Will the Institute of Medicine report-thumping Leapfrog Group change the way you run your hospital?
"It's like when I was a kid and my father used to say, `I can't make you do anything, but I can make you wish you had,' " says one hospital association executive of the purchaser-driven movement, which is on the verge of beginning its initial rollout.
Within the next month in seven targeted regions around the country, the Leapfrog Group, a coalition of Fortune 500 companies and leading purchaser organizations, will begin asking approximately 900 hospitals questions such as how they process medication orders, how they staff their intensive-care units and how many open-heart surgeries they perform each year. By fall, the information collected will be available to millions of hospital-picking beneficiaries through a Web site. The next step may include tweaking copayment levels enough to encourage employees to use the hospitals that meet the standards purchasers have set.
Although cautious not to state it so bluntly, the purchasers are fed up with hospitals' lack of action following the IOM's world-rattling 1999 study that determined that preventable mistakes in hospitals are the nation's eighth-leading cause of death.
As industry consultant Michael Millenson of William M. Mercer says, "It's become the elephant that can no longer be hidden under the rug." General Motors Corp., which covers more than 1.2 million employees, retirees and their families, extrapolated from the IOM data and found that hospital mistakes kill an average of one to two of its beneficiaries every day.
Last November, the well-heeled Leapfrog Group used public relations giant Porter Novelli to announce its plan to make a "business case" for hospitals to actually do something about patient safety. Leapfrog, sponsored by an association of U.S. corporate chief executive officers called the Business Roundtable, started with a membership of 60 purchasers providing healthcare benefits for 20 million Americans and has since grown to 80 members with 25 million beneficiaries.
The initiative started in fall 1999 when GM Chairman and CEO Jack Smith, having seen an internal report that related the medical-error crisis to the GM population, petitioned his fellow members of the Business Roundtable to fund Leapfrog.
The hospital industry doesn't argue with the worthiness of the group's lifesaving crusade, but says the standards, which focus on process measures rather than patient outcomes, are wrong--too narrow, too expensive and simply not feasible to implement.
Depending on whose perspective you consider, the Leapfrog standards are somewhere between "setting the bar high," as the group says, and being completely out of touch with reality. Providers say no off-the-shelf computer physician order- entry systems for processing medication orders are available. They also say there are not enough specially trained physicians to supply demand if every hospital with an intensive-care unit decided tomorrow it wanted to have that department managed by intensivists.
The potential untidiness of surmounting those obstacles, some hospital officials quietly predict, may be enough to derail the buyers' noble efforts. Purchasers have a history of getting bogged down in the messiness of defining quality expectations, tracking outcomes and holding providers accountable.
Both sides publicly extol the virtues of working together to solve a crisis that takes as many lives every day as a 747 jet crash. But this effort by big business represents the first time purchasers have gone so far as to tell hospital administrators how their computer systems should be set up, who should be running their patient-care units and how many procedures they should be doing.
Brilliant plan, tragic situation
"I would say it is brilliant," Watson Wyatt Worldwide senior consultant Helen Darling says of the Leapfrog Group's strategy. Though some may nitpick about how the group is going after its objective, Leapfrog has "picked things that for the most part nobody in the field is arguing about," Darling says.
But hospitals are arguing. "We do have concerns about the approach the Leapfrog Group has taken," says Carmela Coyle, senior vice president of policy at the American Hospital Association. "It could end up misleading consumers."
Coyle says Leapfrog's three-standard approach--regarding computerized physician order- entry systems, physician management of intensive-care units and number of certain high-risk procedures performed--fails to include such basics as whether the hospital is accredited by the Joint Commission on the Accreditation of Healthcare Organizations or the credentials of its medical staff members. She worries that consumers may base their assessment of a hospital's safety on Leapfrog's three benchmarks alone (See chart, p. 32).
Other hospital leaders have faulted Leapfrog for relying on measures that focus on the process of providing care, rather than on the clinical outcomes of patients using the facility.
"I think the concern that the hospitals have is that while the standards seem to make sense and people are fairly comfortable with some of the volume standards, it would be much better to have some kind of outcome measures," says Nancy Auer, M.D., vice president of medical affairs at 601-bed Swedish Health Services in Seattle.
Leapfrog's leaders, however, say the process approach makes the most sense given difficulties with agreeing upon and using severity-adjusted patient outcomes measurement systems. Leapfrog Executive Director Suzanne Delbanco says she looks for the group to move to outcomes-based approaches as the initiative evolves, but values the consensus of support around the process measures they've picked. She describes the use of computerized physician order-entry systems as the current "gold standard" in the industry for preventing medication errors.
According to the Leapfrog Group's literature, the three standards combined have the potential to save up to 58,300 lives annually.
Some see the concerns raised by hospitals--whether around the process nature of the standards or their limited scope--as more foot-dragging and inability to bring about any meaningful changes in the wake of the first IOM report. The IOM published a second report on the inconsistent quality of care in the U.S. healthcare system in March.
"It is a tragedy that it takes the employers to make this happen," Darling says.
Industry groups point to a variety of tactics they have used to address the patient-safety issue. The AHA has produced a series of advisories to senior executives and has developed several learning tools for hospital staff to use to improve patient-safety practices. Premier, a group purchasing organization based in San Diego, has more than 400 hospitals participating in an effort to design ways to reduce medication errors. The VHA hospital alliance based in Irving, Texas, conducts 16-month workshops in which 200 hospitals have participated to develop strategies for safer medication practices.
"It is totally inadequate, what they are doing," Darling says.
Purchasers are unapologetic about being prescriptive in their dealings with hospitals. Jim Astuto, a regional healthcare manager in Atlanta for Verizon Communications, says the approach is common among business partners. "You think Delta Air Lines doesn't tell Boeing what it wants in its planes?" he asks.
Leapfrog's effort to create a business case for patient safety will be a switch for the hospital industry that historically has been financially rewarded for increasing volume and reducing length of stay, not taking extra measures to guard against errors.
"In many cases hospitals have not taken the steps that they ought to have taken, but there have not been the incentives in place to get them to push safety," says Peter Lee, president and CEO of the Pacific Business Group on Health, a healthcare purchasing coalition in San Francisco with 45 members.
Some industry leaders agree. "We need to be pushed as an industry, and this is what that does," says Craig Becker, president of the Tennessee Hospital Association.
Growing in `an organic fashion'
Though Leapfrog will have a national presence and commitment, its implementation is taking on a decentralized, regional flair.
The seven pilot regions include Atlanta, California, Eastern Tennessee, Michigan, Minnesota, Seattle and St. Louis. Delbanco, a former senior manager with the Pacific Business Group on Health, says these regions were chosen because of local interest and the existence of structures, such as purchaser coalitions, that allow healthcare buyers to effectively work together.
Included in the first wave are some of the nation's best known healthcare purchasing coalitions--Pacific Business Group on Health, Buyers Health Care Action Group in Minneapolis and Gateway Purchasers for Health in St. Louis--as well as some of the nation's largest employers--GM in Detroit and Boeing Co. in Seattle.
Leapfrog will assume a unique identity in each area, Delbanco says. The leadership will be different, sometimes consisting of coalition representatives or employer representatives, and sometimes a combination. Also, each local Leapfrog Group will develop a way of communicating with purchasers' employees and create plans to "recognize and reward" hospitals that are meeting the standards.
But the timelines for phase one will be coordinated nationally. In June, the regional groups will invite hospitals to complete a 22-page survey available on Leapfrog's Web site--www.leapfroggroup.org. The survey includes questions such as "What percentage of your hospital's total medical orders are entered by physicians via a computer system linked to prescribing error-prevention software?" and "What is the percentage of time physicians on call for ICU patients return pages within five minutes?"
By fall, purchasers' employees and the public will have access to a database on Leapfrog's Web site that will show to what extent hospitals are complying with the standards, or not responding to the questionnaire. Purchasers will either direct their employees to the Leapfrog Web site or possibly publish their own literature to share the hospital findings.
Providers that comply with the standards will be rewarded with more market share or higher reimbursement, or be recognized publicly. Both Astuto and Bruce Bradley, GM's director of managed-care plans, say they look to make compliant hospitals less expensive for their employees. Whether the strategies are viewed as a carrot or stick, the ultimate goal is clearly to get the attention and action of hospitals.
"If they find over time that they (the incentives) are not creating any change, then they will need to intensify their efforts," Delbanco says. "We are going to keep sort of turning up the volume until we can be effective."
Purchasers assure that the push forward will be reasonable. "The goal of Leapfrog is not to expect that every hospital will by tomorrow have in place (computerized physician order entry), for example," says Lee of the Pacific Business Group on Health. "Leapfrog set the bar high enough that we know it will make a difference in saving lives, and it is something hospitals will shoot for next year and the year beyond."
The role of the health plans, typically the middlemen between purchasers and hospitals, is also up to regional design. Some industry representatives worry that insurers may be left to pressure providers into making the changes desired by the Leapfrog purchasers.
Delbanco predicts insurers will be used primarily as collectors and disseminators of information, but at least one industry leader disagrees. "I think that the plans are going to be asked to be enforcers or the police, and I think that design won't work," says Cleve Killingsworth, president and CEO of Health Alliance Plan, a managed-care organization in Detroit. "Health plans are playing a key role in partnering with physicians and hospitals to advance the Leapfrog quality agenda."
Delbanco could not say where the Leapfrog movement will go next after the first phase, but she stresses that over time it will have a national presence. She anticipates that "natural regions" will emerge and the movement will grow in what she describes as "an organic fashion."
Today, most U.S. hospitals are not in compliance with the Leapfrog Group's standards. Coming into compliance will cost some organizations millions of dollars in capital costs and ongoing staffing expense.
Only about one-third of hospitals have computerized physician order-entry systems available, and only 5% of those hospitals require that physicians use them, according to a study completed in 1998. Based on various estimates, the systems are likely to cost most hospitals more than $1 million. David Bates, M.D., chief of general medicine at Boston's Brigham and Women's Hospital, says it would cost about $5 million to buy and install a computerized physician order-entry system in a large hospital. Bates says the system he was involved with creating at Brigham and Women's cost $1.4 million to develop internally in 1993 and has an annual maintenance expense of about $500,000.
Though Bates says the system pays for itself with cost savings to the organization of between $5 million and $10 million annually, its long-term value still doesn't help hospitals overcome the staggering upfront costs.
As hospitals live on "margins so slim you could pinch them between your fingers," Swedish's Auer says, the need to comply with Leapfrog's standards represents a major economic challenge to many organizations. "They are what one wants to call an unfunded mandate," she says.
But cost isn't the only issue; computerized physician order-entry systems tend to be custom-made products, which need to be specifically designed to fit into a hospital's complex patient information systems. "(Computerized physician order entry) is not simply a piece of software that you buy off the shelf and plug into an existing computer system," says the AHA's Coyle.
The expense or the lack of a true industry standard will not deter Leapfrog from making it a priority, however. "The fact is that there are hospitals out there doing it," Delbanco says. "It's not easy, but it is doable."
There are similar problems with using intensivists to manage ICUs. Leapfrog reports that only about 10% of ICUs in the U.S. would meet its ICU physician-staffing standard today. Leapfrog-commissioned research shows that hiring the 1.9 full-time-equivalent specially trained physicians needed to manage a unit would cost a facility $543,000 in annual salary and benefit expenses. While studies indicate the hiring will result in savings to more than cover the cost, there is a shortage of physicians to pull it off.
"There are not enough trained intensivists in the country to do what they want to do," says California Healthcare Association spokeswoman Jan Emerson. Further complicating the issue, says Emerson, is that California has a law that prohibits hospitals from directly employing physicians.
Delbanco maintains that only one in three doctors nationally with training in critical-care medicine are using their skills as intensivists in ICUs. So the supply issues aren't as dire as some depict, she says.
Will purchasers pay hospitals to buy computerized physician order-entry systems and hire intensivists? Purchasers such as Verizon's Astuto and GM's Bradley say they don't rule it out, but their preference is to see these expenses become part of hospitals' normal capital or operating budget process, rather than end up as some sort of "carve out" that the purchaser pays.
Astuto has a standard response when hospitals say they can't afford computerized physician order entry: They're asked if they have a computerized billing system. "When they say yes, I say, `Where did you get the money for that?' " he says.
Leapfrog's evidence-based hospital referral standard, derived from research showing that higher volume means better patient outcomes for some high-risk procedures, may be especially costly for some low-volume hospitals. Facilities that don't perform enough coronary bypass graft surgeries, coronary angioplasties, deliveries of low-weight infants or other identified procedures will not be used by Leapfrog purchasers for those services. Leapfrog says this standard won't apply in rural areas, where the only providers in some regions may have low volumes. Also, the group says purchasers will use risk-adjusted outcomes data to evaluate providers, instead of volume standards, in areas where it is publicly reported.
It's a bitter pill for hospitals doing less than the standard that don't have publicly reported patient outcomes to help make the case that their quality is comparable to their larger competitors. Delbanco acknowledges the group's methods for evaluating hospitals on safety aren't perfect, but they provide what purchasers have determined is a fair place to start.
"Ultimately, I think the patient is the unit of analysis we need to focus on," Delbanco says. "The question we all have to ask ourselves is, where would we want to go?"