One Giant Leap (frog) For Health Care. (Quality).

IN THIS ARTICLE ...

Fed up with skyrocketing health insurance costs, poor qualify care and low patient satisfaction, a group of powerful benefits executives from some of the country's largest employers decided to do something about it. They formed The Leapfrog Group, a coalition of companies setting out to build a better American health care system.

THEY WERE FRUSTRATED.

"All the evidence on quality shows that American health care is unreliable to a degree beyond belief," says Arnold Milstein, MD, medical director of the Pacific Business Group on Health.

So they began to talk.

Four years ago, Milstein and a handful of like-minded corporate health benefits executives started exchanging phone calls and e-mails lamenting the state of health care.

Costs were mounting.

"Whatever we're doing as purchasers, it's not getting us happy results," says Milstein, whose group is a coalition of 45 major San Francisco Bay Area employers.

Patient care was failing.

"Enrollees are grouchy. The insurance cost trend is on the rise. And quality stinks. This industry is a sick man. And are we helping? No."

Bruce Bradley, director of managed care plans covering 1.25 million General Motors workers, retirees, and dependents, was part of the group trading e-mail. So was Charles "Chuck" Buck from General Electric.

They hated the gridlock.

Employers couldn't judge quality, Bradley says. The health plans weren't tracking quality. And the patients didn't have enough information to make sound decisions about quality providers.

Soon, the discussion turned to patient safety.

"It's an issue that's much bigger than we appreciated," Bradley says.

One 1997 study, for example, found that almost one in five hospital patients experiences a serious adverse event during a stay, with the risk rising for every day of hospitalization. Those most likely to suffer a major complication due to staff error are patients in the intensive care unit. (1)

So they took action.

The group targeted three patient safety measures and put pressure on the health insurers to:

1) Require hospitals in their networks to adopt computerized physician order entry systems (CPOEs).

2) Steer plan members to hospitals and clinical teams whose volume of high-risk procedures offer the best survival odds.

3) Make sure the facilities they work with are staffing ICUs with physicians certified, or eligible for certification, in critical care medicine.

What's croaking?

The group's get-togethers were informal meetings by teleconference. But by late last year, they were ready to take their initiative public, reasoning that leadership by a critical mass of America's largest employers could jump start the effort and lure other purchasers to join.

They called themselves The leapfrog Group because they so frequently talked about the need for "great leaps" in health care quality and customer value. The health care economy, they said, was a "pond" in which health care purchasers are "frogs."

The Leapfrog Group doesn't have dues. Anyone willing to endorse the health care purchasing principles can join. Leadership rests in a bullfrog (currently Bradley) coordinating the "croaks" from various "lily pads."

Foremost is the "Governance Lily Pad," or steering committee, made up of the "Founding Frogs" that includes some very powerful corporations such as:

* Buyers Health Care Action Group (a coalition of leading Minnesota employers)

* GE

* GM

* Verizon

* PBGH

* U.S. Office of Personnel Management and the Centers for Medicare and Medicaid Services (OMS, formerly HCFA, the Health Care Financing Administration)

Ten frogs sit on the Governance Lily Pad. Occupancy is limited to health care purchasers, as are perches on the Special Focus Lily Pad that develops principles and standards for the group's initiatives.

Clinical, academic, and research experts sit on a Safety Standards Lily Pad. There are also Regional Lily Pads, uniting purchasers in defined geographical areas -- currently Atlanta, California, eastern Tennessee, Michigan, Minnesota, Seattle/Tacoma, and St. Louis.

And there are Industry Lily Pads that bring together businesses with vertical or strategic relationships, and a Consumer Lily Pad whose members consult on methods for promoting informed patient choice in health care.

Growing by leaps and bounds

In 2000, The Leapfrog Group received sponsorship and three-year funding from the Business Roundtable for a small staff. The Roundtable is an association of chief executive officers of leading U.S. corporations.

And the chorus of frogs began to swell.

Today, The Leapfrog Group claims a Fortune 500 membership of more than 80 major employers directing more than $40 billion in health care expenditures annually, Bradley says.

Their focus is a set of basic principles for purchasing health care coverage for their workforce, explains Leapfrog Group executive director Suzanne Delbanco.

Leapfrog companies will:

* Compile risk-adjusted performance information on major providers in their geographic area, either directly or through their health plans. Publish comparative ratings based on the data, both internally and on the Leapfrog Web site (www.leapfroggroup.org).

* Inform and educate their employees in a compelling and understandable way about the importance of using comparisons to make decisions about which health plans, doctors, and hospitals they should patronize.

* Reward delivery systems that achieve the highest comparative ratings. This will be accomplished by boosting patient volume through selection or deselection, enrollment freezes or lower out-of-pocket costs, raising their reimbursement using value-based bonuses, rebates, or risk-adjusted negotiation of cost targets and recognizing and trumpeting superior performance.

* Use a common request-for-proposals template for plans and providers that specifically measures implementation of three "safety leaps" -- CPOE, evidence-based hospital referral and ICU physician staffing.

* Hold health plans accountable for advancing Leapfrog principles.

* Encourage the support of benefits consultants and brokers in advocating these principles among their clients using equally strong incentives.

Planting a stake in the pond

The first comparative performance data on hospitals in The Leapfrog Group's seven target regions will be posted on the Web within the next few months, Delbanco says.

For a preview, check out the PBGH website, www.pbgh.org, where outcomes are posted for 79 of 118 California hospitals where Coronary Artery Bypass Grafts surgery was performed in 1997-98.

Note that 39 hospitals that refused to open their records -- representing about 30 percent of the state's bypass volume -- are identified by name. Under Leapfrog rules, it is presumed that these hospitals perform procedures below the optimal volume thresholds.

If The Leapfrog Group meets its goals, by December 31, 2004, those institutions will be essentially off limits to enrollees in health plans sponsored by member companies. The aim by that date is to have more than half of the group's book of covered lives seeking hospitalization at facilities that meet the three Leapfrog safety standards.

Responding to payer pressure

Although barely out of the tadpole stage, The Leapfrog Group is already making big splashes.

In Atlanta, for example, the largest hospital system, Promina Health, is installing the market's first CPOE in its seven acute care facilities over the next 36 months.

"We want be recognized as the system that has achieved the quality benchmark and grasped the future faster and better than anyone else," declares chief medical officer Robert Ryan, MD.

Promina is trying to please large, powerful local frogs such as Delta Airlines, Georgia Pacific, UPS and Verizon Their embrace of The Leapfrog Group's agenda, in conjunction with the Georgia Health Care Leadership Council, was a catalyst that accelerated investment in a $40 million, system-wide CPOE, Ryan says.

Similarly, the corporate medical director for a small Midwest health system -- a former surgeon who wished to remain anonymous -- is quietly collecting and comparing data on his system's success rates in the high-risk procedures listed in the Leapfrog initiative.

"Our hospitals are not in an area large enough t expect to get the numbers necessary," he says, "but we take it as a shot across our bow. This is the future. Payers and patients are going to demand to know outcomes. We're already in the process of putting in a computer physician order entry system.

"The value of Leapfrog is that it's letting clinicians know that the time is coming when good data are going to be forthcoming and they're going to have to take ownership of them."

The former surgeon is a big Leapfrog fan. "The Leapfrog Group is great!" he exclaims . "They're right where they should be! Unfortunately, it's probably going to take payers to drive us to do what we should be doing.

That's a theme echoed by Bradley.

"I'd be a lot happier," he says, "if the provider community were to take a much, much stronger leadership role in this."

Reactions go both ways.

"There are the foot-draggers, who give you endless reasons why things can't be done, who challenge the data and question the evidence," Bradley says. "And then, at the other extreme, there are the enlightened people, who say, 'We're embarrassed that employers ever had to bring this up!'"

The Leapfrog Group will be "focusing on the enlightened and worrying less about the foot-draggers. We'll let [the latter] show themselves for what they're worth," Bradley says.

"It's very disturbing that best practices, which are clearly known, are not being implemented. There's no excuse, for example, for CPOE not to be at the top of every hospital's list of necessary expenditures, no matter how financially pressed they are," he adds.

"There's a moral obligation here. Physician executives need to come away with a sense of urgency, a sense of responsibility!"

Practice Makes Perfect

The Leapfrog Group's evidence-based hospital referral standards require
Institutions to prove they meet the following annual procedural volumes:


Coronary artery bypass            At least 500/year

Coronary angioplasty              At least 400/year

Abdominal aortic aneurysm repair  At least 30/year

Carotid endarterectomy            At least 100/year

Esophageal cancer surgery         At least 7/year

Delivery with expected            Regional neonatal
birthweight <1500 grams or        ICU with average
gestational age < 32 weeks        daily census of at least 15

Delivery with prenatal            Regional neonatal
diagnosis of major congenital     ICU with average
anomalies                         daily census of at least 15

This information, along with reports on referrals to hospitals that meet
the evidence-based volume criteria, will be posted on the Leapfrog Web
site. Hospitals that decline to report will be presumed tom operate
below the optimal volume thresholds.

RELATED ARTICLE: What made the frog jump?

Here are three primary factors that led to the formation of the Leapfrog Group.

Errors plague U.S. hospitals. Researchers calculate, for instance, that fully half of all patients come within a whisker of receiving the wrong drug, or the wrong dosage, perhaps given in the wrong way, because of misinterpreted handwriting or failure by doctors to follow proper prescribing protocols. Luckily, most of these mistakes are not potentially serious and more than 95 percent are caught and corrected before they result in an "adverse drug event." Still, nearly 1 million patients suffer preventable ADEs annually, and some 7,000 die of them. The costly toll could be more than halved, studies have shown, if hospitals adopted computer physician order entry systems. Yet fewer than 400 of America's 5,890 hospitals have CPOE capability. (1)

Chances of surviving common high-risk elective procedures like coronary angioplasty, coronary artery bypass graft, carotid endarterectomy, abdominal aortic aneurysm repair and esophagectomy improve enormously when the operation takes place at a hospital where such complex surgeries are performed regularly and often. Similarly, low-birth-weight babies and those with congenital anomalies are much more likely to live if delivered at large regional hospitals with neonatal intensive care units. Indeed, research indicates that more than 4,000 deaths could be averted in the United States every year if physicians and health plans referred all candidates for these procedures to institutions with the high-volume characteristics associated with better outcomes. (2)

Mortality and morbidity are significantly lower in intensive care units where physicians credentialed in critical care medicine are on staff full-time or can be summoned reliably by pager within five minutes. (3) Even so, an estimated 54,000 patients die every year nationwide because no trained intensivist is on duty in or near the ICU. (1)

Leapfrog Safety Standards Could Save Nearly $10 Billion A Year, Researcher Says

Hospitals face what amounts to patient safety ultimatums from The Leapfrog Group. And while some don't mind being forced to comply, others do. Those most likely to suffer a major complication due to staff error are patients in the intensive care unit. (1)

Computerized physician order entry systems don't come cheap. A recent analysis of the economic implications of The Leapfrog Group's requirements by a team of researchers from Dartmouth and Johns Hopkins' estimated upfront costs for CPOE range from $500,000 to almost $15 million.

Factors that affect the price include the size of the hospital and the state of its existing information system. Lead researcher John D. Birkmeyer, MD, says those variables also affect the ongoing costs, which can range from $200,000 to $2 million a year.

On the other hand, savings from the medication errors and adverse drug reactions prevented by CPOE can be substantial -- from $180,000 to $900,000 a year.

Additional savings come from medication substitutions, reduced lab testing and imaging, better adherence to clinical pathways and clinician efficiency. Although these are hard to quantify, Birkmeyer says, "some hospitals which have implemented CPOE report annual savings exceeding $5 million."

It isn't just about money.

"The primary motivation for the three Leapfrog standards is not reducing health care costs, but improving quality of care," Birkmeyer says. His calculations show at least 1,250 lives could be saved if all U.S. hospitals computerized doctors' instructions.

Evidence-based hospital referrals carry economic ramifications, too.

Hospitals that lose patients because of low volume will lose revenue. Payers may realize some savings from economies of scale and perhaps experience shorter lengths of stay when procedures are performed at tertiary and quaternary facilities. But as teaching institutions, their costs tend to be higher.

While the bottom line impact of evidence-based referrals may be a wash, Birkmeyer and his associates predict that an enormous number of lives will be saved every year:

* 1,369 low-weight babies

* 494 babies with major congenital anomalies

* 1,486 coronary artery bypass graft patients

* 464 abdominal aortic aneurysm surgery patients

* 345 coronary angioplasty patients

* 168 esophagectomy patients

* 118 carotid endarterectomy patients

Staffing lCUs with doctors certified in critical care medicine will raise labor costs for hospitals, but the specialized care creates substantial savings, Birkmeyer says.

He and his colleagues calculate that reductions in inappropriate ICU admissions, ICU lengths of stay, the need for ancillary testing and treatment of complications can save small hospitals at least $800,000 each year. Those with large ICUs may bank up to $3.4 million annually.

What's more, because half a million patients die in America's ICUs each year, even a conservative estimate of a 15 percent reduction in mortality due to intensivist care in all of the nation's urban hospitals (the smallest impact shown among nine studies of the issue) indicates that 53,850 additional lives could be saved.

Birkmeyer says health economists usually peg the value of each year of life at $50,000. Implementation of The Leapfrog Group's three patient safety measures would result in a gain to the U.S. economy of $9.7 billion each year.

--David Weber

Leapfrog's Buying Power Helps Ensure Quality

When a corporation as big as General Motors wants health coverage for its employees, insurers are willing to listen.

With employees or retirees in virtually every zip code in the United States, GM works with a nationwide network of HMOs, says Bruce Bradley, director of managed care plans for the automotive giant.

Every year, GM scores its plans on quality performance based on NCQA, HEDIS/CAHPS, and its own rigorous, Leapfrog-linked guidelines. The plans are also rated on cost to see how HMO premiums stack up against GM indemnity plans for salaried employees in the same region.

The two scores (a maximum of 50 points in each category) are added. The plans are then divided into six bands tied to a different out-of-pocket contribution an enrollee must pay.

The plan with the highest score is considered the benchmark and GM kicks in more to create coverage for employees who find it financially attractive.

For example, the employee contribution for family coverage in HMO A, with a benchmark score of 77, is $35 a month.

Enrollment in Plan B, with the lowest score, 66, will cost the employee $103 a month.

That's $70 less, however, than employees shell out if they opt to enroll in Plan C, even though it had a slightly better total score of 67.

That's because Plan B outperformed Plan C on GM'S quality measures.

Bradley says the strategy pays off.

GM'S salaried employees and retirees migrated from indemnity plans to HMOs at a 3 percent annual clip, and they have progressively switched out of the poorer performing plans either to save money or because the plans are dropped by GM or enrollment in them is frozen.

"GM is probably the example of how to do this correctly," says George Isham, MD, medical director and chief health officer of Health Partners, a 660,000-member health services provider and insurer in Minneapolis. "And it may be the only example."

In the real world, sham says, most companies aren't operating that way.

For instance, employers say they want health plans to contract only with providers that demonstrate quality. Yet, on the other hand, "they want very, very broad networks, because their employees want choice. That makes it difficult to funnel patients," Isham says.

"I've spent a lot of time working with HEDIS," he adds, "and there is pretty good information on quality out there. It makes a difference when it comes time for enrollment - but relative to simple choice, it's not as strong a factor. So what's a well motivated organization to do with that conflicting set of criteria?"

What's more, he points out, heavyweight purchasers push hard for the lowest price when negotiating with health plans and they often get it. "But that means the capital and investment hospitals need for expensive things like computer physician order entry systems must come from other purchasers," Isham says.

In other words, the Leapfrog Group's patient safety requirements are being underwritten disproportionately by smaller companies lacking the clout to bid health plans down.

"Without taking anything away from General Motors, Isham says, "most of health care isn't purchased the way they do it. Oh, they have some colleagues, but it gets pretty thin pretty quick. And there are a lot of employers who aren't exactly poster boys for safety issues. If only the whole world did follow GM'S example!"

--David Weber

National Quality Forum Jumping High, Too

The Leapfrog Group certainly isn't the lone fish - or frog -in the quality-improvement pool. Another aggressive campaign is under way from the National Quality Forum in Washington, D.C.

"A larqe reason they're (Leapfroq) separate from us is a question of timing," says Kenneth Kizer, MD, MPH, president and CEO of NQF. "The Leapfrog Group wanted to move forward quickly. But the bottom line, I believe, is that we're going to be the entity that will be much more influential and important to quality in the long run."

A unique alliance of health care consumers, purchasers, providers, health plans, accrediting bodies, labor unions, supporting industries and research organizations -- more than 120 at last count--NQF was incorporated in 1999 to develop and implement a national strategy for health care quality measurement and reporting.

Funding for the NQF comes from a variety of foundations and member dues that range from $1,000 to $25,000 based on revenues. A 19-member board of directors governs NQF with four stakeholder councils:

1. Consumer

2. Purchaser

3. Provider

4. Research/quality improvement

Chaired by Gail Warden, president and CEO of the Henry Ford Health System in Detroit, the NQF board also includes John Eisenberg, MD, director of the federal Agency for Healthcare Research and Quality (AHRQ) and Thomas Scully, administrator of the Centers for Medicare and Medicaid Services.

A nine-member Strategic Framework Board headed by Donald Berwick, MD, founder of the Institute for Healthcare Improvement, in Boston, provides additional policy advice.

First out of the NQF pipeline in the next six to eight months, according to Kizer, is likely to be a National Medical Error Reporting System. It will be followed by a compendium or guidebook of patient safety practices that all acute care facilities should have in place to quality for Medicare or Medicaid reimbursement. "The Leapfrog three (safety measures) will appear somewhere on the list," he says.

"Part of our process is to try to lay out a national strategy for how all quality reporting is to be done," Kizer explains. "So the punch line is that if physician executives want to play a role in determining the things they're going to have to implement, they should be part of the Forum."

Kizer says Leapfrog is imposing standards on hospitals and health plans, but NQF represents an "equitable process" by which consumers, purchasers and providers share in deriving "a standard set of measures of health care quality with the best evidentiary base."

The ultimate effect, Kizer says, will be to reduce the reporting burden placed on providers. And that makes it even more important for physician leaders to get involved.

Bruce Bradley, director of managed care plans for General Motors and The Leapfrog Group's bullfrog, sits on the NQF's board as well as. He sees the two groups working together.

"We've got to move the nation much more rapidly down the path of quality measurement. The NQF's role is to examine the evidence. They appeal to many audiences. We (Leapfrog) are the implementation side."

References:

(1.) Birkmeyer, J.D. "Leapfrog safety standards: the potential benefits of universal adoption." The Business Roundtable, November 2000. Available at www.leapfroggroup.org/PressEvent/birkmeyer.pdf.

(2.) Pronovost, P.J. "Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery." JAMA. 281(14): 1330-1, 1999.

(3.) Andrews L.B. "An alternative strategy for studying adverse events in medical care." The Lancet. 349:309-313, 1997.