The frog that roared

A powerful business group with an unlikely name aims to change the way hospitals and physicians provide care.

By Ken Terry
Senior Editor

If you haven't yet heard of the Leapfrog Group, you probably will soon. Despite the whimsical moniker, this payer organization is dead serious about changing the practice of medicine. And it has the economic clout to make reluctant hospitals and physicians pay attention.

Backed by more than 100 Fortune 500 companies and other large private and public health care purchasers covering 35 million patients, Leapfrog wants to encourage hospitals to improve care and reduce medical errors. It plans to do so by giving bonuses to top-ranked institutions and lower copayments to employees of member companies who use those hospitals.

Leapfrog has set three goals for hospitals: install computerized physician order entry (CPOE) systems; increase the number of intensivists working in ICUs; and do a high enough volume of specified procedures to make institutions and physicians proficient at them. While it's unclear how many institutions can meet these goals, Leapfrog's efforts have clearly shaken up the hospital community.

In a recent survey, Leapfrog found that only 3 percent of the responding hospitals had implemented CPOE. But about 30 percent planned to do so by 2004. "Leapfrog has been a driving force in this, and most hospitals are at least talking about it now," says Sandy Lutz, a Dallas-based consultant with PricewaterhouseCoopers. "Pretty soon it's going to be a standard of care."

At this point, however, physicians who know about Leapfrog view it warily, says internist David Nash, associate dean of Jefferson Medical College and director of the office of health policy and clinical outcomes at Jefferson University Hospital in Philadelphia. "From an individual doctor's viewpoint, this is the scary new world of accountability," says Nash. "But for patients, it's probably going to be a good thing."

Patients already can view data submitted by 241 urban hospitals in six regions around the country surveyed by the group. This year, Leapfrog will expand its initiative to 12 new regions. When it finishes this initial rollout, its survey will include hospitals serving about 40 percent of the country's population.

Employer members of Leapfrog disseminate the data on hospital quality to their employees. The data is also available on the Leapfrog Web site ( www.leapfroggroup.org) as well as other Web sites that report on hospital quality. The Centers for Medicare & Medicaid Services has provided a link to the Leapfrog site on www.medicare.gov.

A closer look at Leapfrog's agenda

Leapfrog wants to educate consumers about the differences among hospitals and reward hospitals that provide superior care, says Suzanne Delbanco, executive director of the organization. Promoting patient safety is one reason. The big corporations also see poor quality as a source of waste and inefficiency—and therefore of unnecessary costs.

"If you go to a hospital without a CPOE, get a drug that interacts badly with something else you're on, then go home and have to be readmitted, that's incredibly expensive," notes Delbanco. "And right now, the purchaser has to pay." Consequently, she says, some Leapfroggers are willing to pay extra to have hospitals install CPOE.

Still, the amount hospitals receive depends mainly on their negotiating power. Many hospitals feel Leapfrog is trying to force them to spend buckets of money on new systems without being compensated for it. And not all hospitals can afford a CPOE system, which costs up to $15 million, depending on the facility's size.

"To many hospitals, the investment doesn't make good sense right now," says Ann Berdahl, senior associate director of policy development for the American Hospital Association. Some CPOE systems, she adds, are poorly designed and don't fit in well with the clinical workflow.

Intensivists aren't widely available

The AHA also criticizes Leapfrog's emphasis on intensivists, who cover ICUs in only 10 percent of the hospitals the group surveyed. "The issue is making sure that patients in the ICU are getting appropriate care," says Berdahl. "Hiring intensivists provides the potential for better outcomes based on the physician's specialty. But other specially trained physicians and critical care nurses are an important part of the equation. It's very narrow to think that simply increasing the pool of intensivists will result in better outcomes."

Leapfrog cites studies showing that the use of intensivists does save lives. Even so, the supply of critical care physicians is low. "Only one of three physicians with critical care training works in the ICU," notes Delbanco. Luring the others back into the ICU would be difficult, and medical schools aren't turning out enough new intensivists to staff most hospitals.

To supplement this measure, Leapfrog has begun working with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to develop methods of measuring risk-adjusted outcomes in the ICU. "We hope that in the next 18 months, we'll have more than the staffing structure to look at," says Delbanco.

How much does volume say about excellence?

Only 12 percent of hospitals surveyed by Leapfrog performed enough CABG procedures to meet the group's minimum thresholds for optimizing expected outcomes. For abdominal aortic aneurysm repair, the figure is 21 percent; for carotid endarterectomy, 20 percent; for esophageal cancer surgery, 15 percent; for neonatal ICUs' handling of high-risk deliveries, 22 percent; and for coronary angioplasty, 31 percent.

While Leapfrog's Delbanco insists that a hospital's volume of high-risk operations correlates well with its risk-adjusted outcomes, she admits it's an inadequate yardstick. So Leapfrog will accept state outcomes measures, such as the cardiac surgery mortality reports done in New York and California, as a substitute for volume.

Under an agreement with Leapfrog, Zynx Health, a health services research firm based in Los Angeles, is searching for evidence-based process measures that can be applied to Leapfrog's high-risk procedures. For example, says Zynx president Scott Weingarten, if overwhelming evidence indicates that antiplatelet therapy benefits patients after a CABG, an expert panel would decide whether that measure is valid. Some approved measures might be used in future Leapfrog surveys, says Delbanco.

What's the impact on hospitals?

Observers are divided on how much attention hospitals are paying to Leapfrog. In a market like Philadelphia, where hospitals are the leading employers, Leapfrog members don't have enough clout to make a difference, says Nash. Robert Margolis, CEO of HealthCare Partners, a large physician group and IPA based in Los Angeles, doesn't think the Leapfroggers have much market power in California, either: Leapfrog companies employ only 5 to 10 percent of managed care enrollees in the state, he says.

"Leapfrog is measuring things that have very little impact on physician choice of hospitals," Margolis adds. "HealthCare Partners already has high-risk, high-intensity procedures done at the tertiary care hospitals that are the best for those things. Hospitals are struggling with CPOE, and physicians haven't made hospital choices based on that. Every managed care organization in the state uses hospitalists to do their inpatient care. So Leapfrog has good intentions and is measuring some interesting things, but it's not a big story in California."

On the other hand, Promina Health System, one of Atlanta's leading health systems, has embraced Leapfrog's principles. According to Robert Ryan, Promina's chief medical officer and executive vice president, the system is spending $40 million to equip its four main hospitals and two smaller ones with CPOE, which will be implemented within 18 months. While Promina isn't hiring more intensivists, some of its hospitals meet the volume criteria for high-risk operations. Ryan views that as a "reasonable proxy" for outcomes.

Promina plans to use its compliance with Leapfrog standards as a marketing tool. "In the long run, you'll end up with a more efficient, less duplicative hospital that's receiving notoriety because it has a higher-quality product," says Ryan. "Potentially, you'll get patients referred to you because of that."

Because there will be winners and losers, Lutz believes, more hospitals across the country will hop onto the Leapfrog lily pad. "They don't want the press to say they haven't made any of these leaps, while maybe their competitor has."

Using benefit structures to rev up consumers

Whether patients will pay attention to the ratings, however, is another question. "Patients don't make educated decisions about which hospital to go to. They just go where their physician tells them," notes Lutz. "What might make that change is that some payers are introducing tiered payments in different plans. If you're deciding between a $100 deductible and a $500 deductible, then you'll want some information about which hospital to go to."

Tiered-benefit packages, which use lower copayments as well as deductibles to steer patients to lower-cost hospitals, could actually discourage patients from using better institutions. But in California, the Pacific Business Group on Health is encouraging plans to use the Leapfrog criteria in deciding which tier to place a hospital in.

Meanwhile, some Leapfrog members are offering hospitals incentives on their own. For instance, IBM, PepsiCo, and Verizon paid 4 percent bonuses to two New York hospitals that have CPOE and intensivists in the ICU. Leapfrog is working to devise a standard method of rewarding "quality" hospitals financially, says Arnie Milstein, medical director of PBGH and chair of a Leapfrog committee.

Isn't this unfair to smaller or weaker hospitals? "Hospitals are realizing that employers are putting a huge premium on protecting the safety of their enrollees, rather than thinking about what would be fair to every hospital," replies Milstein. "It's a change in values. The idea is to prioritize quality and safety, and let the market support those hospitals that are able to deliver it.

"It's obviously unfavorable to hospitals that don't have much capital to spare. But it favors hospitals with heads-up managers who are able to mobilize their human resources and their capital to deliver what customers are asking for."

Other hospital scorecards use outcomes data

The Leapfrog Group's fledgling scorecard on hospitals is only one of several available on the Web. Among the others are Healthscope, HealthGrades, Subimo, Select Quality Care, and Doctor-Quality—all of which provide access to Leapfrog data.

Healthscope (www.healthscope.org), a Web site of the Pacific Business Group on Health, provides patient satisfaction data. The other sites use Medicare data and outcomes data gathered by some states as the basis for comparing complication rates and risk-adjusted mortality rates. (DoctorQuality, www.doctorquality.com, also supplies information on patient satisfaction.)

All-payer outcomes data is collected in 36 states, but many of them don't publish their information. HealthGrades (www.healthgrades.com) uses data from 18 states, and other companies say they have data from up to 23 states.

HealthGrades rates hospitals according to the difference between their predicted outcome score and their actual score. The patient chooses a diagnosis or procedure and asks to compare hospitals within a geographic area. Measures for high-risk procedures include volume of cases, in-hospital mortality, and mortality one and six months after discharge. Other procedures such as total hip replacement focus on complication rates.

Subimo ( www.subimo.com) provides complication rates on some procedures that HealthGrades doesn't, but it doesn't offer any mortality comparisons. It also supplies patient satisfaction and hospital profile data, and will weigh consumer preferences for such things as NICUs and facility type in choosing a hospital.

Whereas HealthGrades sells its services to hospitals, health plans, and insurance underwriters, Subimo contracts with health plans such as Blue Cross of California and PacifiCare. To sign on to Subimo, enrollees must go through the plan Web site.

Select Quality Care (www.selectqualitycare.com ) also counts health plans among its clients, along with employers and hospitals. Instead of general complication rates, it focuses on specific quality indicators, such as the incidence of pneumonia and wound infection. These evaluations are based on data reported to the federal government and measured by the Agency for Healthcare Quality Research. Select also considers volume and mortality rate for each procedure or diagnosis, as well as length of stay and cost. And it allows users to weigh the importance they wish to place on each of these factors in choosing a hospital.

A recent JAMA study compared HealthGrades' ratings with data from the Cooperative Cardiovascular Project, a retrospective chart review on 142,000 Medicare patients. It found that HealthGrades' rankings "poorly discriminated between any two individual hospitals' process of care or mortality rates during the study period." It said that mortality was a poor measure of the quality of care and that the validity of comparisons between individual hospitals dropped with the number of cases evaluated for each facility. While the study didn't say so, these limitations are likely to apply to other hospital report cards.

Ken Terry. The frog that roared.

Medical Economics

2002;21:31.