In an interview earlier this week, Leah Binder previewed some of the concerns likely to be aired at next week's Chasing Zero Summit in DC.
The Leapfrog Group, an organization whose members include some of the largest employers -- and thus, purchasers of health care services -- in the country, works to "leverag[e] their purchasing power to try to influence improvement in quality in America’s hospitals."
The Leapfrog effort begins with transparency -- using a small number of NQF measures, includes some early pay for performance efforts -- such as the Leapfrog Hospital Rewards Program, and also serves as a platform for evangelizing about the need to reduce hospital-acquired infections down to zero. As Binder says, "It isn't brain surgery."
To date, most of the measures in common use are process, rather than outcome measures. Binder calls for more research and development in the outcomes measurement arena. The whole pay for performance arena seems to be underdeveloped to my mind; I would agree with Binder that we need to evolve into focusing more on outcome than process measures and tie outcome measurement performance to payment.
The "no pay for never events" rule, though -- adopted by Leapfrog before Medicare -- is only part of Leapfrog's armamentarium. Medical apologies and root cause analyses are at least as important. (I had a bit of a dialogue with Binder about this issue a number of months ago.)
As my home state of Massachusetts heads down the path of reporting on hospital-acquired infections and other serious reportable adverse events, Binder suggests that the regulators stick with the core 28 NQF serious reportable adverse events. This advice holds for other payors and regulators as well; Binder says, "It is our goal, at Leapfrog for sure, and I know it’s at CMS as well, to get these indicators harmonized and start to get a smaller set, a dashboard if you will, that people can really use to decide where to go for their health care."
Finally, we touched on the question of post-election health care reform. Binder's take:
"[U]ltimately the financing model for health care in our country really isn’t going to work. So, regardless of who is in the White House, [we need] to find a way to get people to look for the best possible care for themselves at the best possible price because with the aging of the baby boomers and the current financing structure of health care, it is just not tenable. . . . I think we’re going to have to look to all of us individually -- not just our government in Washington or our employer -- we’re going to have to look at ourselves to figure out how we can contribute to improving the situation. So I think that the change that’s coming is going to be quite substantial regardless of who’s in the White House and it would be really driven in part by our own use of health care."
In the end, Binder is concerned about assuring access to care, but emphasizes that "as we improve access to care we must also really address the issue of quality."
This is a tremendous challenge, as the Massachusetts experience has shown; it is very difficult, if not impossible, to address access, quality and cost issues simultaneously.
-- David Harlow
Interview: Leah Binder, CEO of the Leapfrog Group
September 2, 2008
David Harlow: This is David Harlow on HealthBlawg and I am speaking today with Leah Binder, CEO of the Leapfrog Group. Thank you for joining us today, Leah.
Leah Binder: It’s a pleasure.
David Harlow: I am interested in a number of things that your organization is doing but the opportunity for our conversation today is connected with the upcoming Chasing Zero Conference that’s going on next week in Washington sponsored by Cardinal Health. But for starters, I would like to ask if you could describe in, I don’t know, 25 words or less, the mission of the Leapfrog Group.
Leah Binder: We represent large employer purchasers in the country in leveraging their purchasing power to try to influence improvement in quality in America’s hospitals.
David Harlow: That’s great. So what I understand is that you collect a tremendous amount of information, and try to put that information to use in productive ways. Most recently –
Leah Binder: Yeah.
David Harlow: -- I saw in the news a few weeks ago information that’s been collected by Leapfrog and also by CMS – Centers for Medicare and Medicaid Services, in the government. We’ve seen basically two sets of quality indicators and a publication of those indicators on the web. And I’m wondering if you could speak a little bit to the differences between the approaches of your organization and CMS.
Leah Binder: Well, there are more similarities than differences. It’s very important to Leapfrog that we harmonize our measures with the measures that CMS is using, as well as health plans and hospitals. I think the goal for all of us is ultimately to have in this country a dashboard we can all use to understand and immediately know the differences in quality of various providers. So I would say first and foremost that there are similarities. I think CMS is a little more cautious in their approach to the number of indicators and measures that they are really using to influence their payment policies, whereas Leapfrog really is pushing to use measures of quality in sort of a pay for performance way. So we would really encourage health plans and certainly employers to pay more for better performance and pay less for poor performance. And we’d like to see more of that happening in the marketplace.
David Harlow: Has that started to happen in the marketplace that’s defined by your member employers?
Leah Binder: It has started happening. There are some pockets of real energy. So for example the State of Maine, state employees are charged more if they use hospitals that do not meet Leapfrog standards. That has had a very profound impact on the hospital community in Maine. New Jersey has, through Blue Cross and Blue Shield has been using something called the Leapfrog Hospital Rewards Program to offer incentives and bonuses that are quite substantial to hospitals that demonstrate improvement or demonstrate achievements in their performance. So the Leapfrog Hospital Rewards Program is something we’re also going into sort of a generation two with, and we expect to see many more health plans using that system. But there are other places where, like in Seattle, Boeing has been very active in Leapfrog and really –
David Harlow: Mm-hmm.
Leah Binder: -- using many incentives to try to encourage their employees to use high performing hospitals.
David Harlow: Right. Now, do you see this approach as influencing quality in other hospitals, and in the existing high quality hospitals that you’ve identified? Do you see greater improvement?
Leah Binder: It’s hard to measure whether it’s greater or the same kind of improvement that —
David Harlow: Yeah.
Leah Binder: -- you see from any other kind of incentives. I mean, I guess I have to be honest. I couldn’t necessarily measure that. It would have to be anecdotal information. And I would have to say that when a hospital knows that their own market, their own service area, the folks that use their facilities are going to know how this hospital is doing, that that can have a profound influence, because more than the money, certainly, it’s simply being a reputation that a hospital has in their community as they can demonstrate that their quality is superior, obviously that’s something that, you know, is going to incentivize them, and hopefully to make the kind of profound changes that are necessary to really see improvement in performance.
David Harlow: Mm-hmm. Now, I want to turn a little bit to the subject of the Chasing Zero conference coming up next week. And I wanted to ask a sort of as a followup to the Leapfrog hospital survey of the last year or so, which showed that really the vast majority of hospitals really don’t take all of the recommended steps to prevent avoidable infections. Is merely asking the question enough, or what are the other steps that you think can be taken in those hospitals?
Leah Binder: Well, we have to hold hospitals accountable for taking those steps. And the first step is what Leapfrog can do which is make the information available, and publicly report on a hospital-by-hospital basis on whether or not hospitals are taking the steps that are important for prevention of infection. So start with transparency and then we have to use incentives and rewards. So that’s kind of a second pillar of what Leapfrog is all about. As we have been discussing this concept of introducing the idea that we are actually going to pay for improved or achieved performance. And we are not going to pay as well when we don’t see that performance. And I think, that’s – so we start with transparency and then we could start to get the marketplace to respond to what we know. And that’s sort of the perspective that Leapfrog would take. How a hospital handles it internally is they just – it needs to be on the top of the agenda for every hospital CEO to address hospital-acquired infections. It is important that leadership in hospitals takes this as a very important and serious priority. It’s very hard for them to do that because addressing infection does not – in the past has not been tied to their reimbursement. It’s not been tied to their bottom line. And hospital executives do need to worry about their bottom line. Quite obviously, no one wants to deny that fact. And infections just don’t always obviously impact the bottom line the way they should. So, what we need to do at first, is to try to change that and make it clear to hospital leadership that this will impact their bottom line. This is of major importance. This is what will affect your market share and it’s time to put this higher on the priority list.
David Harlow: Right. In fact I would say historically that the hospital acquired infections have, to a certain extent, improved the bottom line for hospitals. With the readmissions –
Leah Binder: Sure and that’s an irony.
David Harlow: – and resurgeries. So it is an irony. I’m wondering whether there are sort of too many markers on the table. Are there too many goals on the table or are you focusing on hospital acquired infections alone? I thought you are also focusing in your organization as well as CMS on a number of other pay for performance or never events. I guess my question is, are there too many targets for hospitals to achieve, are they spread too thin?
Leah Binder: When my child is admitted to a hospital, I expect that they will be safe. And if it is too much for a hospital to account for all the factors that would assure that safety, then that hospital should be out of business because quite frankly, it is long past time that hospitals begin to take all aspects of safety as seriously as they do, achieving the highest level of reimbursement. And that is something that – it is incumbent on us as consumers of health care, as parents, as family members to really demand the highest level of safety. We pay for that. We pay a lot of money in this country for health care. And we certainly put a lot of respect and trust into the hands of providers of health care. I think the least we can expect in return is that they keep our family members safe. And that requires more than just one thing. It is very difficult. And it is something that hospitals have not always been frankly great at which is making system changes. And they have to change how they do business. And it is long past time that we made it clear that we want that to happen now.
David Harlow: One of the questions or one of the problems that people have raised with respect to pay for performance programs is that if you incentivize a hospital or health system to focus on indicator X, Y, or Z then there are other things that sort of fall off the table. So I guess the question there is, are there particular indicators that you have confidence in or are indicative of a broader area of quality rather than having a focus on – if a hospital focuses on one particular indicator because that’s what their payment incentive is tied to, you know, the danger is that other things will fall by the wayside. So in the Leapfrog Group’s work, have you identified particular indicators that are really valuable more broadly than just with respect to a particular measurement, that have an impact on a broader piece of the healthcare delivery system?
Leah Binder: I will say that we have focused to Leapfrog survey on just, as you’re saying, on some very specific aspects of patient safety and quality that we believe are telling about the overall safety and quality of the hospital. So we have focused on patient safety indicators and best practice indicators that are known to affect the overall safety of every patient that walks in to the hospital. So for example, does the hospital have intensivist coverage in this ICU? That can reduce – that’s been demonstrated to reduce mortality by as much as 50 percent. Does the hospital have computerized physician order entry, in other words, a system for managing its prescriptions and medication administration, that’s computerized, that’s been shown to reduce error rates from 50 to 100 percent. We’re talking about a lot of errors that can be averted.
David Harlow: Right.
Leah Binder: We use a bundle – we offer a score on a bundle of safe practices which are NQF-endorsed, practices that are demonstrated to effect a safe environment. And we also look at the mortality and volume rates for certain common procedures, and we offer sort of a predictor of the survivability of the average patient going in that hospital for those procedures. So those are really the cornerstones of what Leapfrog looks at, which again, our experts and our employers have agreed, really do suggest, through the evidence, seems to just that a hospital has a better or less or not so great record of patient’s safety. So you’re safer no matter what specific procedure you walk into a hospital, if you can demonstrate that you’re going to a hospital that scores well on those indicators, we feel confident that you’re going to a high quality hospital.
David Harlow: Great. So it is possible to sort of extrapolate from a smaller number of indicators to a broader sense of a general safety score, if you will, for an institution?
Leah Binder: Yeah. I mean it’s not perfect, and there’s certainly nothing that’s perfect, but we do think that that gets closer. But then, you know, I know that there is a sense that pay for performance by its nature does need to focus in on certain particular aspects of what a provider does, and then – and so therefore encourage a provider to focus only on those aspects. When they’re focused on patient safety, they’re genuinely focused on the entire system, their whole hospital. You can’t reduce infections unless every single person in the hospital knows how to wash their hands and does it, and follows the protocols. That takes more than simply issuing a memo, you’ve really got to be committed, you’ve really got to bring people in. So that’s when – when you see a hospital that’s that committed and demonstrating those kinds of results, that tends to be a higher quality hospital.
David Harlow: Some providers complain about having to track and report on ever-increasing number of indicators, particularly on the CMS side. They seem to add more and more each year. So would you say that it’s possible to, as in with your experience, to limit the number of indicators to a more manageable list and still get the same impact in terms of safety and quality?
Leah Binder: Yeah. I think that’s got to be a goal for all of us. As I said, we are really aiming towards having a harmonized set of indicators that are used by CMS and employers and health plans and others who are interested in the quality of health care. We aren’t there yet, but I think that’s definitely got to be a goal. We can’t have hospitals spending all their time collecting indicators and not actually spending their time achieving results from those indicators.
David Harlow: Right, right.
Leah Binder: Obviously all of us want a hospital working on the results. At the same time, we’re so new in this game – we shouldn’t be new, by the way. It’s almost unbelievable to a lot people who know how the health care system works, that we’re only now figuring out how to collect data on the effectiveness of hospitals –
David Harlow: Right.
Leah Binder: But that’s in fact the case. We are very new to this, and we got to have a little patience as we get through it, but it is our goal, at Leapfrog for sure, and I know it’s at CMS as well, to get these indicators harmonized and start to get a smaller set, a dashboard if you will, that people can really use to decide where to go for their health care.
David Harlow: Right, I think that’ll be very, very valuable. Are there other things that you would like to see happen in terms of harmonizing with the public sector? Are there things that you’ve been talking about with CMS, that you would have to say to your public sector counterparts at this Chasing Zero Conference next week?
Leah Binder: Well, I think we do need more research into outcome measures and as well as so-called process measures that affect the outcomes, and how they affect outcomes. Oftentimes, a lot of our indicators that we’ve been using, a lot of the measures that have been approved by NQF really are measuring how health care is delivered. Did you consult this guide or was there this protocol implemented before you did this? I mean, those kinds of things are obviously important to providers, but what we need to understand from a consumer perspective is they want to know how does that impact whether I do well or not in my treatment. Am I going to be better because of this? And we just have such a dearth of outcome indicators. And ultimately, that’s what people need. That’s what you want to know before you go to a hospital. You don’t want to know that the radiologists looked at the, you know, the screen in a certain way. You don’t care about that; you just want to know, am I going to do all right? And are they good at getting people to their maximum health, so are they good at it? And that’s what we aren’t able to always tell people. I’d like to see more research in that area.
David Harlow: Right.
Leah Binder: And more approved measures on outcomes.
David Harlow: Right. Now, some providers and other critics of this sort of never events payment system will say that some hospital-acquired infections are unavoidable, that there’s a certain percentage that maybe should be your target rather than having zero as a target. That sort of reminds me of other government regulation efforts in the past where the legislation sort of came up with a zero tolerance approach, and in the real world, the regulations had to approach it with a substantial compliance approach because you can’t really get to zero. I mean, do you think that this is sort of a Sisyphean task that’s unachievable, or is it in fact really achievable?
Leah Binder: I think it’s achievable. I think we have to set our sights as high as possible. Reducing infection, you know, to use a term that’s strangely appropriate, it’s not brain surgery. If hospitals can handle brain surgery, why can’t they handle reducing infection?
David Harlow: Right.
Leah Binder: This is not brain surgery, it is simple protocols that are known that can reduce or eliminate it.
David Harlow: Right.
Leah Binder: Now, maybe we’ll go down – we’ll set our sights high, we go for the best of the best, we expect the best of the best from our health care system as they are capable of delivering. And then if they can’t do it five years from now and they say, “look, we’ve reduced it by so much, but it can’t get down to zero,” then maybe I guess we’ll review it at that point. But right now I think it is perfectly appropriate for us to have the highest possible expectations of the best health care system in the world.
David Harlow: Mm-hmm, absolutely. So my home state of Massachusetts has just recently passed legislation that will get a registry off the ground for health care acquired infections, and they need to now define what is a serious reportable event, et cetera. What advice might you have for Massachusetts in getting this system off the ground?
Leah Binder: Well, I think they could start with the NQF endorsed or the NQF definition of a serious reportable adverse event. There are 28 particular situations that had been defined as such. And then they obviously are going to need to look at their own internal procedures for coding and contracting that in order to identify those particular events and decide to what extent they can – their own definitions can adhere to what we recommend, which is the NQF definitions.
David Harlow: Mm-hmm.
Leah Binder: And I just want to say one other thing about never events. You mentioned never events as a financing policy. You know, the Leapfrog Group is the first organization to issue a policy on never events and our policy is not a financing policy although it does include as one of its principles that people should not be charged for the services related to a never event. So that clearly got a lot of attention but it also has other parts to it that we think that are equally important such as that a patient who experiences a never event should be apologized to and that hospitals should do a root cause analysis and publicly report the event. Those things are also very important we think and should be part of our thinking. Those are restoring the simple humanity of the experience to the patient for one thing but also it is looking at how we prevent them from happening in the future. The best way to really do that is to have a more open, transparent culture and to also get hospitals to do the kind of root cause analysis that will ultimately prevent it from occurring again.
David Harlow: Yeah, it goes beyond just the payment issue if we want to really work on improvement –
Leah Binder: Absolutely.
David Harlow: – of quality.
Leah Binder: Absolutely.
David Harlow: One type of infection that’s been in the news a lot in the past year or so has been MRSA, and I’m wondering if any of the information that you’re tracking or protocols you may recommend are MRSA-specific or if they’re directed at infection in general?
Leah Binder: Well they’re directed at infection in general but that would include MRSA and the problem we’ve had with really getting our arms around the problem with MRSA is that until CMS issued its regulation requiring present on admission data be collected by hospitals we had no way of actually knowing what MRSA was coming from hospitals and what was community-acquired. And that does matter, a lot, and it also matters in terms of how the infection spreads and when we’re even aware that it exists, etc. They’re just now getting protocols to do that and it’s common in all kinds of infections so I think now we‘re making some real progress now that CMS is requiring present on admission data and it’s taking a much more aggressive approach around infection in general.
David Harlow: Well, I have a couple of questions for you in terms of looking to the future, and one is: With health care very much in the public eye throughout the presidential campaign, I’m wondering what you see as the potential for change as it relates to the issues we’ve been discussing, come November, come January. What could happen in a new administration that would improve things from your perspective or what things that you think are likely to happen would have an effect on the work that you’re doing?
Leah Binder: I think that it’s the leadership from CMS in encouraging a pay for performance kinds of models or non-pay for non-performance kinds of models. If we continue to see that leadership -- which I believe regardless of who is in the White House and we will continue to see that leadership -- then I think we will ultimately see a transformation in the way health care is done and financed in this country. I think that thinking about health care as something that you need to get value from, you need to get great care at a good price is just a completely new way of approaching the whole health care system and as soon as more Americans start approaching their own health care that way and more employers start purchasing care that way, I think that will really transform the health care system. And in a way it has to happen. I mean, ultimately the financing model for health care in our country really isn’t going to work. So, regardless of who is in the White House, they’re going to find a way to get people to look for the best possible care for themselves at the best possible price because with the aging of the baby boomers and the current financing structure of health care, it is just not tenable and I think we’re going to have to look to all of us individually -- not just our government in Washington or our employer -- we’re going to have to look at ourselves to figure out how we can contribute to improving the situation. So I think that the change that’s coming is going to be quite substantial regardless of who’s in the White House and it would be really driven in part by our own use of health care.
David Harlow: Are there any hopes or wishes that you would have for the future in addition to what you’ve just talked about in terms of change coming down the pike in Washington?
Leah Binder: My biggest hope is that as we move to improve access to health care for the millions of Americans who are uninsured -- which I think is a huge issue and I wholeheartedly support efforts to reduce or eliminate the number of uninsured people -- as we improve access to care we must also really address the issue of quality and do so at the same time. I think it would be disastrous if we were to suddenly extend access to everyone without actually scrutinizing what it is we’re giving them access to. And our health care system needs a fundamental reform to improve its quality and we need to do that at the same time or else we are just creating a bigger and bigger problem.
David Harlow: Yes, well, thank you, thank you very much. I’ve been speaking with Leah Binder, CEO of the Leapfrog Group who will be participating in the Chasing Zero Summit, September 8th and 9th in Washington, DC. Thank you very much for joining me today and I’ve enjoyed this conversation very much.
Leah Binder: So have I. Thanks a lot.