Panel 1: Consumers and Purchasers
Testimony by Steve Wetzell
Member, The Leapfrog Group Steering Committee
Executive Director, Buyer’s Health Care Action Group
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 Summit’s 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
PART 1: Background on The Leapfrog Group
The Leapfrog Group, sponsored by The Business Roundtable, hopes to mobilize employer purchasing power to initiate breakthrough improvements in the safety and the overall value of healthcare to American consumers. This voluntary program is working with large purchasers to alert America’s health industry (both directly and via health plans) that big leaps in patient safety and customer value will be recognized and rewarded with preferential use and other intensified market reinforcements.
Leapfrog's mission is to trigger giant leaps forward in patient safety, as well as in the overall quality, customer service, and affordability of health care by:
- Harnessing the power of purchasers of health care through joint adoption of purchasing principles.
- The promulgation of specific safety standards throughout the health care system, including building public awareness of the need for and availability of a small number of highly compelling and easily understood advances in patient safety.
The Founders of Leapfrog include the Minneapolis-based Buyers’ Health Care Action Group, GE, General Motors, GTE (now Verizon), the Pacific Business Group on Health, and US West. The U.S. Office of Personnel Management and the Health Care Financing Administration also participate.
Purchasers can take an important role in driving improvements in patient safety. The Leapfrog Group consists of purchasers who want to implement strategies that encourage health care providers to make breakthroughs in patient safety and reduce medical errors. In addition, The Leapfrog Group wants to identify how to teach and mobilize enrollees to become discerning consumers of health care services, making choices with an eye to protecting their own safety, and sending their own signal to the healthcare marketplace that consumers value safer care. Thus, while Leapfrog is beginning as a purchaser-driven movement, The Group hopes it will also become consumer-driven.
The Leapfrog Group’s first objective is to assemble a critical mass of large health care purchasers who commit to Leapfrog’s Purchasing Principles. They can then use their joint leverage to stimulate breakthroughs in patient safety. In Washington, D.C. on September 26, 2000, The Group will launch its national recruitment efforts at Leapfrog’s first conference for health care purchasers. Following the launch, The Group will also work to organize large health care purchasers in regional "roll-outs," where purchasers will join forces in specified geographical areas and collaborate with the other local stakeholders to fulfill Leapfrog’s Purchasing Principles and Safety Standards.
The Group expects its Purchasing Principles to:
Leapfrog Purchasing Principles
- Encourage more purchasers to conduct value-based purchasing at the health care provider level.
- Create a business case for providers of health care to make breakthroughs in the safety and overall value of the care they deliver.
- Activate consumers to choose safer care. The details of the Leapfrog Purchasing Principles follow:
Leapfrog purchasers will implement the following principles, either directly and/or through their health plans.
- Use of Comparative Rating. Purchasers will aggregate available validated performance information on their major providers of health care into comparative value ratings for their employees, irrespective of the associated insurance mechanisms. Whenever available, the performance measures will be endorsed by nationally recognized sources, such as NCQA, JCAHO, PMCC and medical specialty societies, to assure validity in performance comparisons.
Rationale: Ratings of comparative provider value will demonstrate clearly to the health industry how variations in performance cause the variations in comparative value that customers perceive. Nationally recognized sources of information will promote consistency and validity of comparisons.
- Inform and Educate Employees. Purchasers will educate employees about the importance of comparing the performance of health care providers, and assist them in understanding how to use such measures to make informed health care choices.
Rationale: Employees/consumers are central in making important improvements in the health care system. Their behavior can send powerful signals to providers about the value patients place on better care.
- Use of Substantial Incentives. Purchasers will use two or more of the following methods to reward their major providers with higher value ratings; and will annually increase their intensity until they prove sufficient to motivate widespread and substantial annual performance improvement among their major providers.
- Patient Volume. Support consumers’ selection of higher value providers via one of the following methods: (a)promotion such as "blue ribbon" designation, selection/deselection of plans/providers and enrollment freezes; (b)consumer economic incentives such as Enthoven’s model of price-conscious enrollee choice applied to providers or other methods of varying consumer out-of-pocket costs; and, (c)consumer decision support such as easily accessible and understandable performance comparisons.
- Price. Vary the prices paid to providers, based on comparative value such as value-based bonuses, rebates, and/or incorporating risk-adjustment into the negotiation of cost targets or prices.
- Public Recognition. Publicly recognize and disseminate information about providers that demonstrate superior performance.
Rationale: To motivate delivery systems to stretch for major breakthroughs in customer value, purchasers must build more robust market rewards.
- Focus on Discrete Forward Leaps in Patient Safety. In implementing comparative rating and substantial incentives, purchasers will highlight a common set of discrete delivery system improvements likely to yield the largest safety gains ("safety leaps"). These will be earmarked for special visibility in purchasers’ interaction with providers, insurers/administrators, and consumers. For example, purchasers will use common Leapfrog RFP questions to rate the implementation status of the safety leaps for their plans and providers and explicitly integrate such status information into every method used to reward superior value (patient volume, price, and/or public recognition). With expert input, The Group identified three initial safety leaps and transformed them into safety standards.
- Computer Physician Order Entry: Physician order entry in hospitals should be computerized. Adverse drug events are the leading preventable cause of avoidable death and disability in American hospitals. As documented in research by Dr.David Bates at Brigham and Women’s Hospital, computer physician order entry (CPOE) is a highly effective, discrete remedy. In well-managed installations, its costs are likely to be offset substantially by savings from avoiding the costs of treating complications, and by promoting more cost-effective prescribing.
- Evidence-Based Hospital Referral: Providers should guide patients planning on elective treatments to hospitals and clinical teams with superior outcomes, when valid comparative outcome measurement systems exist. Where outcome comparisons do not exist, such guidance should be based on scientific evidence assessing volume-outcome relationships. For many treatments, the scientific literature documents significantly superior patient outcomes in hospitals with higher volumes.
- ICU Physician Staffing: Hospital ICU care should be managed by physicians certified (or eligible for certification) in critical care medicine, who are present during daytime hours, provide care exclusively in the ICU and, at other times, can return ICU pages promptly, and rely on a certified "effector" to implement telephone orders. Current scientific evidence on strengthened ICU physician staffing models indicates that the risk of death for patients managed in such units may be reduced by more than 10%.
To maximize initial safety gains and minimize unintended negative consequences on rural health care systems, initial efforts to promote these three safety leaps will focus on urban areas, using SMSA boundaries.
The preceding safety initiatives are well suited for purchasing standards because:
- There is reasonable scientific evidence that they would significantly reduce avoidable danger.
- Their implementation by the health industry is feasible in the near term.
- Consumers can readily appreciate their value.
- Health plans, purchasers and consumers can easily ascertain their presence or absence in selecting among health care providers.
The initial selection of these three safety standards does not imply lack of support for other methods of improving or assuring patient safety. Drawing on the four criteria noted above, The Group intends to expand this list as it identifies other opportunities to improve safety.
Rationale: Of all types of quality improvement, advances in patient safety are likely to produce the most dramatic improvements in patient care and garner the widest support from the public, the media, regulators, accreditors, other purchasers and the health industry.
Hold Health Plans Accountable for Leapfrog Implementation. In advancing these principles, purchasers who utilize health plans as their intermediaries may delegate responsibility to plans for applying the principles to their network providers. If so, purchasers would hold their health plan(s) accountable via nationally standardized Leapfrog questions in health plan RFPs, heavily weighted scoring criteria, robust health plan performance incentives, and other methods of assuring successful health plan application of Leapfrog principles. Purchasers would intensify these health plan incentives annually until their largest health plans fully meet their delegated responsibility for Principles A, B, C, and D.
Rationale: Many purchasers utilize health plans as their intermediaries to health care delivery systems. Inducing health plans to apply Leapfrog principles to their relationships with providers for their whole book of business will further leverage purchaser efforts.
Encourage the Support of Consultants and Brokers. In selecting benefits consultants and brokers, purchasers will strongly incentivize them to incorporate Leapfrog principles (1) in their advice to other purchaser clients and, (2) in their standard tools for assessing health plans and delivery systems.
Rationale: The purchasing principles advocated and utilized by these advisors to purchasers profoundly shape the market experience of insurers and delivery systems. As major customers of these advisors, purchasers can motivate them to advocate these principles on behalf of all of their clients.
Purchaser Role in Supporting Safety Standards
Leapfrog purchasers will specifically commit to (1) identify for their enrollees which geographically proximate providers publicly warrant their fulfillment of (hospitals) or promotion of (physicians) each of these safety standards on a Leapfrog-designated web site; (2) provide this information proactively in a compelling and understandable way to all enrollees; (3) include a clear statement of each safety standard’s limitations; (4) assure that all enrollees in urban areas have access to providers that warrant they meet the standards; (5) utilize the Leapfrog substantial incentives detailed in Section II. C. For this, the goal is that by 12/31/04 more than half of urban hospitalizations of their enrollees occur in hospitals that offer such a warranty; (6) annually intensify their efforts until they achieve significant annual improvement in hospital fulfillment and physician promotion; and (7) cooperate with Leapfrog Regional Leaders in their largest enrollee locations to encourage the support of providers, plans and consultants/brokers.
The Leapfrog Group has an action plan that is gaining momentum among many large health care purchasers. However, it is unknown whether its efforts will succeed, or whether they are appropriately directed. The Leapfrog Group’s action plan brings purchasers into new territory. As purchasers employ innovative techniques to drive improvements in the safety and overall value of American healthcare, it is critical that resources are devoted to evaluate them. Which techniques lead to positive change? Which techniques run the risk of unintended negative consequences? Which specific improvements offer the best ratio of consumer benefit to cost?
There are multiple areas in which further research and information could potentially help health care purchasers be more effective in their efforts to reduce medical errors. The Leapfrog Group has identified six areas in which further research and information would help:
- Is there a case for purchasers to use their leverage in the health care marketplace to stimulate breakthroughs in the safety and overall value of health care? What factors make it worth their while?
- Can purchasing practices drive improvements in the safety and overall value of health care. If so, how?
- What incentives might drive health care providers to improve the safety of the care they deliver?
- How can we engage health care consumers to make more informed health care decisions?
- What is the evidence on how to make hospitals safer? How can this evidence inform purchasing practices?
- What evidence is there about how we can make ambulatory care safer? How can this evidence inform purchasing practices? What aspects of ambulatory care need further study before purchasers can identify safety measures that lend themselves to purchasing standards?
We explore each of these areas in greater depth below.
- Is there a case for purchasers to use their leverage in the health care marketplace to stimulate breakthroughs in the safety and overall value of health care? What factors make it worth their while?
The Leapfrog Group would like to learn more about the impact of medical errors on employee productivity and health, as well as on health care expenditures. Not only would this information help direct Leapfrog purchasers’ efforts to reduce medical errors, but it also would potentially help create a business case for additional purchasers to get involved in stimulating improvements in patient safety. The Leapfrog Group would like information to help answer the following questions:
- What impact do medical errors have on employee productivity and absenteeism?
- How much do medical errors increase the cost of health benefits?
- Will the implementation of Leapfrog’s safety initiatives improve employee productivity and health status and reduce health care costs?
- Will Leapfrog’s safety standards, or other initiatives to reduce medical errors, accrue added costs or cost savings to health care purchasers, to hospitals, to health plans, and/or to consumers? How would various safety initiatives affect the distribution of added costs or savings?
Can purchasing practices drive improvements in the safety and overall value of health care. If so, how?
While many individual purchasers and groups of purchasers across the country are actively shaping their purchasing practices to drive improvements in the safety and overall value of health care, there is a lot to learn about the effectiveness of these strategies. The Leapfrog Group’s regional "roll-outs" may provide a unique opportunity to evaluate different approaches. While each region will pursue similar goals using the Leapfrog purchasing principles and safety standards, purchasers in each region will choose their own tactics and employ them in different markets. There are many important questions an evaluation of these efforts could address:
- How can purchasers and consumers, as co-customers in the health care system, effectively drive improvements? Given that each group sends its own signals to the health care marketplace about how to deliver care, how can we coordinate these signals to send clear demands for improvement? What are the various degrees of influence each group has, and under what conditions?
- When is it appropriate for purchasers to activate consumers to demand improvements, versus demanding changes from the health care system directly?
- In a given geographical region, at what size or number do individual purchasers or groups of purchasers reach a mass large enough to influence the care enrollees receive, or to effect improvements in the system as a whole through purchasing practices?
- Which purchasing strategies work best in various market conditions?
What incentives might drive health care providers to improve the safety of the care they deliver?
- Are there incentives that work to encourage quality and safety improvement efforts?
- Are positive incentives (financial reward, public recognition) more effective than negative incentives (financial penalties, public criticism)?
- Are financial incentives more effective than non-financial incentives?
- How does the effectiveness of different types of incentives vary with market conditions? For example, when is it most effective to use public recognition or public reporting? When might flat financial awards be appropriate versus higher reimbursement rates? When is higher patient volume perceived as a reward?
- Can programs that require health care providers to report publicly on the quality and safety of the care they provide drive change? If so, under what conditions?
How can we engage health care consumers to make more informed health care decisions?
While The Leapfrog Group is hopeful that it will engage the power of purchasers to drive positive change in American health care, it also hopes that it can contribute to efforts to activate consumers and reinforce positive changes in the health care system with their health care choices. Employers and consumers both purchase health care, and demand from both sides for safer care will amplify the case for providers to improve the care they deliver. While some research has been conducted on how to "activate" health care consumers, there is still much to be learned.
What Information will resonate with consumers?
- What information do consumers find useful? Differences in clinical quality, safety, or the Leapfrog safety standards?
- What quality measures process or outcome will get people to select "high quality" providers?
When and how is it best to reach consumers?
- At what point after the illness/medical condition discovery can we impact a consumer’s decisions about treatment options and hospital choice? And how can we reach them at that point?
- From whom do consumers want their medical information? Who do they trust enough to deliver the information? Will consumers trust their employers?
How can we activate consumers to make informed health care choices?
What is the evidence on how to make hospitals safer? How can this evidence inform purchasing practices?
- What messages will prepare healthy health care consumers to be active when they discover they have an illness or serious medical condition, prompting them to look for information about treatment options and hospital safety ratings?
- What support tools are best suited scientifically valid and user friendly for consumers when they become active information seekers?
- Will consumers act on the information they receive or rely only on their physicians to guide them?
- What information about quality/safety would actually cause consumers to switch providers? If we are going to create a "market" for quality (to minimize the amount of regulation required) then we must have a much better understanding of what information would cause consumers to "vote with their feet." How would this information vary by segments of the population?
- What portion of the current population is prepared to be an active participant in their own medical care? What information would they use to do so? How can we generate additional "active consumers"?
- How can benefit designs encourage employees to make the appropriate choices (to be healthy and productive)?
- What levels and types of cost sharing would encourage consumers to be more active in their own decision making?
- Does increasing cost sharing encourage employees to become more active consumers? What’s enough? What’s too much? At what point (e.g., percent of disposable income) does cost sharing cause an access problem for employed individuals?
- How might consumer messages about patient care differ for the inpatient setting versus the outpatient setting?
Based on input from nationally recognized experts and researchers in quality and quality improvement, The Leapfrog Group identified three initial safety initiatives and transformed them into the standards outlined above. There are clearly other systems and processes that can reduce medical errors in hospitals, perhaps even more effectively than those The Leapfrog Group identified. A comprehensive and systematic review of the evidence on "what makes a hospital safer" would be extremely helpful to The Leapfrog Group and others. Such a review might be able to identify:
What evidence is there about how we can make ambulatory care safer? How can this evidence inform purchasing practices? What aspects of ambulatory care need further study before purchasers can identify safety measures that lend themselves to purchasing standards?
- What interventions most significantly reduce errors?
- What interventions produce the best ratio of error reduction to cost?
- What are reasonable timeframes for hospitals to implement various patient safety improvement programs?
- What role do staffing patterns play?
- How important are modern information systems?
- Does it make a difference if hospitals attempt to engage patients in their own care?
The Leapfrog Group is focusing its initial patient safety standards on in-patient care because there is much more evidence on where the errors occur and how to prevent them than for out-patient care. However, The Group plans to add to its three launch initiatives as experts identify significant opportunities to improve patient safety. The Group is eager to identify safety measures for the ambulatory setting, in part because most Americans receive care in that setting. The Group needs expert guidance to select measures that are evidence-based. To meet The Group’s criteria for safety standards, the measures should also be understandable by the average consumer, feasible with today’s technology and know-how, and easily ascertainable by purchasers. Keeping these criteria in mind, The Group would like answers to the following questions:
- What measures are well-substantiated by the medical literature to improve patient safety in ambulatory care?
- How might purchasers target their purchasing practices to reduce errors in out-patient care?
- What new research must be conducted on medical errors in ambulatory care to identify how to minimize the most serious errors?
The Leapfrog Group is grateful for the opportunity to share its views on research and information needs in the area of patient safety. As we all work to articulate a productive agenda, The Group is eager to enter into dialogue with the Agency for Healthcare Research and Quality and others who share our goals.
Current as of September 2000
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