Making the grade: insurers are increasingly turning to The Leapfrog Group and other organizations for hospital care and safety data to help prevent medical errors and encourage better-informed health-care decisions.
Patient safety is in the spotlight because of the upsurge in medical errors. These errors claim the lives of up to 98,000 patients each year, according to a 1999 report by the Institute of Medicine, and they're a leading cause of death in the United States, resulting in more deaths annually than car accidents, breast cancer and AIDS.
A recent study reports even more startling numbers of annual patient deaths from medical errors. The HealthGrades Patient Safety in American Hospitals study, which looks at the mortality and economic impact of medical errors and injuries that occurred among Medicare hospital admissions nationwide between 2000 and 2002, said that an average of 195,000 people in the United States died due to potentially preventable, in-hospital medical errors in each of the studied years. The study looked at 37 million patient records, and this Medicare population represented approximately 45% of all hospital admissions, excluding obstetric patients, in the United States from 2000 to 2002. Health-Grades is a Colorado-based consulting firm that rates hospitals based on a variety of criteria and provides information to insurers and health plans.
Insurers are relying increasingly on quality and safety indicators and report cards to assess hospitals and medical facilities and to help prevent such errors. In addition, the measures are allowing insurers to place valuable information in the hands of members, employers and providers to help them make better informed health-care decisions.
Taking the Leap
One of the quality measures most commonly relied upon by insurers is information gathered by The Leapfrog Group, a voluntary program founded by the Business Roundtable and aimed at mobilizing employer purchasing power to alert America's health industry that big leaps in health-care safety, quality and customer value will be recognized and rewarded.
Formed in November 2000, The Leapfrog Group consists of 150 of the nation's Fortune 500 companies and other private and public health-care purchasers, such as GE, IBM, Merck, PepsiCo, Schering-Plough, UPS and Xerox--companies that provide health benefits to approximately 34 million Americans and spend more than $62 billion on health care annually. Several national health plans have also joined Leapfrog's membership over the past several years.
"A group of large employers came together after realizing that negotiating price all the time to provide coverage for employees wasn't actually sustainable long term, and they wanted to improve quality and affordability of health care ... through incentives and rewards and supporting informative health-care decisions by those who pay and use health care," said Claire Turner, a spokesperson for The Leapfrog Group. The result? They are getting better value for their healthcare dollar, she said. "And if they are improving quality, there's less waste in the system."
Leapfrog was initially focused on general quality improvement in the medical arena; however, shortly after the Institute of Medicine published its first report on medical errors, capturing tremendous public attention, Leapfrog realized patient safety was the perfect vehicle for it to adopt, said Dr. Michael Mustille, associate executive director of the Permanente Federation. "Their focus is on patient safety as an element of quality, and they seized the opportunity to look at this in a way that would have an immediate impact on both quality and cost, in addition to being compelling for the purchasing public, consumers and policymakers." Mustille was involved with the early formation of the group in the late 1990s.
Leapfrog initially developed three patient safety standards, which they call "leaps," as the focus for hospital recognition and reward. Hospitals across the United States voluntarily submit to Leapfrog's Hospital Quality and Safety Survey information about their performance pertaining to these "leaps," including computerized physician-order entry; evidence-based hospital referral, in which hospitals are surveyed about certain high-risk surgeries and conditions; and intensive-care-unit physician staffing to make sure hospitals staff ICUs with physicians specially trained in critical care. Leapfrog believes the leaps have the potential to save up to 63,341 lives and prevent between 567,000 and 907,000 medical errors each year, resulting in approximately $9.7 billion in annual savings for the health-care industry.
Leapfrog recently introduced a fourth leap. In May 2003, the National Quality Forum released its Safety Practices Consensus Report, identifying 30 practices that can have a major impact on patient safety in health-care settings. Three of the practices are Leapfrog's original leaps, and the fourth leap comprises the other 27 practices. Some examples of these practices include measuring hospitals' safety culture, the ways they prevent infections, communication among health-care workers and doctor and patient communication.
Leapfrog decided to focus on hospital care because information on performance is available though hospital reporting systems, and most hospitals collect data in a fairly standardized way, said Mustille. "Also, some evidence in the medical literature about important hospital practices shows what potential improvements in patient outcomes and costs can be made," he said.
Information in Hand
Health insurers are arming members and providers with safety indicators to help them perform various quality checks about hospitals, in addition to making more informed health-care decisions.
Leapfrog data, along with several other quality measures, is an important source of information for Blue Cross of California. The Blues plan has a link on its Web site to a site that provides information on contracted hospitals. The Leapfrog status of each hospital is noted as well as a report card with performance data about the hospitals so that members can compare the quality of care available. The health plan is planning to share information with members about high visibility surgeries, such as cardiac surgery. The goal is to establish a network of hospitals it believes demonstrate good outcomes and compliance with high-quality protocols Leapfrog and other organizations provide.
In addition to sharing Leapfrog results with consumers and using them to assist in developing high-quality/low-cost products, PacifiCare Health Systems Inc. said the data is an important ingredient used to educate providers. "It's very helpful for us to communicate not just with hospitals in terms of inpatient safety practices and programs that they should be mindful of and institute, but it's also a very important part of our initiative to educate physicians regarding the patient safety practices of hospitals to which they admit patients," said Dr. Sam Ho, senior vice president and chief medical officer.
Employer purchasers of health care are also interested in Leapfrog data. Health insurers are increasingly receiving requests for information and for proposals about their support and involvement concerning Leapfrog data.
"[Leapfrog] information makes us aware that preventable errors are occurring in hospitals and that there are things we can do to try to minimize them," said Dr. William Alexander, national quality medical director for Cigna Health Care. While each of the three initial leaps provides great value, he said that Cigna is most able to use the evidence-based referrals information. "Evidence-based referrals using volume as a proxy for quality has helped because you can see volume and look at outcomes," he said.
In addition to Leapfrog data, some insurers are relying on other hospital quality indicators, such as the Centers for Medicare & Medicaid's Voluntary Hospital Quality Initiative, in which participating hospitals report to CMS on one or more of 10 quality measures. CMS posts an online directory of participating hospitals and the first display of clinical quality data on its Web site. The Joint Commission on Accreditation of Healthcare Organizations, the American Hospital Association and the Federation of American Hospitals are also involved in the effort.
In July, JCAHO launched its Quality Check Web site designed to allow consumers and physicians to compare the quality of medical care at thousands of facilities. Patients and doctors can search hospitals in any state or ZIP code. The site grades facilities based on how consistently they deliver care proven to improve health outcomes. The site is limited at this point, displaying quality measures for only four conditions: myocardial infarction, heart failure, pneumonia and pregnancy.
Some insurers are optimistic about eventual unification of various data sources. "One of the encouraging things happening now is that Leapfrog is moving to adopt standards and measures endorsed by other national bodies like the Joint Commission and the National Quality Forum," said Tom Granatir, senior adviser, clinical health policy for Louisville, Ky.-based Humana Inc. "I see movement eventually to converge all organizations around a set of measures that everyone can agree on, and when that happens, we'll see even more hospitals reporting their data."
Many of insurers' contracted hospitals are generally making the grade.
Excellus BlueCross BlueShield, in the Rochester, N.Y., region, is noticing continued improvement in compliance by its four regional hospitals, all of which are voluntarily reporting data to Leapfrog. "At least one hospital does very well in the evidence-based area, and three of the four in the region meet the [critical-care specialist] measure," said Dr. Edgar Black, vice president and chief medical officer. Rochester is one of Leapfrog's 23 regional roll-out areas, in which its concentration of membership heavily supports reporting data.
Kaiser Permanente's California hospitals are also making the grade. More than half of its 28 facilities have already implemented Leapfrog's recommended safety practice for ICU staffing and are making good progress in implementing Leapfrog's Quality Index practices. Like many hospitals across the nation, however, Kaiser is seeing a somewhat lower score when it comes to the first leap concerning computerized physician-order entry. "Our lower scores on CPOE are due to the tight timeframe for implementing systems required in the Leapfrog standard. Our new, comprehensive electronic medical record system will more than meet the standard, but will not be fully implemented until 2007," said Mustille.
Electronic prescribing systems allow physicians to enter orders into a computer rather than in writing. The order is checked against patient information, including laboratory and prescription data, according to Leapfrog. Cost constraints are hampering U.S. hospitals' efforts to implement the technology. Many insurers, however, are hopeful that computerized physician-order entry will one day become a more common staple in many health-care facilities. One of Excellus' contracted hospitals recently announced it will be moving forward with a major computer initiative. "Our Leapfrog activities are just one piece of information that encouraged them to move forward with this initiative," said Black.
The U.S. government is spearheading a move to get hospitals and clinics to use electronic prescribing methods and databases. But not all research finds promise in computerized physician-order entry as an answer to prevent fatal medical errors. The recent HealthGrades study said that such proposals as order entry technology and electronic medical records would do little to reduce the number of medical errors.
Reaping the Rewards
Hospitals and physicians complying with safety and quality measures are reaping the rewards.
Leapfrog recently released an incentives and reward compendium--a Web-based program of 77 schemes where health plans, physicians, hospitals and consumers are being rewarded in various ways for quality compliance. For instance, physicians making improvements in quality might be rewarded through employers participating in the Leapfrog Group. Individual physicians are rewarded through the Bridges of Excellence--a not-for-profit organization created in response to a challenge by the Institute of Medicine that payments for care should be redesigned to encourage providers to make positive changes to their care processes. Established by a group of employers, physicians, health plans and patients, Bridges to Excellence offers three "links" for incentives: one for physician office sites, another that enables physicians to achieve one-year or three-year recognition for high performance in diabetes care, and another for those in cardiac care.
Businesses and consumers are also being rewarded for their quality and safety efforts. Aerospace company Boeing recently introduced a new health plan that rewards employees who enroll in a certain scheme and select hospitals that implement Leapfrog practices. Patients' bills are paid in full, therefore reducing their copay amount.
Leapfrog data plays an integral role in PacifiCare's quality pay-for-performance incentive program. Leapfrog standards are included within more than 20 measures on which the company rewards extra compensation to its physicians. "They aren't only being rewarded for their cancer-screening results or a physician's diabetes management program, but also if they admit a majority of their patients to hospitals that score well on the Quality Index Profile," said Ho. "So there is a direct correlation between incentives for doctors' own performance as well as the performance of hospitals to which they admit patients."
Health insurers are doing what they can to encourage hospitals to participate in Leapfrog's voluntary survey. In addition to putting the Leapfrog status of hospitals on its Web site, Blue Cross of California, for instance, mails letters to the management of its contracted hospitals to highlight the importance of reporting information. The health plan recently saw an 80% increase among urban California hospitals reporting public data to Leapfrog, said Dr. Michael Belman, staff vice president and medical director of quality management.
Health insurers aren't the only ones relying on Leapfrog data and related quality measures. Some medical-malpractice insurers also are keeping a close eye on the information for underwriting hospital covers.
"Because hospitals are implementing our safety and quality practices, it could possibly be used as a carrot for insurers to think about reducing premiums and rates," said Leapfrog's Turner. It gives insurers an idea of which hospitals have implemented certain quality improvements, she added.
GE Employers Reinsurance Corp. is finding that value. While the underwriting application remains the insurer's main source for health-care organization data, Dorothy Berry, vice president of clinical risk management, said Leapfrog data plays a supplemental role in providing quality indicators and assessing organizations' commitment to patient safety, quality and risk management. She's also hopeful this may one day shave time off the data submission process for both customers and the company. "As this data and other data become available, it may eventually take the burden off of organizations to fill out applications and other information to send to us because it's available elsewhere, reducing repetitive work," said Berry.
There's still concern, however, because the information is self reported and isn't audited, Berry said. "There's also significant variability in responses in its reporting. So in taking a look at that, we need to weigh the strength of where the data set is now in its response rate and compliance to these measures." While she said it's too early to draw too many conclusions from the data, she's confident that as the quality and safety measures continue to progress, companies will take a more serious look at the information when underwriting hospitals and healthcare facilities.
* Medical errors claim the lives of up to 98,000 Americans each year.
* Many health insurers are relying on hospital and physician quality and safety measures gathered from The Leapfrog Group.
* Leapfrog believes its original three standards--or leaps--potentially can save up to 63,341 lives and prevent between 567,000 and 907,000 medical errors each year.
* Insurers also turn to other quality measure data sources, such as the Centers for Medicare & Medicaid's Voluntary Hospital Quality Initiative.
Blue Cross of California
A.M. Best Company # 68970
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Cigna Insurance Group Inc.
A.M. Best Company # 68124
Distribution: independent agents, brokers, consultants
Excellus Health Plan Inc.
A.M. Best Company # 60082
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Employers Reassurance Corp.
A.M. Best Company # 06976
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Humana Health Plan Inc.
A.M. Best Company # 68898
Distribution: Agent/broker, direct to employees, direct
Kaiser Foundation Health Plan Inc.
A.M. Best Company # 64585
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PacifiCare of California Inc.
A.M. Best Company # 68705
Distribution: National accounts staff, brokers