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"There's one other thing," Maxin said. "I noticed that your mom has a do-not-resuscitate order in her file, but your dad doesn't. Should we add it on?" I told Maxin that Dad acted as if old age were a reversible condition. He probably would want to be resuscitated. "Are you sure about that?" he asked. "You know that he broke two ribs when he fell in the bathroom last week. He's very frail. If we tried to resuscitate him, we'd probably break the rest of his ribs." This was startling but undeniable. I approved a do-not-resuscitate order for Dad. It was becoming clear to me that in the gentlest possible way, these Geisinger doctors did not mess around.
The Geisinger medical center seems almost like a mirage. It is a giant, state-of-the-art medical facility plopped down amid farmland in the town of Danville, Pa. The hospital is the mother ship of an extensive network of medical practitioners tending to 2.6 million patients in 44 mostly rural Pennsylvania counties, including the doctors who took care of my parents at the Fairways. It was founded in 1915 by a widow named Abigail Geisinger and first directed by Harold Foss, a surgeon who had been an assistant to the famed Mayo brothers. Like the Mayo Clinic, it employed a team approach, with doctors, paid as employees rather than as independent operators, cooperating on patient care. "It's like hiring a general contractor to supervise the renovation of your house," says Henry J. Aaron, a health expert at the Brookings Institution. "He brings his team of subcontractors and coordinates their work. It's a lot more efficient than finding and organizing the carpenters, the electricians and the painters by yourself."
There are good contractors and bad ones. The accountable-care-organization model--which is the emerging term of art for places like Mayo and Geisinger--was emulated in all its worst aspects when health-maintenance organizations (HMOs) emerged as a cost-cutting tool in the 1970s and then became unpopular when they became synonymous with hellish bureaucratic medical rationing. But during the years that HMOs were going in and out of fashion, a quiet revolution was beginning--the computerization of medical records. And Geisinger became a pioneer in analyzing those records to find out which sorts of treatment worked and which didn't. Over time, as the data accumulated, it has become clear that quality health care can be provided in a way that makes patients happy, with a minimum of draconian bureaucracy and for less money. "Our core belief is that about 40% of what doctors and hospitals do is wasteful," says Dr. Glenn Steele, Geisinger's president. "If you can extract that percentage of crap, you can redistribute it into savings and profits but also into procedures that actually help patients."