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Update from The Pond

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Title: 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
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