Panel 1: Consumers and Purchasers
Testimony of Gregg Lehman, PhD,
President and Chief Executive Officer, National Business Coalition on Health
The first National Summit on Medical Errors and Patient Safety Research was held on September 11, 2000, in Washington, DC. Sponsored by the Quality Interagency Coordination Task Force (QuIC), the Summitís goal was to review the information needs of individuals involved in reducing medical errors and improving patient safety. More importantly, the summit set a coordinated and usable research agenda for the future to answer these identified needs.
Individuals were selected by the Agency for Healthcare Research and Quality (AHRQ) to testify at the summit as members of the witness panels. Each submitted written statements for the record before the event, documenting key issues that they confront with regard to patient safety as well as questions to be researched. Other applicants were invited to submit written statements.
Disclaimer and Copyright Statements
An important function of the National Business Coalition on Health is to work with our membership in local health care markets to support local market-based reform efforts. In doing so, it is important for us to be cognizant of where health care markets might be in five years in order to determine what the predominant purchasing model will be. This allows us to support and guide responsible purchaser/coalition leadership. Purchaser roles are affected by decisions made in four areas:
- Provider payment models used in the future
- Employer contribution models used in the future (i.e. defined contribution vs. defined benefit)
- Regulatory/legislative action taken (i.e. liability model)
- Consumer access to information on quality/value/price
Today, I am here to talk about safety. We believe that safety is a component of quality and we have long advocated and supported community efforts to ensure that our health care delivery system is safe, efficient, cost effective and accessible. And we believe that decisions made today about the research agenda for medical errors and safety will impact consumer access to information on quality/value/price.
The National Business Coalition on Health (NBCH), through its multi-stakeholder National Advisory Council in January, 2000, committed to five strategic "first steps" for employers and business coalitions to improve patient safety and reduce medical error. These steps are:
- Develop and support consumer awareness of safety issues.
- Support standardized voluntary and mandatory reporting efforts that will advance safety and quality issues.
- Support and demonstrate the creation of innovative financial models with the goal of rewarding providers for high quality, safe, affordable healthcare.
- Support and demonstrate the development of organizational indicators of safe practice to be used by consumers, purchasers and policymakers.
- Support the development and demonstrate the effective use of contractual standards for safety for use by purchasers.
With health care costs escalating, NBCH's 90 member coalitions who represent 8,000 employers with 30 million lives have some key points to make regarding our commitment to improving patient safety. We have long been advocates of allowing the market to work in health care, all the while cognizant of the fact that three primary features are missing: 1) information on price, 2) standardized information on quality and 3) information on outcomes. And it is our long-held belief that if you buy "value" you will, in the long run, buy right. That is why it is difficult for us to separate the issue of patient safety and medical errors from the quality equation as we leverage our buying power, market to market.
In our coalition markets, we face the challenge of 1) identifying the safety issues, 2) measuring and quantifying the improvements, 3) buying right through alignment of incentives that reward safe, high quality care.
As major purchasers of healthcare, we recognize that the groundswell to demand a safe health care system must come from consumers as well. Though the establishment of competitive models encouraged by employers creates the initial price pressure, the opportunity for selective purchasing (choice) must be most apparent with consumers.
We believe that coalitions and employers can play a major role in developing price pressure. However, the choices they offer their employees (i.e. among health plan, among systems of care, etc.) must be open to measurements of quality and safety that give the buyer a sense of security and confidence that they are "buying right".
Properly informed, purchasers can and will demand patient safety and they are in an ideal position to create a demand for patient safety with employees as consumers if they can develop the appropriate messages and media.
On behalf of the NBCH member coalitions, we appreciate the opportunity you have given us to make our recommendations on the research agenda that the Agency for Healthcare Quality and Research should embark on to build leadership and knowledge for patient safety.
I. What patient safety considerations should be considered part of contractual standards?
Adoption and use of contractual standards for safety by health care purchasers is important to the development of safe systems of care. Advocacy will get you to the door of influencing market change. But creating a demand for safety requires local influence, market to market. The presence of coalition leadership can offer sustaining energy to use purchasing leverage for implementation, execution and ongoing support of safety and medical error reporting, combined with monitoring and communications initiatives. Eventually, a local market commitment to a set of purchasing standards that consider safe practice and medical error reporting and correction becomes essential for long-term success. We believe that coalitions can use their leverage to ensure the focused attention necessary to bring pressure to bear on a local level. Once standards are set, adopted and implemented, then it would follow that one would move to reward those that meet or exceed those standards. And, holding local stakeholders accountable is not easy, as those coalition pioneers on the forefront of the quality movement will tell you.
Recognizing the influence purchasers have in local markets, several NBCH coalitions have banned together to form a group called "V8". The coalitions involved in the V8 group include Buyers Health Care Action Group (MN), Central Florida Healthcare Coalition (Orlando), Gateway Purchasers for Health (St.Louis), Colorado Business Group on Health (Denver), Greater Detroit Area Health Council (Detroit), Health Policy Corporation of Iowa (Des Moines), Midwest Business Group on Health (Chicago) and the Pacific Business Group on Health (San Francisco). With efforts coordinated by Suzanne Paranjape, PhD (GDAC) who serves as a consultant to NBCH on this initiative, the V8 group has developed a common request for information or "RFI" (RFI can be accessed on the NBCH website at www.nbch.org).
Though the common RFI includes areas that encompass multiple dimensions, I am here today to talk about the standards for safety. The RFI project is a continuous quality initiative, and this was the first year the group focused on safety. The group believes that it is critical that any focus areas for patient safety, as part of contractual standards, be founded in evidence-based research. Along with The Leapfrog Group, the V8 member coalitions focused on the following three evidence-based patient safety areas:
- Intensive care unit staffing by intensivists
- Computerized physician drug order entry
- Evidence-based hospital referrals
Research is being submitted to support the standards set by the V8 group as well as the specific standards in the RFI that speak to these areas.
The group is taking an incremental approach setting standards to ensure that they support efforts of The Leapfrog Group and those large national employers that become early adopters of this initiative. The first generation of the RFI standards for safety was established to ensure that systems of care and health plans had a safety plan in place. Therefore, those receiving the RFI for a 2000 plan year were "scored" on whether they committed to develop a work plan for safety by December 31, 2000. Dr. Suzanne Paranjape, NBCH consultant on this project, has just reported that General Motors has committed to working with the V8 group on a common request for information for health plan evaluation in 2001. As a result of this commitment, the V8 request for information (RFI) will not only be used in the V8 local markets, but also in the evaluation of the 80-plus health plans offered by General Motors to its employees. This, we believe, will create significant standardization of the purchasers' desired direction on these three key areas of patient safety.
Because the RFI is an evolving instrument based on evidence-based research, we believe that what AHRQ does in its research efforts will have a profound effect on our effectiveness in local markets. Likewise, we believe that many of our coalitions are in the position to serve as "test sites" to demonstrate the effectiveness of certain strategies that encourage and reward safe systems of care.
In order to advance the knowledge, it would be most helpful if we had a current baseline.
Each area outlines three specific opportunities for research listed as (a), (b), and (c).
I am here today to outline the direction we believe that AHRQ should take in establishing its research agenda. I have grouped my recommendations in four areas to focus research:
- Contractual Standards.
- Managed Care and Safety Issues.
- Purchasers Assisting Consumers.
- Economic Incentives: Provider Payment Strategies.
I. Research FocusContractual Standards
I(a) Do health plans currently have safety measures built in to their credentialing and contracting standards? If so, what are they?
Health plans or care systems have access and the ability to obtain data from subcontractors such as hospitals, physician groups, and individual providers. An evaluation of what current safety measures are built into the credentialing and contracting standards of health plans would be of great assistance as we look at building a demand for patient safety market to market.
As an example, in support of the Leapfrog Groups initiative, current access to data on the presence of computerized order entry systems (COE) in hospitals, the use of hospital volumes for select procedures and the presence of ICU physician staffing are essential as we work to build consumer demand for patient safety. While informed consumers may inquire about the presence of these before making a decision to access the health care system, if the network of care they have access to through their health plan does not include the "safe provider" they choose, we have a disconnect, and market perception does not match market reality.
Transitional "lags"such as I have described are sure to occur. But, if we are to advance this initiative, and work to encourage leadership and support through employers, we need to know where we are starting from. Coalitions and employers do not want to waste valuable time across the table from local health plans debating the relevance and presence of safety standards that do not meet our needs or the needs of consumers.
Likewise, knowledge of what is currently available and identification of health plans that are currently working on medical error and safety plans will allow us to focus on and promote "best practices".
I.(b) Do employers/coalitions ask health plans and systems of care to report on the existence of safety and medical error reporting plans? If so, what are they reporting?
While I have mentioned the efforts of the V8 Group and their work with the Leapfrog Group, a comprehensive knowledge of current employer/coalition awareness, willingness to adopt and ability or desire to act on safety standards as part of a purchasing strategy is needed. We must understand where we are in order to overcome the obstacles to our success as we move to encourage employer leadership and promote safe systems of care that are accountable to the consumer. If we find that purchasers are not going to adopt alternative delivery system options, it is important that our safety and medical error reporting efforts focus on these alternative delivery systems as well.
In a survey we did with a focused group of our coalition membership in preparation for this meeting, we asked, "Do you believe an overall safety program should be the responsibility of the health plan?" One respondent said, and I quote, "No. (Safety) is everyone's responsibility but generally the largest role is with the provider. Managed care organizations are not well suited to play a leadership role in this area as it wouldn't be efficient or enable full disclosure to put plans in a key reporting role."
While our coalitions' employer members adopt multiple modelssome purchasing through systems of care, some through physician group practice, and some through traditional insurancethe majority still purchase through health plans. However, this may not continue to be the model of choice. Though the need for information on quality, safety, and medical errors transcends any particular form of purchasing model, evaluating current and future trends and considering the financial models that will be used, will be of use as both a baseline and a planning tool for medical error and safety program efforts. NBCH stands ready to assist in these efforts on a market-to-market basis.
I(c) Since the IOM report was published, what has been the reaction of individual employers, coalitions, health plans, systems of care, and physician groups? Have any said groups implemented a safety monitoring/evaluation/consumer education program on a voluntary basis?
I have already discussed the influence of the IOM report and The Leapfrog Group on the efforts of the V8 group's common RFI process. What I didn't mention was that through the RFI process this year, Dr. Suzanne Paranjape and the V8 group have seen an unprecedented collaboration of local managed care plans around patient safety. For example, Michigan health plans worked together jointly to gather data for the patient safety section of the RFI and to craft a common plan to implement computer order entry (COE), ICU physician staffing, and evidence-based hospital referral in Michigan.
We have reason to believe that these success stories are being repeated, market to market. It is important for us to identify, outline critical success factors and duplicate, when possible, the approaches used by the early adopters of this movement.
II. Research FocusManaged Care and Safety Issues
There is no reason to believe that issues with medical errors and safety have anything to do with the discipline of managed care. We believe that medical errors happen in managed systems and unmanaged systemsan error is an issue that is systemic.
Currently, the majority of our member coalition employers purchase "managed care" products that offer access of health care to their employees through health plans. While health plans offer an array of services from claims processing to medical management and risk assumption, we believe that the purchaser's choice of who provides the tools can have an impact on the success of a safety program. Vendors that employers contract with to provide services in the management of their health care benefitsfrom benefit consultants and actuaries to case management, utilization review, and disease management companies to consumer empowerment groups that use internet strategies to inform consumersall have a role to play in the support of patient safety and quality initiatives overall. Please note that safety initiatives should not supplant or take precedent over quality: they should be viewed as part of an overall quality program.
NBCH, along with the Washington Business Group on Health (WBGH) and other employer groups have long called for accountable systems of care. NBCH believes that health plans have a role in maintaining provider accountability through the contracting process. The power of the contracting process and judicious use of this power is as important to health plans as it is to employer purchasers. But with the power comes the responsibility of establishing standards, holding parties accountable and ensuring continued improvements. We are concerned that if there are not consistent messages sent to providers in the area of medical error reporting, medical error resolution and quality improvement, we will risk failure. Unambiguous standards of what constitutes an overall safety program are something that health plans and employers should broadcast in a clear and concise fashion. We, therefore propose research of the following type:
II(a) Is There Currently Any System-Level Safety Information Self-Reported by Health Plans and Available, on an Ongoing Basis, to Employers and Consumers on Patient Safety?
While on the surface it would make sense that the plan would be responsible for tracking and reporting information on provider level safety and disseminating it back to enrollees and prospective customers, what we have found in the experience of local coalitions is that plan level data, not system level data is available. As in previous recommendations, having a baseline understanding of what is currently available and having a point of reference for employers and coalitions that will facilitate and create momentum for change, market to market, is important.
II(b) Are health plans, as they are currently structured, in a position (authority and span of control), to reward or penalize the providers of care on the institutional or individual level (i.e. patient safety initiatives)?
Let's assume for a moment that one entity is in control of the health care system. Now let us assume that this entity has the ability to reward or penalize those providers who have been shown to be high quality, affordable, safe and accessible providers. Clearly, if that were the case, I would not be here, and rising health care costs would not be the mantra of the 2000 elections.
Fantasy aside, as the financing of care has been divorced from the delivery of care, and the customer (or end user) has been separated from the decision making process by his/her employer and his/her doctor, how do we know that health plans, as they are currently structured, are the most appropriate vehicles to encourage, promote, reward, ensure and communicate safe systems. Will we build a demand for steerage to safe/quality systems of care through such an approach?
As many of our coalitions have shown, there are other models out there that may show promise as we move carefully and responsibly into direct contracting with physician groups, integrated delivery systems and products on the horizon brought to us by e-health companies. NBCH member coalitions stand ready to demonstrate effectiveness of alternative models that are patient-focused that integrate the financing and delivery of care, empower the consumer and result in price stability.
II(c) What are the incentives for health plans to ensure that patient safety measures are in their contracting strategy?
I have already addressed the need for employer/coalition leadership in the adoption of contractual standards for patient safety. But, it is important for us to determine if there is a business case for health plans adopting contractual standards with health care providers for medical error reporting, medical error correction and patient safety. Implicit in the establishment of safety standards through purchaser contracting with health plans and systems of care is the monitoring of such programs, the tracking of their success and the adoption of a continuous quality improvement process. This, by its nature, requires investment in time, human and capital resources and a fundamentally different way of doing business. It is important that we understand what the incentives are for the development of medical error reporting systems, patient safety programs and continuous quality improvement initiatives that spring from these efforts.
III. Research FocusPurchasers Assisting Consumers
III. (a) What will aid and facilitate development of consumer awareness of patient safety issues?
It appears that most of the work in the area of purchasers providing information to employees (consumers) has been in the development of messages and the media to deliver them. For example, FACCT, acting on behalf of The Leapfrog Group, has developed some specific basic messages for employees and made some recommendations for dissemination of the information. In addition, the QuIC Consumer Information Work Group has developed "Five Steps to Safer Healthcare", from some of the FACCT background work.
FACCT and The Leapfrog Group collaborated on the development of a packet to help employers explain to employees their interest in improving health care safety and what employees can do to receive safer care. The information in the packet is based on some research over several years, primarily in the form of focus groups of consumers. Most of the research was done for the purpose of testing certain principles and specific messages. However, FACCT emphasizes that the messages have not been tested in final form with consumers.
FACCT draws the conclusion that medical error and patient safety are not well understood by most Americans, but there is little specific quantitative data to pinpoint what consumers know now about patient safety and what degree of importance consumers place on patient safety, especially when they are not in need of medical treatment of any kind. Moreover, there seems to be little or no information about the fears consumers do or do not have in the area of patient safety for themselves and their families.
A qualitative assessment of the issues involved in giving consumers knowledge about patient safety and speaking to their fears about safety would establish the framework for a nationwide quantitative assessment of specific knowledge and fears which need to be addressed.
The data gained in this research would be invaluable to those involved in developing a comprehensive plan to communicate with employees and consumers about patient safety and would help to ensure success in educating these audiences.
III. (b) What information is currently being distributed (through coalitions) to consumers on medical errors and patient safety, and does it impact their purchasing decisions?
Our informal survey with coalition leaders gave us some excellent insight as a basis for further research about how consumers can use information to participate in and to some degree control their own safety in the health care environment.
One respondent said that instruction on how to be responsible for one's own health is the starting point. This instruction could include questions to ask health care providers and information that patients are expected to supply to providers. On a more complex level, other respondents felt that consumers should know the volume of procedures done at particular facilities and the success and failure rates of such procedures. And, some felt that consumers should know whether a facility has computerized physician order entry and that perhaps consumers should have standardized reporting in the same or similar form as that of NCQA.
FACCT and The Leapfrog Group recommend stimulating interest in medical errors, patient safety and health care quality first so that consumers will want to have help in making safe health care decisions. They also warn that you cannot exhort people to take action without giving them the tools to make the best decisions. There seems to be little or no data about the influence of patient safety information on consumer purchasing decisions.
While the consumer messages developed by the QuIC Consumer Information Work group are useful in telling the consumer what questions to ask, it does not give any guidance as to how to determine whether a particular provider is more "safe" than others.
All in all, there is a consensus that consumers need to know how to take charge of the quality of their own health care, and employers need to know how to help them. The need for more qualitative and quantitative research to find out what consumers already know and what they need to know about patient safety to make wise purchase decisions is obvious from the information we have gained from coalition leaders, employers and even communicators.
III. (c) Are employer coalitions appropriate sites for the collection and dissemination of consumer information on patient safety?
FACCT and The Leapfrog Group found through their research that most people don't think about patient safety issues much. Generally, they believe that someone else has made sure they will get safe care when they need vital or even risky health care services. One respondent in our survey said most of us don't pay attention until we are about to have a medical procedure and find out our health plan won't pay for it because it doesn't fall within established standards.
Another coalition leader said that patients need to have information on proven, safe medical practices and information on lives saved and errors avoided by "safe" providers. The overriding question, however, seems to be how to get this kind of information to consumers "just in time" for them to make the right decision about specific health care services they need immediately.
There is general consensus that most consumers aren't listening to safety messages during open enrollment when they're choosing their health plans and when they're overloaded with information. Moreover, consumers want the information only when they need it, and that is often at the point of crisis. There is a school of thought that suggests that consumers will pay more attention to safety at this crisis point if they are properly informed and educated beforehand at their workplace. However, there seems to be little or no qualitative or quantitative research to document this premise at this point in time.
There are literally hundreds of communications tools and techniques, including the Internet, that could be used to give consistent education and just-in-time information to consumers. However, the process of message and media development, especially as to how to answer consumer questions in times of medical crises, is unclear and needs to be established by more research in this area.
Research FocusEconomic Incentives: Provider Payment Strategies
IV. (a) What are the current reimbursement mechanisms that work to reward "unsafe" practices?
At the NBCH Advisory Council meeting last January, participants focused on whether purchasers should offer incentives or disincentives to make sure that health care systems provide safe, quality care. In the case of General Motors, for example, if the brake lights from a vendor have an error rate that is unacceptable, that vendor doesn't continue to get business from General Motors. In general, the same standards do not apply to health care transactions.
Billions of dollars are spent because of medication errors alone every year. Since these are avoidable costs, many questions need to be answered as to how coalitions, employers and other purchasing groups should confront the issue of financial models for providing incentives or disincentives for providing or not providing safe, quality care.
Health care purchasers recognize that there must be accountability on the part of providers, and probably health plans, when it comes to paying (or not paying) for the quality (or the lack thereof) for which they pay. However, much more research and work is needed to develop the right standards for reporting and measuring safety (as a part of quality) before this accountability becomes a reality.
IV. (b) What incentives are necessary to encourage employers to support, on an ongoing basis, purchasing strategies that reward for safety?
While the V8 Group has a section on financial models in its RFI for plans and systems of care, the information sought does not speak to performance-based reimbursement that might have bearing on incentives for patient safety and effective outcomes.
Health care purchasers need to know whether financial incentives and/or disincentives would get the attention of providers and systems of care to the extent that safety and quality would be more important to them than they are now. Issues surrounding payment of services that produce poor quality and our ability to identify and measure such quality are already of paramount importance to purchasers. But there are few, if any, financial models that can be used to test, if not affirm, the effectiveness of payment (or non-payment) for performance as measured in quantified quality.
Secondary research to determine if there are financial models that demonstrate effectiveness or ineffectiveness of incentives and/or disincentives in measurable patient safety improvements is certainly in order. However, also needed is primary research, perhaps in the form of testing specific financial models with a control group of providers and health systems to determine whether financial incentives and/or disincentives are likely to be worthwhile in measuring and then improving patient safety and ultimately reducing costs for purchasers.
IV. (c) If there were economic incentives and disincentives for providers, would quality matter more?
There is very little information available about the use of incentives for providers and health plans which may (or may not) lead to increased attention to patient safety and thus quality health care.
In the NBCH preliminary survey for this testimony, one coalition leader suggested a demonstration project aligning physicians and other providers and employers on a community level to test the effect of financial incentives on medical errors and quality health care delivery.
The outcomes of such a project could form the basis for broader, more quantitative research to determine specifically how financial incentives/disincentives might make patient safety a priority for providers at all levels.
Current as of September 2000
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