan (GHP). In the two
programs, 11 health navigators serve a patient population of approximately 45,000.
While GHP is distinct from Genesys Health
System, collaboration with the health plan “enables us
to bring our model to serve the most needy in our community,” Torres says.
Unlike many case management programs that
focus exclusively on high-risk patients, patients may
enter the health navigator program with varying health
status levels, whether they are generally healthy, have
a chronic disease, or recently suffered an acute episode
8 T he  C ommonwealth F und
Exhibit 4. County Health Ranking*
(out of 82
Michigan counties)
Health outcomes
Premature death
Poor or fair health
Poor physical health days
Poor mental health days
Low birthweight
Health factors
Health behaviors
Adult smoking
Adult obesity
Binge drinking
Motor vehicle crash death rate
Chlamydia rate
Teen birth rate
Clinical care
Uninsured adults
Primary care provider rate
Preventable hospital stays
Diabetic screening
Hospice use
Social & economic factors
High school graduation
College degrees
Children in poverty
Income inequality (1)
Inadequate social support (2)
Single-parent households
Violent crime rate
Physical environment
Air pollution-particulate matter days
Air pollution-ozone days
Access to healthy foods
Liquor store density
* Data were collected from various sources and represent time periods ranging from 2000 to 2008. (1) Income inequality can range from zero (representing
equal income distribution among households in a community) to 100 (representing the hypothetical concentration of all income in one household in a community). (2) Inadequate social support is the percent of the adult population that responded that they never, rarely, or sometimes get the support they need.
G enesys H ealth W orks : P ursuing the T riple A im
of illness. The health navigator supports both the
patient and the physician: helping the patient identify
and achieve his or her health behavior change (which
may include setting a health goal); reinforcing the physician’s recommendations related to healthy lifestyles,
medication adherence, self-monitoring, provider visits
and preventive screening; and linking the patient to
community resources. (See the Results section for evidence of the effects of this program on patient health.)
Within the PHO, health navigators are registered
nurses who document their interventions and provide
updates in the EHR on patients’ progress toward goals.
This feedback enables the primary care physicians to
reinforce health goals at subsequent visits. The cost
of the health navigators for this population—approximately $72,000 for each full-time equivalent (FTE)
with a caseload of roughly 6,000 patients—is shared
equally by the PHO and the hospital.11
At GHP, where the background of the health
navigators varies to include health educators, social
workers, dieticians, and others in health-related fields,
the cost per FTE with a caseload of 6,500 patients is
approximately $69,000. GHP initially contracted with
Genesys Health System for the services of navigators
but has begun to employ some navigators as the program has expanded at the health plan.
The health navigator program at GHP initially
targeted patients with diabetes and asthma. The health
plan has since broadened the program to include smokers, patients with chronic diseases, and those with acute
needs upon enrollment and post-emergency department
visits. The intensity of the intervention depends on
the nature of the patient’s social and emotional needs
in combination with their medical condition. In both
programs, the team members typically spend 30 to 45
minutes on an initial call or an in-person interaction
with a member to assess his or her needs. Follow-up
calls (lasting approximately 10 to 15 minutes) are made
to the member at a frequency determined by individual
needs. Health plan members, who are reassessed at
three and six months, often work with multiple navigator staff over time. “Right out of the gate (we tell them)
we work as a team that works for the client,” says
Jemeka Thomas, a health navigator.
In both settings, the skills required of health
navigators are not related solely to medical care but
also include motivational interviewing, rapport building skills with patients and providers, and a broad
understanding of community resources, which may be
tapped to address patient needs. “You meet the patient
where they are and you do what’s a priority for that
patient,” Torres says. That may mean overcoming
barriers to care, accessing community resources, or
helping to get answers to questions about clinical care
or prescription medications, in addition to supporting
lifestyle change.
The following case report illustrates the impact
of the health navigator program. The patient described
is a member of Genesee Health Plan.
In addition to supporting Genesee Health Plan (through
the PHO physician network and the health navigator
model), Genesys engages in other community efforts to
help improve population health. The health system is
a member of the Greater Flint Health Coalition, which
joins local providers, purchasers, consumers, insurers, schools, and faith-based organizations in efforts to
improve the health status of Genesee County residents,
while decreasing costs and inefficiencies in care. The
coalition sponsored a community campaign to increase
physical activity in the area, among other activities. In
addition, the health system and its community partners
advocate for greater funding for the uninsured.
The health system’s participation in IHI’s Triple
Aim initiative has also enabled Genesys Health System
to forge partnerships with organizations around the
world, working to accomplish similar goals. “This collaboration has been wonderful because it has allowed
us support from the IHI faculty and the participants
around the globe who continue to challenge us to push
the envelope. In this context, we can share our learnings. We can also learn from others in areas that they
excel in,” Torres says.
10 T he  C ommonwealth F und
A middle-age male with a history of hypertension was contacted by a GHP health navigator following his admission
to the hospital for uncontrolled blood pressure. During their first conversation, the patient mentioned that he had
stopped taking his medication a few years ago because he lacked health insurance. Because of his high blood
pressure, he had failed an employer-required physical and was unable to return to work. He was also experiencing
high stress due to a recent change in his family situation and financial pressures, which were exacerbated by the bill
he received for his recent hospital admission.
During their call, the health navigator offered support to the patient, assuring him that he had access to his
primary care physician for follow-up appointments through GHP. She also encouraged him to build a relationship
with his provider. To assist him in covering the cost of his recent hospital admission, the health navigator also linked
him to the hospital’s charity care coordinator. She also connected him to GHP’s prescription assistance program
so that he could obtain medications that were not covered by the plan. Finally, she engaged him in a discussion of
healthy eating, exercise, and smoking cessation and helped him to identify ways to fit these into his daily lifestyle.
The health navigator called the patient several times over the next three months to support his progress in
making behavior changes. During the thee-month follow-up call, he said he had developed a relationship with his
primary care physician and was visiting the office regularly, as scheduled. He also was taking his medication as
prescribed, which helped him pass his physical and return to work. He also said he had changed his diet (by taking
fruits and vegetables to work as snacks and substituting Mrs. Dash for salt). He also reported he was riding his bike
regularly for exercise and had stopped smoking.
As an example of this intersite learning,
Genesys shared its model for health navigators with
the Vermont Blueprint for Health, a statewide partnership to improve the health and health care system for
Vermont residents. That helped inform the design of
Vermont’s community care teams. “In return, they have
shared their success with implementation statewide,
which informs our efforts toward regional spread,”
Torres says.
Genesys is also participating in the Dartmouth/
Brookings Accountable Care Organization Learning
Network to help position the health system and its partners for anticipated payment reforms that will promote
transformational changes in health care delivery.12
Genesys HealthWorks demonstrates a model for pursuing the Triple Aim by emphasizing primary care, health
promotion, and self-management support, as well as
partnerships with community groups to improve access
and area health status. Genesys Health System measures the impact of these efforts in a variety of ways,
which are outlined below. This section illustrates the
progress that Genesys HealthWorks and its physician
and community partners have made in reaching for
these goals of the Triple Aim.
Population Health
The health navigator model has been tested and demonstrated in several pilot and research projects in various populations of patients over 11 years, suggesting
its effectiveness.
The health system first applied the model as a
part of a health risk reduction service that it operated
from 1997 to 2003 to help 1,400 patients and employees quit smoking and/or increase physical activity.
G enesys H ealth W orks : P ursuing the T riple A im
“Many of the patients weren’t trying to change their
behavior before they were engaged,” Torres says. “Our
service helped increase their readiness for change and
achieve results.” The program led to a 25 percent quit
rate (120 of 478 smokers), which is higher than quit
rates based on physician advice (between 5% and 8%
percent) and on par with the quit rate for dedicated
smoking cessation programs in which participants are
often highly motivated.13 Fifty-five percent, or 255 of
463 patients, increased the number of days they were
physically active compared with a six-month prior
period. Through this program, Genesys found that
average annual health care claims were $300 lower for
employees who were physically active than for those
who were sedentary, and $200 less for nonsmokers
than for smokers.
The health system subsequently used the model
in a Community Health Educator and Referral Liaison
(CHERL) Project from 2003 to 2008, which supported
800 patients from 15 primary care practices in reducing unhealthy behavior. The grant-funded project led to
statistically significant improvements in health behaviors and outcomes, including smoking, physical activity, body mass index, and health status, as described in
Exhibit 5.14
The health navigator program led to the following improvements in behaviors among 1,763
low-income, uninsured patients enrolled in Genesee
Health Plan who were engaged in the health navigator
program from Aug. 2003 to April 2010 and who were
assessed (by telephone survey) at both baseline and six
months after engagement.15
Among patients at risk of unhealthy behaviors
at baseline, who reported improved risk at six-month
follow-up (Exhibit 6):

53 percent who did not eat adequate amounts of
fruits and vegetables, now do;

53 percent who reported no regular physical
activity, now are physically active;

78 percent who were physically active at baseline, maintained their physical activity;

17 percent of smokers quit; and

85 percent of patients who were not taking their
medications regularly, now do.
Exhibit 5. Self-Reported Health Behaviors Among 800 Participants in the
Community Health Educator and Referral Liaison Project: 2003–2008
Current smokers (%)
Body mass index
Physical activity (minutes/week)
Days of limited physical activity in past month
due to poor physical/mental health
Alcohol drinks/occasion (all patients)
Source: Adapted from J. Summers Holtrop, S. A. Dosh, T. Torres et al., “The Community Health Educator Referral Liaison
(CHERL): A Primary Care Practice Role for Promoting Healthy Behaviors,” American Journal of Preventive Medicine, Nov.
2008 35(5 Suppl.):S365–S372.
12 T he  C ommonwealth F und
Exhibit 6. Impact of Health Navigator Program on
Selected Health Risks Among Engaged Patients
Enrolled in Genesee Health Plan
At baseline
Number of patients
At 6-month follow-up
Not taking
No regular
Do not eat enough
fruit & vegetables
Source: Genesys Health System based on telephone survey data collected between August 2003 and April 2010 for
1,763 engaged patients who were assessed at both baseline and at 6 months post-engagement. Of the 1,763 patients,
797 have diabetes.
Among 797 patients with diabetes who were not
engaged in self-management at baseline, the following reported changed behavior at six-month follow-up
(Exhibit 7):

82 percent who did not regularly check their
blood sugar, now do;

90 percent who did not check their feet regularly, now do;

45 percent who had never received formal diabetes education, now have attended Diabetes
Self-Management Education; and

52 percent who had not had a diabetic eye exam
within the past year, received one.
A previous analysis of data from August 2003 to
July 2009 found the following:

In a subanalysis of 34 diabetic patients, each
self-reported health behavior improvement was
associated with an average 0.8 improvement in
hemoglobin A1c, a measurement of blood sugar

Among patients reporting poor management
of chronic pain, 37 percent (182/488) reported
improved pain management. Likewise, among
patients screening positive for depression, 42
percent (260/620) reported improved symptoms.
Among a subset of Genesee Health Plan patients
engaged in self-management support from 2006 to
2008 for whom hospital utilization data were available
at both baseline and six months later, engagement was
associated with reductions of approximately 50 percent
or greater in hospitalizations and emergency department visits (Exhibits 8 and 9).
To gauge the impact of integrated self-management support on patient health, Genesys also is monitoring the patients of PHO physicians participating in
the patient-centered medical home trial. On a monthly
basis, it counts the number of patients engaged in setting health goals. Of approximately 18,000 patients,
5,179, or 28.7 percent, have set 10,251 health goals.
For Genesee Health Plan during 2009, about 20 percent
of 8,385 new enrollees were engaged in health navigator interventions. In 2009, health navigators supported
these new patients and existing patients through 25,073
contacts, attempts, or patient-related activities and
4,810 links to other services based on patient needs.
In the inpatient setting, an analysis of Medicare
data by the private firm HealthGrades ranked the
G enesys H ealth W orks : P ursuing the T riple A im
Exhibit 7. Impact of Health Navigator Program on
Self-Management Among Engaged Diabetic
Patients Enrolled in Genesee Health Plan
At baseline
Number of patients
At 6-month follow-up
Did not check blood Did not check feet
sugar regularly
No diabetic
eye exam
within last year
Never received
formal diabetes
Source: Genesys Health System, based on telephone survey data collected between August 2003 and April 2010 for 797
patients with diabetes who were assessed at both baseline and at 6 months post-engagement.
Genesys Regional Medical Center among the top (best)
5 percent of hospitals nationally on risk-adjusted mortality and complication rates for 27 common Medicare
inpatient procedures and diagnoses.16 Data from the
federal Hospital Compare Web site indicate that the
Genesys Regional Medical Center performs better than
the 90th percentile (i.e., in the top 10 percent) of hospitals nationally on 30-day mortality for patients hospitalized for heart failure and pneumonia.
navigator in the patient-centered medical home using
an internally developed survey instrument. More than
eight of 10 agreed or strongly agreed that the doctor
helped them to be healthy and cared about them, and
more than seven of 10 agreed or strongly agreed that
the doctor knew them well and helped them set a health
goal at the visit (Exhibit 10; no comparative data are
Per Capita Cost and Resources Used
Patient Experience
To assess patient experience, the PHO annually surveys patients in its affiliated physician practices using
an internally developed survey instrument adapted in
part from the work of other Triple Aim prototype sites.
The survey asks patients to evaluate their physicians
and their state of health (among other matters) on a
five-point scale. The average rating from respondents
reporting whether they could achieve life changes
they set was 3.27 out of 5, while the average rating
from respondents reporting whether the provider team
knows them was 3.95 out of 5. The average rating for
overall satisfaction was 4.4 out of 5 (no comparative
data are available).
In 2009, Genesys PHO conducted a one-time
survey of the 2,102 patients who engaged with a health
An analysis sponsored by General Motors and the
United Auto Workers and conducted by Thomson
Reuters analyzed non-managed care medical claims
data for nearly 50,000 PPO enrollees in the Flint area,
a group that included GM’s salaried and hourly workers and early retirees. It covered the period from 2004
to 2007 and showed that costs for patients treated by
Genesys physicians were 26 percent lower overall
(plus or minus 5%) than those treated by the system’s
competitors (Exhibit 11).17 The health system attributes
the savings to lower lengths of stay and fewer admissions and readmissions per patient, which the analysis
More recent managed care data received by
Genesys PHO from insurers with managed care contracts with the PHO showed hospital days per 1,000
14 T he  C ommonwealth F und
Exhibit 8. Percent of Patients Engaged in Self-Management
Support Who Report One or More Hospital Admissions
in the Past Three Months
At baseline
At 6-month follow-up
Source: Genesys HealthWorks and Genesee Health Plan.
covered patients are 26.2 percent lower than competitors, emergency department visits are 14.7 percent
lower, and the rate of generic drug utilization is 72
percent—one of the highest generic utilization rates
in the state. A lower rate of referrals to specialists also
contributes to the cost savings. “When we focus on
those four things—hospital days, ED admits, generic
prescribing rate, and specialist referrals—we are
achieving about 30 percent better utilization than our
competitors,” James says.
In the BCBSM Physician Group Incentive
Program, the PHO performs better on some measures
of efficiency compared with its peers (Exhibit 12).
The health navigator intervention also contributes to reductions in the rate of hospital admissions and
the use of emergency department services (Exhibits
8 and 9), which in turn can be expected to result in
reduced costs.
Exhibit 9. Percent of Patients Engaged in Self-Management
Support Who Report One or More E.D. Visits
in the Past Three Months
At baseline
At 6-month follow-up
Source: Genesys HealthWorks and Genesee Health Plan.
G enesys H ealth W orks : P ursuing the T riple A im
Exhibit 10. Patient Experience in the Patient-Centered
Medical Home Trial: Genesys Physician Hospital Organization
Percent of patients who agree or strongly agree with the following statement:
“My doctor…”
Knows me well
Helped me set a
health goal at a
doctor’s visit
Helps me be as
healthy as I can be
Cares about me
Source: Genesys Health System, based on a Spring 2009 survey distributed to 2,012 Genesys PHO patients who had the
opportunity to engage with a health navigator.
Opportunities for Improvement
The system may have additional opportunity to
improve efficiency for Medicare patients relative to
the state and nation. Data from the Dartmouth Atlas
of Health Care, which examined care in the last two
years of life for Medicare patients with chronic illness,
indicate that those who received the majority of their
care from Genesys Regional Medical Center from 2001
to 2005 had somewhat higher Medicare spending and
more physician visits per person compared with the
state and national averages, although hospital use was
closer to the average (Appendix Exhibit C1). Genesys
performed somewhat better than the regional average
for the Flint Hospital Referral Region (HRR) on these
measures (with particularly lower specialists visits per
person) while accounting for about 40 percent of the
Exhibit 11. Health Care Spending Per Patient:
General Motors Flint Area Employees and Early Retirees
Enrolled in a PPO Benefit Plan: 2004
Patients receiving care from
Genesys-affiliated providers
Patients receiving care from
other area providers
Source: Genesys Health System, based on Thomson Reuters analysis conducted for General Motors/UAW. Includes
50,000 salaried and hourly employees and early retirees. Analysis did not adjust for differences in patients’ health risks.
PPO= Preferred Provider Organization.
16 T he  C ommonwealth F und
Exhibit 12. Selected Results for the Genesys PHO Among 35 Michigan Physician Organizations
Participating in the Physician Group Incentive Program (PGIP)
Total risk-adjusted rate of hospital discharges per 1,000 covered
Risk-adjusted rate of discharges for ambulatory care-sensitive
conditions per 1,000 covered patients
Risk-adjusted rate of emergency department visits per 1,000
covered patients
Use of high-tech imaging services (standardized cost per member per month)
Use of low-tech imaging services (standardized cost per member per month)
Measures (lower rates are better)
Source: Blue Cross Blue Shield of Michigan Physician Group Incentive Program. Based on dates of service from July 1, 2008 to June 30, 2009.
patients, suggesting that Genesys is a lower-cost provider in a higher-cost region of the state and nation.18
The total increase and annual rate of growth in
Medicare reimbursements from 1992 to 2006 in the
Flint HRR was substantially lower than for the state
or the nation (Appendix Exhibit C2). Torres suggests
that higher Medicare costs at baseline may reflect the
historical influence of generous employer benefits and
poorer population health status carrying over to care in
the Medicare years, while the lower rate of growth may
reflect the moderating influence of the area’s relatively
greater reliance on primary care (Appendix Exhibit
C3). The fact that Medicare enrollees are not obligated
to select and use a primary care provider inhibits the
system’s ability to effectively manage their care,
Torres notes.
In the inpatient setting, Genesys Regional
Medical Center ranked above the average for the Flint
Hospital Referral Region and the state of Michigan but
below the average of the top 25 percent of hospitals
nationally on composite measures of clinical quality
for patients hospitalized for heart attack, heart failure,
pneumonia, and surgical care. In a count of patients
rating a 9 or 10 on a 10-point scale on patient experience ratings on the Hospital Consumer Assessment
of Healthcare Providers and Systems (HCAHPS),
Genesys Regional Medical Center was above the Flint
regional average on five of 10 measures and met or
exceeded the state average on two measures, but was
below the average of the top 25 percent of hospitals
nationwide on all 10.19 Genesys Health System leaders recognize the need to match its primary care focus
with excellent inpatient care and are putting increased
emphasis on inpatient quality through the comanagement companies, described above, as well as on patient
experience and coordination of care across the delivery
The application of the Genesys HealthWorks model
described in this case study illustrates how physicians,
local health care systems, and community organizations can work together to pursue the objectives of the
Triple Aim: a healthier population, better patient-care
experiences, and more efficient use of resources that
may result in lower costs. The multilayered populationbased vision that Genesys Health System articulated
for its participation in the Triple Aim—reaching concentrically through its own patient population to the
broader community and region that it serves—makes
partnership essential to achieving the vision. “We will
continue to expand our Triple Aim partners until we
G enesys H ealth W orks : P ursuing the T riple A im
can engage the entire population in a new model of
care that focuses on health, not just disease, and thus
lead us toward achieving the Triple Aim in our community,” says Torres.
By emphasizing partnership in each of its
components, the HealthWorks model facilitates the
“macro-integrator” role envisioned by the progenitors of the Triple Aim—that of bringing stakeholders
and resources together to pursue a shared vision of
an optimized system of care for a defined population.
In particular, this has involved a partnership with the
Genesys PHO and the Genesee Health Plan to enhance
the primary care infrastructure for both insured and
uninsured patients. A key intervention, health navigators partner with both physicians and patients to support improved self-management and health behavior
changes that can lead to improved health outcomes.
The following sections highlight lessons learned in
these two related elements—primary care infrastructure and population health, followed by a discussion of
the tensions inherent in pursuing the Triple Aim.
Enhancing the Primary Care Infrastructure
Genesys saw early on that a strong primary care
delivery system built around a “right-sized” hospital would be essential to meeting purchasers’
demands for greater value and efficiency in health
care. To develop such a model, Genesys partnered with
physicians in private practice to develop a virtually
integrated delivery system that could help to change
practice patterns and lower costs. “It is the sincerity of
getting the engagement of the physicians . . . so that
they understand, this is not a courtesy invitation into
the operations of the health system. It does not work
like an appendage of the hospital. It is a true joint
venture,” says Mark Taylor, CEO of Genesys Health
System. He credits this partnership building with creating a culture where “turf and walls and silos become
very offensive.”
Involving physicians in decision-making and
problem-solving has been the linchpin for change.
Physicians helped to determine the appropriate
guidelines for clinical care and specialty referral. And
once those guidelines were set, the PHO reinforced
them by negotiating with insurers to obtain delegated
authority for medical management so that primary
care physicians would not be overruled by an outside
managed care organization. This clinical autonomy
appears to have given the Genesys PHO an endurance
that was often lacking in other efforts to establish the
model. “Nationally that was what was wrong with
HMOs,” James says. “They were trying to block
necessary care. In our system, you can’t override the
primary care physician.”
Creating a mutually beneficial partnership between
physicians and the hospital requires a shift in management philosophy. Many hospital CEOs who operate from a hospital-centric paradigm are reluctant to
share control with physicians, although doing so was
critical to the success of the Genesys PHO, says Taylor.
He says he warns other hospital executives not to
attempt such change if they expect to continue business
as usual. “This transformation is not possible if the
hospital leadership insists on controlling the process.
Trust is a key piece of this partnership, and having a
hospital that attempts to control the process will break
trust and cause the venture to fail.”
A peer-to-peer culture created a strong incentive for
physician engagement, as did the identification and
involvement of motivated doctors who act as peer
leaders to test and spread innovations such as the
patient-centered medical home and self-management
support. “They act as champions to help bring that
message to the next round of learners who then help
bring it to the next round of learners, so that a lot of
the engagement becomes doctor-to-doctor in terms of
adoption of a new approach,” Torres says.
The threat of constrained resources also played a
part in bringing various stakeholders together. Few
places in the U.S. suffered the type of economic collapse that Flint did when the auto industry downsized
there. That collapse precipitated an equally uncommon
18 T he  C ommonwealth F und
level of cooperation among health care providers, hospitals, and community groups to ensure that the medical system would survive to provide care. A long-term
plan, ratified by community leaders, that spells out
Genesys Health System’s commitment to transforming
care and to meeting community needs was a key step
in undertaking and sustaining change. The plan creates
“a clarity and certainty of purpose,” says Taylor.
“To treat your risk (managed care) patients one way
and treat your fee-for-service patients another way is
wrong . . . . When somebody comes into your office,
you use the same approach, which should be an
evidence-based, cost-effective approach regardless
of what kind of insurance that they have.”
Mike James, president and CEO, Genesys
Physician–Hospital Organization
Improving Population Health
A central value that guided the PHO—consistency
of care for all patients—laid the foundation for its
population-based focus. “The idea is that from a provider’s perspective, you practice medicine the same
way. When somebody comes into your office, you
use the same approach, which should be an evidencebased, cost-effective approach regardless of what kind
of insurance that they have,” James says. That same
philosophy supported its partnership with Genesee
Health Plan to ensure that the low-income, uninsured
residents could obtain basic primary care through its
network. In return, those patients were less likely to
use the emergency department and inpatient services
inappropriately, which reduces the burden of uncompensated care supported by other payers and insured
patients and thus improves overall efficiency.
Building on a strong foundation of primary care
enables a health system to more fully realize its
potential for improving population health. “We are
doing a lot of work to improve our health care delivery
[but] no matter how well you do in health care delivery that is really only a fraction of the determinants of
overall health,” Torres notes. In support, she points out
that Genesee County ranks relatively well in the state
of Michigan on clinical care, yet poorly on health status and outcomes measures (Exhibit 4). “Clearly these
data support that the fact that we need to go above and
beyond health care delivery. That [is] why we put so
much of our focus on improving healthy behaviors,”
she says.
Improving population health requires reorienting
health care delivery from acute care episodes to
chronic disease management and ultimately to prevention. This requires a concomitant shift from health
care delivery to engage the community and reach people “where they live, where they work, and where they
go to school,” Torres says. Yet, Genesys has found that
worksite wellness programs and school-based health
programs are more effective when linked to health
care delivery. “People tend to see doctors as authorities on health; you can get a lot of mileage from giving
primary care providers a role in reinforcing the health
promotion message,” she says.
The health navigators act as a bridge across
health care delivery and health improvement by engaging both physicians and patients in the effort to promote healthy behaviors and link patients with community resources. “In our health navigators’ interventions,
a significant focus is on reaching beyond the doctor’s
office to support patients in their homes and in the
community,” Torres says.
“As a health care organization, we see ourselves
as having the responsibility to help bring everyone
together and lead this effort. But we are missing an
opportunity if the message we are giving is: ‘we’ve
got medicine, we’ve got technology, we can cure you.’
That is not the primary message our community needs
to hear. The message our community needs is: ‘we
want to help you be healthier by engaging in healthier
lifestyles,’” she says. That requires engaging with community partners to change the environment to support and
promote health, a process that the health system’s involvement with Genesee Health Plan helps to facilitate.
G enesys H ealth W orks : P ursuing the T riple A im
Balancing the Triple Aim
There are inherent tensions in pursuing the Triple
Aim, requiring constant balancing to keep the
overall vision in alignment as particular objectives
need more or less attention. Congestive heart failure
provides an example. “When we improve the health
of our congestive heart failure patients through better
ambulatory care management and they don’t end up in
the hospital, the hospital loses revenue. There has to
be a conscious decision that it’s okay for the hospital
to lose revenue in this context because it improves the
health of the community,” Torres says. Taylor calls this
“an acknowledgment that sometimes we will be making decisions that will harm a part of the organization
for the greater good.”
One way to do that is to reposition the reduction
in hospital admissions as a benefit to the whole system.
The message is as follows: By lowering admissions,
the system lowers its costs, which attracts payers and
patients to the extent that they are focused on better
value. Hospital leaders also point out the hospital can’t
be allowed to shrink. If it did, “we can’t maintain the
education and research and the other component parts
that are attractive to a high-quality medical staff,” and
are of benefit to the community, Taylor says.
The solution, from the health system’s perspective, is to encourage the physician group to increase
the base for its primary care patient population from
400,000 to 500,000 people. The focus is on expanding
more into contiguous counties around Genesee County,
which are more rural and rely on smaller community
hospitals. The health system’s leaders note that the hospital would likely partner with other regional hospitals
to supplement their services to better meet the needs
of an expanded patient base and may draw relatively
small numbers of patients from several distant competitors.
Under payment reforms that encourage more
efficient use of hospitals, some health systems may
seek to follow the approach taken by Genesys to maintaining inpatient capacity by expanding the primary
care service area. These systems may face a limit in
their ability to do so, depending on their local market
conditions and the point at which efficiency gains
reach an equilibrium. Not all hospitals may be able
to undertake such a strategy, however. In either case,
some health systems may need to reduce their inpatient
bed capacity, as Genesys did early in its transformation, to realize the benefits of more efficient care patterns in reducing costs.
In summary, there are many aspects of the
HealthWorks model that make it appealing as an
approach for transforming health care delivery to better achieve the goals embodied in the Triple Aim. For
example, the model was applied in an environment of
small private physician practices that predominates in
most of the United States today, demonstrating that
achieving greater integration and organization of care
does not necessarily require an employed physician
staff model. Genesys and its partners have begun to
make progress toward achieving the goals of the Triple
Aim. They are further along than many other communities while also facing much more difficult economic circumstances. Although some aspects of their
approach may be unique, the lessons they have learned
may be transferrable to other organizations and communities that share similar circumstances and interests
in improving both care and health.
For a complete list of case studies in this series, along with an introduction and description of methods,
see The Triple Aim Journey: Improving Population Health and Patients’ Experiences of Care,
While Reducing Costs, available at
20 T he  C ommonwealth F und
This appendix describes how the Genesys Physician–Hospital Organization works to improve quality and efficiency
of care. It also provides an overview of the Blue Cross Blue Shield of Michigan Physician Group Incentive Program,
in which the Genesys PHO participates. Key elements of the PHO’s strategy have been summarized in the case study.
Physician-Directed Quality Improvement
Physicians lead committees that oversee utilization management, quality improvement and credentialing (for both
primary care and specialty care physicians), finance, electronic medical record standards, and other matters (see
Exhibit A2).
The PHO’s Quality Improvement and Credentialing Committee is composed of approximately 20 primary
care physicians who develop clinical practice guidelines for conditions such as acute pharyngitis in children, management of adults with major depression, and outpatient management of uncomplicated deep vein thrombosis,
among others. Committee members also help to implement programs to increase and document the quality of care
provided by physicians for conditions such as asthma and diabetes care, as well as screenings for breast and cervical cancer. “They are setting the guideline for 150 doctors who will be held accountable to that benchmark. They’re
very cognizant of that and there’s lots of discussion,” says Ann Donnelly, senior vice president of administration and
medical management for the PHO.
The Quality Improvement and Credentialing Committee also sets performance targets for outcomes and
management goals for these diseases and screenings after reviewing recent organizational performance and external
benchmarks, such as the 90th percentile of performance (top 10 percent of health plans) reported by the National
Committee for Quality Assurance (NCQA). Recent results indicate that the PHO is achieving rates of performance
that are better than the national average for health plans on several quality measures and better than the national 90th
percentile benchmark for some measures (Exhibit A1).
G enesys H ealth W orks : P ursuing the T riple A im
Exhibit A1. Selected Quality of Care Metrics
2009 Genesys PHO Results*
HEDIS 2009**
Managed Care
(claims data)
Breast cancer screening
Cervical cancer screening
Colorectal cancer screening
Diabetes HbA1c testing
Diabetes control

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