Update from The Pond

1
Update from The Pond
Founded By The Business Roundtable with Support
From the Robert Wood Johnson Foundation
Greg Belden, Senior Program Associate
gbelden_at_leapfroggroup.org June 18, 2004
2
Populating the Pond

• Leapfrog represents..
• More than 155 large health care purchasers
• More than 34 million Americans
• More than 62 billion in health care expenditures

3
Leapfrog Members to Date

• Ford Motor Company
• Gateway Purchasers for Health
• General Electric Company
• General Mills, Inc.
• General Motors Corporation
• Georgia Health Care Leadership Council
• Georgia-Pacific Corporation
• GlaxoSmithKline
• Greater Milwaukee Business Group on Health
  and the Health Care Network of Wisconsin
• Hampton Roads Health Coalition
• Hannaford Bros. Co.
• Healthcare21 Business Coalition
• HealthPartners
• HealthPlus of Michigan
• The Health Action Council of Northeast Ohio
• Health Alliance Plan (HAP)
• Health Care Payers Coalition of New Jersey
• Health Language
• Health Net Inc.

ATT Aetna Inc. Allscripts Healthcare
Solutions American Century Services Corporation
American Federation of Teachers American Medical
Systems American Re-Insurance Company AmerisourceB
ergen Corporation ArvinMeritor,
Inc. AstraZeneca The Auto Club Group Aventis
Pharmaceuticals Inc. Barry-Wehmiller Group,
Inc. Bath Iron Works Corporation Becton,
Dickinson and Company (BD) Bemis Company,
Inc. Bethlehem Steel Corporation Board of
Pensions of the Presbyterian Church
(U.S.A.) The Boeing Company Brown Shoes Buyers
Health Care Action Group Cargill, Inc. Carlson
Companies Caterpillar Inc. Ceridian
Corporation Cerner Corporation Charter
Communications Chicago Business Group on
Health CIGNA Corporation CITIGROUP INC. Cleveland
State University Colorado Business Group on
Health Comerica The Commonwealth of Massachusetts
Group Insurance Commission Coors Brewing
Company Cummins Inc. DaimlerChrysler
Corporation Dallas-Fort Worth Business Group on
Health Delta Airlines, Inc. The Department of
Employee Trust Funds and State of Wisconsin
Group Insurance Board The Doe Run
Company The Dow Chemical Company Eastman Kodak
Company Eclipsys Corporation Electronic Data
Systems Eli Lilly and Company Empire Blue Cross
and Blue Shield Employer Health Care Alliance
Cooperative (The Alliance) Employers Health
Coalition ESCO Technologies, Inc. Excellus
Inc. Exxon Mobil Corporation FedEx
Corporation Fidelity Investments Fisher
Scientific International Flint Ink Fleet Boston
Financial
National Rural Electric Cooperative
Association Nevada Health Care Coalition New
Jersey State Health Benefits Program New York
Business Group on Health North Carolina Business
Group o Health, Inc. North Carolina Teachers and
State Employees Comprehensive Major Medical
Plan Northwest Airlines, Inc. Olin Corporation,
Brass Winchester Divisions Oxford Health Plans,
Inc. Pacific Business Group on Health Pediatrix
Medical Group Inc. PepsiCo Pillsbury
Company Pitney Bowes Inc. The Procter Gamble
Company Promina Health System, Inc. Quality
Systems Inc. Quest Diagnostics Qwest
Communications International Inc. Ramsey
County Reliant Energy, Incorporated Robert Wood
Johnson University Hospital Robert Wood Johnson
University Hospital at Hamilton Ryder
System, Inc. Savannah Business Group Schering-Plou
gh Corporation Siemens Corporation Solutia,
Inc. South Central Michigan Health
Alliance Southern California Schools Voluntary
Employees Benefits Association Sprint
Corporation State of Kansas Division of Personnel
Services SUPERVALU INC. TCF Financial
Corporation TI Automotive TRW Inc. Target
Corporation Tennant Company Textron Inc. Trinity
Health Plans Tri-State Business Group on
Health Tufts Health Plan Union Pacific
Railroad Union Pacific Railroad Employees Health
Systems UnitedHealth Group United Parcel
Service University of Maine System Verizon
Communications WEA Trust Washington Mutual
Bank Washington State Health Care
Authority Wausau Benefits, Inc. Wells
Fargo Wiseman and Associates Financial Services,
LTD Xcel Energy Xerox Corporation The U.S.
Office of Personnel Management (OPM) Centers for
Medicare and Medicaid Services (CMS) the
Department of Defense and Minnesota Departments
of Human Services and Employee Relations also
participate as liaison members.
4
Why Isnt Quality Better?
Providers Not Seeing Case for Reengineering
Insurers Not Letting Provider Value Show Through
Purchasers Not Buying Right, Toxic Payment System
Consumers Not In the Quality Game
Gridlock in the Health Care System Everyone
Responsible, No One Accountable
New Thinking Needed to Leapfrog Gridlock
5
The Silent Calamity

• Needless mortality and morbidity
• 44,000-98,000 plus deaths each year from medical
  errors during hospitalizations (IOM, 1999)
• 7,000 deaths from medication errors alone
• 17-29 million in added costs
• Number of avoidable deaths in ambulatory care
  unknown

6
Preventable Deaths Personalized The General
Motors Example

• US Population 250,000,000
• Preventable deaths per year 98,000
• Preventable deaths per 100,000
• Americans per year 39
• GMs covered lives 1,250,000
• GMs preventable deaths
• Per year 488!
• Per day 1.3!

7
The Costs of Poor Quality Care

• Patients, on average, receive recommended health
  care only 55 percent of the time (McGlynn et al.
  2003)
• 30 percent of all direct health care outlays are
  the result of poor care (misuse, underuse,
  overuse, and waste) (Juran Institute/MBGH 2003)

Employers Fund U. S. Health Care System The
Buck Starts Here
8
How Are Employers Responding to Rising Costs?
Source Hewitt Associates, 2002 Kaiser/HRET
Survey, 2003
Less than 15 of employers think these changes
will be very effective.
9
The Leapfrog Groups Mission

• Trigger giant leaps forward in the safety,
  quality and affordability of health care by 
• Supporting informed health care decisions by
  those who use and pay for health care  
• Promoting high-value health care through
  incentives and rewards

10
Leapfrogs Mission and Vision Aligned with IOM

• Pursuit of Comparative Excellence
• Measuring both hospital and physician
  performance across all 6 IOM Health Care Aims
• Timeliness
• Efficiency
• Safety
• Effectiveness
• Equity
• Patient-centeredness

11
Purchasing Principles

• Educate and inform enrollees
• Compare at the provider level
• Reward superior provider value
• Patient volume (select/deselect/freeze,consumer
  incentives, consumer decision support)
• Unit price (pay for performance)
• Public recognition
• Highlight tangible, evidence-based quality and
  safety practices (Leaps)

12
Criteria for Safety Leaps

• Whats the Difference? Leap will produce big
  improvement in safety
• Value Self-Evident Leap can be appreciated by
  consumers
• Feasible Now Implementation steps are doable
• Easily Ascertainable Purchaser or health plan
  can see if Leap is in place
• Keep the List Short Leaps can be remembered

13
Initial Quality and Safety Leap Summary

• An Rx for Rx
• Computer Physician Order Entry (CPOE)
• Up to 8 in 10 serious drug errors prevented
• Sick People Need Special Care
• ICU Daytime Staffing with CCM Trained M.D. live
  or via tele-monitoring, or risk-adjusted outcomes
  comparison
• 29 mortality reduction (JAMA, 11/02)
• The Best of the Best
• Evidence-based Hospital Referral (EHR) or
  risk-adjusted outcomes comparison
• gt 30 mortality reduction for 7 complex
  treatments
• New! Overall Safety (See Appendix)
• Rolled-up score of the remaining 27 of the 30 NQF
  Safe Practices (CPOE, IPS and EHR are the other 3
  of the 30 NQF Safe Practices)

14
What We Stand to Gain from Initial 3 Leaps Alone?

• Annual Gain Projected by Dartmouth
• ? 560,000-907,000 serious medication errors
• ? 61,700 deaths
• ? 61,700 X 5 disabilities
• Potential savings 9.7 billion / year
• (if fully implemented in U.S. urban hospitals)

15
Leap Refinement Creating More Sophisticated
Measures

• CPOE Online evaluation tool developed by First
  Consulting Group
• ICU Staffing Joint project with JCAHO to
  develop risk-adjustment methodologies and
  reporting program e-ICU (telemedicine) now
  applicable
• Evidence Based Hospital Referral Seeking
  additional sources for outcomes reporting

16
Our Approach to Measure Development
Implementation

• Collaborate with measure developers
• CMS, AHA, AHRQ, NCQA, JCAHO, others
• Seek consensus on breadth and content of
  measurement set
• Advance measures through NQF for consensus
  approval
• Develop rapid implementation strategy with key
  partners

17
Leapfrog Leaps, Today and Tomorrow

• Today Hospitals
• CPOE, IPS, EHR, NQF Safe Practices
• Tomorrow Hospitals and Physician Offices
• Physician Office Clinical Decision Support (See
  Appendix)
• Initial development coordinated with HHS,
  awaiting outcome of HHS-led push toward
  nationwide EMR implementation
• Minimum standards E-prescribing, E-lab results
  management, and E-care reminders
• Already in practice- CMS DOQ-IT, Bridges to
  Excellence Physician Office Link

18
Leapfrogs Position on EMRs

• Leapfrog supports the promotion and use of
  electronic data to protect patient safety and
  quality and recommends that hospitals implement
  CPOE systems.
• An effective CPOE system rests on a broad array
  of patient information and an electronic medical
  record is one of the first steps to achieving
  this.

19
How Leapfrog Happens Leaping in Unison
Purchasers
Consumers
Health Plans (MD Leadership Governance)
Health Care Delivery System (hospitals,
physicians, nurses pharmacy...)
20
Leapfrogs Regional Roll-Outs
Leapfrog is a national movement using targeted
regions (Regional Roll-Outs) to develop best
practices, creating early successes and learning
from all stakeholders.

• 23 Regional Roll-Out areas reach 50 of
  Americans.
• Regions must have
• Effective leadership
• Competitive health care market
• High concentration of Leapfrog lives

LF Regions in Green w/ exception of NV and NC
21
23 Roll-Out Regions
On Hold for 2004
22
Collecting Hospital Level Data

• Hospital survey available via The MEDSTAT Group
• Ongoing voluntary Web survey
• Outreach to hospitals in 23 Roll-Out areas to
  date, but nationally available
• Survey captures hospitals on the path
• Data publicly reported, format based on feedback
  from consumers and hospitals (survey and results
  www.leapfroggroup.org

23
Leap Applicability to Urban/Rural Hospitals

• 2001-2003- Leaps Apply to Only Urban Hospitals
• Areas where consumers have a choice of hospitals
• Do not want to raise public expectation that
  rural hospitals should prioritize the leaps
• 2004 and Beyond- Leaps Apply to Urban and Rural
• 4th Leap (NQF Safe Practices) applies to Rural
  Hospitals
• Rural task force working to apply initial 3 leaps
  to rural hospitals

24
Hospitals Are Reporting from All Over the Country
VT
MT
SD
WY
RI
NM
No Participation Participation inRoll-Out
Regions Participation inNon Roll-Out Regions
25
Progress 2nd Quarter 2004 (contd)Hospital
Survey Results - Regions
26
Hospital Survey Results Regions

• CPOE
• Final Version 2.0
• 5 (34) of the responding hospitals have fully
  implemented CPOE - another 17 (118) will
  implement by 2005
• Final Version 1.0
• 5 of the responding hospitals had fully
  implemented CPOE - another 22 said would
  implement by 2005

27
Hospital Survey Results Regions

• IPS
• Final Version 2.0
• 24 of responding hospitals have fully
  implemented IPS
• Final Version 1.0
• 21 of responding hospitals had fully implemented
  IPS - another 15 said would implement by 2004

28
Hospital Survey Results Regions (cont.)

• EHR of responding hospitals meeting Leapfrogs
  standard

29
Consumers as Drivers

• Preventable mistakes are frequent and serious
• Provider differences can be significant
• Enrollee Communications Toolkit by FACCT(NEW
  version available)

30
Engage Consumers

• Heart

31
Engage Consumers

• Heart
• Leapfrog Toolkit
• NEJM survey results
• Mind
• Web Hits

32
Engage Consumers

• Heart
• FACCT Toolkit
• NEJM survey results
• Mind
• Web Hits
• Wallet
• Co-pays, co-insurance

DRAFT
33
The Leap Over the Gridlock Has Begun

• Rapid growth in purchasers signing on to
  Leapfrogs approach
• Rapid growth in hospitals disclosing status to
  their communities
• Active health plan support
• 80 of Americans have access to information for
  at least one hospital in their community
• Massive education of consumers through purchasers
• Market reinforcement beginning through different
  channels

34
Market Reinforcement The Multiplier Effect
Inform Educate Enrollees
Multipliers Health Plan Products
Member Support Activation
Improved Value (Quality Efficiency)
Compare Providers
Federal state purchasers
Rewarding Creating Incentives for Quality
Efficiency
Other distribution channels partners
35
Where We are Beginning to Make Progress

• Transparency
• Movement towards standardization of measures
• The National Quality Forum
• Medicare Modernization Act 2003 IOM to evaluate
  leading health care performance measures
• Education
• Creation of consumer demand for good quality care
  
• 80 of Leapfrog members communicate to their
  employees about medical errors and 70 about
  Leapfrog

36
Putting the Money Where Our Mouth Is- Working
Markets Must Reward Quality

• Current reimbursement system does little to
  encourage quality improvement
• 80 of Leapfrog members publicly recognize
  providers but only 30 are working to reward
  providers
• Optimal Incentive and Reward systems
• Pay-for-Performance/Direct Financial Reward (DFR)
  models
• Bonus payments/Financial awards
• Volume/Market-share Shift/Direct-to-Consumer
  (DTC) models
• Tiering, Payment differentials

37
Lily Pads Opportunities to Shape the Movement
HEALTH PLANS
INCENTIVES REWARDS
CLINICIAN
BENEFITS CONSULTANTS
REGIONAL LEADERS
BOARD MANAGEMENT COMMITTEE
ENROLLEE COMMUNICATIONS
LEAPS MEASURES
38
Paying for Performance (DFR)

• Blue Cross Blue Shield of Michigan
• Blue Cross of California
• Bridges to Excellence
• Excellus
• Pay for Performance - Integrated Healthcare
  Association (IHA)
• Medi-Cal/Healthy Families - Integrated Healthcare
  Association (IHA)
• Massachusetts Health Quality Partners

39
Paying for Performance (DFR)

• Bridges to Excellence
• Physician Office Link
• Physicians can earn up to 50 per sponsored
  patient
• Must pass NCQA office practice performance
  assessment program
• http//www.ncqa.org/pol/

• IHA
• Paying for Performance
• Common measures
• Clinical quality (40 percent)
• Patient experience (40 percent)
• Investment in information technology (20 percent)
• Each plan comes up with own reward methodology

40
Paying for Performance (DFR)

• Other Initiatives
• Empire Blue Cross, IBM, PepsiCo, Verizon, and
  Xerox (NY)
• Hospitals 4 bonus if meet Leapfrogs CPOE and
  ICU standards
• Group Insurance Commission (MA)
• Health plans 25-50K bonus if plans increase
  admissions to Leapfrog-compliant hospitals
• Anthem Blue Cross Blue Shield (NH)
• Physicians 20 per enrollee for group practices
  that finish in top quartile for quality scores

41
Market-share/Volume Shift (DTC)
High
Consumer Resistance
Low
Minimum
Maximum
Provider Pressure
42
Market-share/Volume Shift (DTC)

• Provider Tiering
• Pacificare (CA), HealthNet (CA), Blue Shield
  (CA), Aetna (FL, TX, WA), Patient Choice Health
  Care (MN, CO, OR, MA)
• Co-pay, co-insurance, premium differentials
• Hannaford Brothers
• 250 co-pay difference for employee going to
  hospital meeting the volume criteria for 5 of
  LFs high risk procedures
• General Motors
• Adjusts employee premium contribution based on
  plans cost and quality performance

43
Health Plans Using or Planning to Use Leapfrog
Criteria in Incentive Programs
44
Purchasers Using or Planning to Use Leapfrog
Criteria in Incentive Programs
45
Whats in the Pipeline?
AHRQ Incentive and Reward Pilots
46
Market-share/Volume Shift (DTC)

• Creating Differential Hospital Insurance for
  Employees The Boeing Company
• Part of collective bargaining agreement with two
  largest unions
• Effective July 1, 2004, union employees and early
  retirees will obtain 100 coverage after
  deductible for services provided by a
  Leapfrog-compliant hospital
• Hourly employees hospitalized in facilities that
  do not meet the Leapfrog safety practices will
  obtain 95 coverage after deductible
• This benefit design will remain in place until
  July 1, 2006 when a new collective bargaining
  agreement becomes effective

47
Whats in the Pipeline?

• Leapfrogs E 2 (Effectiveness and Efficiency)
  Hospital Rewards Program- Piggy-backing on
  CMS-Premier Pay-for-Performance Demo
• Actuarial analysis shows win for members
• Data collection method already in place
• No new measures
• Plans can implement quickly for self-insured or
  fully-insured customers
• Can implement nationally or at local level
• Can expand to other GPOs/Hospital groups

48
Other Incentives and Rewards Initiatives/Leverage
Points

• IR Toolkit
• IR Compendium
• Health Plan User Groups
• Standard Health Plan Contract Language
• eValue8 Common RFI
• Update of Economic Implications of original
  three leaps
• Malpractice Study
• Found on Leapfrog Web site http//www.leapfrogg
  roup.org

49
Beginning to Leap Over Gridlock but Gaps Still
Exist

• Transparent Market- nationally standardized
  measures of quality and efficiency
• Market Reinforcement- reward quality and
  efficiency and better demonstrate business case
• Engage Consumers- aware of variation, mechanisms
  for timely and effective delivery of information,
  financial incentives
• Engage Purchasers- including government-
  sufficient tools and critical mass
• New health plan products

50
APPENDIX
51
Appendix A NQF Safe Practices

• 27 Safe Practices from the National Quality Forum
  Safe Practices Consensus Report (May 2003) The
  report is available at www.qualityforum.org
• Applicable to urban and rural hospitals
• Rolled up measure of patient safety for release
  to public in August 2004

52
27 Safe Practices

• 1. Create a healthcare culture of safety
• 2. Ensure an adequate level of nursing care
• 3. Pharmacists available for consultation with
  prescribers on medication ordering,
  interpretation, and overall medication use
  process
• 4. Read backs to the prescriber
• 5. Standardized abbreviations and dose
  designations
• 6. Patient care summaries or other similar
  records should not be prepared from memory
• 7. Care information, especially changes in orders
  and new diagnostic information, is transmitted in
  a timely and clearly understandable form

• 8. Patient or legal surrogate can recount
  informed consent discussion
• 9. Patient's preference for life-sustaining
  treatments prominently displayed in record
• 10. Standardized protocol used to prevent the
  mislabeling of radiographs
• 11. Standardized protocols used to prevent
  wrong-site or wrong patient procedures
• 12. Evaluate and provide prophylactic treatment
  for patients at high-risk of acute ischemic
  cardiac event during surgery

53
27 Safe Practices, cont

• 19. Reduce risk of renal injury based on the
  patients kidney function evaluation using
  standardized protocols
• 20. Evaluate risk of malnutrition, at
  admission and thereafter employ clinically
  appropriate strategies to prevent malnutrition
• 21. When utilizing pneumatic
  tourniquet evaluate patient risk for an ischemic
  and/or thrombotic complication, and utilize
  appropriate prophylactic measures
• 22. Decontaminate hands with either a hygienic
  hand rub or by washing with a disinfectant soap
  after contact with patient or patient objects
• 23. Vaccinate healthcare workers against
  influenza

• 13. Evaluate each patient upon admission, and
  regularly thereafter, for the risk of developing
  pressure ulcers
• 14. Evaluate at admission (and treat), and
  regularly thereafter, for risk of deep vein
  thrombosis (DVT)/venous thromboembolism(VTE)
• 15. Utilize dedicated anti-thrombotic
  (anti-coagulation) services
• 16. Assess at admission, and regularly
  thereafter, patients for risk of aspiration.
• 17. Use effective methods of preventing central
  venous catheter-associated blood stream
  infections
• 18. Assess risk of surgical site infection
  implement antibiotic prophylaxis and other
  measures

54
27 Safe Practices, cont

• 24. Keep workspaces where medications are
  prepared clean, orderly, well lit
• 25. Standardize the methods for labeling,
  packaging, and storing medications
• 26. Identify all "high alert" drugs (e.g.,
  intravenous adrenergic agonists and antagonists,
  chemotherapy agents, anticoagulants and
  anti-thrombotics, concentrated parenteral
  electrolytes, general anesthetics, neuromuscular
  blockers, insulin and oral hypoglycemics,
  narcotics and opiates)

• 27. Dispense medications in unit-dose or, when
  appropriate, unit-of-use form, whenever possible

55
Appendix B Physician Office Clinical Decision
SupportRationale E-Prescribing

• Medication errors affecting as many as 9 of
  prescriptions.
• E-prescribing systems have the potential to
  improve quality and safety by
• Eliminating legibility problems
• Reducing the occurrence of drug interactions,
  dosage errors, and other adverse effects by
  guiding prescribing based on computerized
  assessment of patient and medication information

56
Specifications E-Prescribing

• Physician office adopts and uses an electronic
  system which includes all of the following
• Decision support based on drug reference
  information
• Patient-specific decision support database which
  includes age, weight, medications prescribed by
  that office, diagnoses, allergies, specified lab
  results, and electronically-available formulary
  information inclusion of medications prescribed
  by other physicians is encouraged, but optional
• Printing of a paper prescription or its
  NCPDP-compliant electronic transmission to the
  pharmacy

57
Rationale E-Lab Results Management

• Errors in managing lab results are common.
• E-lab results management systems have the
  potential to improve quality and safety by
• Making a practitioner aware if lab test results
  which have been received have not been reviewed
  and/or shared with the patient
• Reducing unnecessary test ordering by giving a
  practitioner easier access to previous lab test
  results

58
Specifications E-Lab Results Management

• Physician office adopts and uses an electronic
  system which includes all of the following
• Tracking whether results have been reviewed by
  the practice
• Tracking whether results have been communicated
  to the patient, either electronically or via
  telephone or regular mail
• Storage and retrieval of LOINC-compliant lab
  results reports (excepting microbiology) in
  database-structured format

59
Rationale E-Care Reminders

• Preventive services, or services recommended
  for chronic conditions, are underutilized. E-care
  reminder systems have the potential to improve
  quality and safety. Examples include
• Increase vaccination rates
• Improved screening for breast cancer, colorectal
  cancer, cervical cancer, and other diseases
• Improved cardiovascular risk factor reduction
• Smoking assessment and counseling

60
E-Care Reminders, cont.

• Dietary assessment and counseling
• Improved management of hypertension
• Improved management of diabetes
• Increased detection of medication errors and
  adverse drug events

61
Specifications E-Care Reminders

• Physician office adopts and uses an
  electronic system which includes all of the
  following
• Patient-specific database which includes age,
  gender, diagnoses, treatment codes, lab test
  results, and medications documented by a
  clinician, AND
• Specified reminders for clinicians drawn from
  current US Preventive Services Task Force and
  other nationally recognized care guidelines
  (Appendix B)

62
Specifications E-Care Reminders (2)

• The electronic system enables all of the
  following clinician reminders
• Patients needing guidelines-based services at the
  time of patient contact
• Patient lists for outreach communications to
  patients who require scheduling for
  guideline-based services
• Generation of periodic reports of
  guideline-adherence rates for the physician
  offices patient population as a whole