| Purchaser Q&A
(For specific questions about The Leapfrog Group's Hospital Quality & Safety Survey and recommended quality and safety practices, please refer to The Hospital Survey FAQ)
I. Comparative Rating of Provider Performance
What goes into this?
Will The Leapfrog Group create a template to allow easy comparison of providers by plans, purchasers, and consumers?
What levels of performance are good enough?
Do we intend to demonstrate that consumers notice differences?
II. Educate and Inform Enrollees
Are there minimum requirements for this?
III. Substantial Incentives
What does it mean to incentivize?
How will the Leapfrog Group determine if purchasers are fulfilling their commitment to Leapfrog's Purchasing Principles?
IV. Purchasers and Leapfrog's Recommended Quality and Safety Practices
(For specific information on the practices themselves please refer to The Leapfrog Group's Fact Sheets)
Computerized Physician Order Entry
How can a purchaser know if a hospital's CPOE system meets the Leapfrog standard?
How can intermediaries get the physician community to buy into this?
How can intermediaries work with purchasers to get hospital, physician, physician organization (e.g., medical society) buy in?
Intensivist Physician Staffing in Intensive Care Units
Are the standards applicable only to tertiary care hospitals?New Link
It is difficult for plans to dictate hospital staffing, response time, etc. Can you help us with this?
If it were a national priority, could enough intensivists be provided (or mobilized from ambulatory care) for urban hospitals within the next 4 years?
How will The Leapfrog Group address the Intensivist shortage?
Evidence-based Hospital Referral
Where will purchasers get hospital performance information for the high risk procedures in the EHR practice?
How can we verify physician behavior?
Plans in some areas have no leverage with hospitals (census penetration is small) or physicians - even if they all band together. How can they work with purchasers to increase leverage on this issue with hospitals? Physicians?
In areas where plans have little leverage with the hospitals, attempts to refer specialty care selectively to other hospitals can lead to the hospital refusing to do any business with the plan. If that is the only hospital in the geographic area, what can plans do?
How can plans work with purchasers to educate local/regional/national hospital associations on the issue?
V. Cross-Cutting Quality and Safety Leap Questions
What should we do if a hospital won't provide necessary information?
Is it important to consider the context for safety Leaps, such as hospital location, size, or collateral hospital features?
Should Leapfrog's safety leaps focus on structural improvements (i.e., CPOE) or actual performance?
How can purchasers verify the presence of the safety standards in hospitals?
What is the final definition of rural vs. urban?
Will we make available to purchasers the list of hospitals falling outside of MSAs?
Is the Leapfrog considering new safety leaps for services outside the hospital?
I. Comparative Rating of Provider Performance
Q What goes into this?
A We will start with today's scanty set of scientifically valid provider performance measures and controlled performance reporting systems. We will encourage nationally recognized health care performance assessment organizations (e.g., NCQA, NQF, JCAHO, Centers for Medicare & Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA) -- and Foundation for Accountability (FACCT)) to expand provider performance measures and controlled performance reporting systems. We will officially adopt their measures and reporting systems as they progress.
In the interim, comparative rating will consist of comparisons of hospitals' progress towared implemented the three Leapfrog patient safety practices. As more measures become available for comparative rating, Leapfrog purchasers will consider a broader array.
To encourage hospitals to report their performance publicly, we will designate hospitals that do not participate in or publicly report their scores from relevant reporting systems on our website as follows: "Did not disclose."
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Q Will The Leapfrog Group create a template to allow easy comparison of providers by plans, purchasers, and consumers?
A Yes. The section of the Leapfrog website dedicated to comparative rating will initially post only the self-reports of providers who report to the website whether or not they fulfill any or all of the three safety Leaps. It will be organized to support geographic comparisons of provider performance.
Eventually, it will encompass not only hospitals' status on the Leapfrog safety practices, but also on all valid comparative provider measurement/reporting systems. Purchasers and consumers will be able to weight each performance measure, thereby enabling custom global comparisons of providers/provider networks (i.e., computerized support of consumer's provider selections).
For an Illustrative 2002 Comparative Leapfrog Rating of Hospitals in Louisville, Kentucky MSA, click here.
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Q What levels of performance are good enough?
A The website will eventually identify whether performance scores are within a range considered by evaluation methodologists to be not statistically different than the maximum obtainable score.
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Q Do we intend to demonstrate that consumers notice differences?
A Yes. The Leapfrog Group will contract for periodic evaluation studies to document whether performance differences influence consumer, purchaser and plan choice of providers.
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II. Educate and Inform Enrollees
Q Are there minimum requirements for this?
A Yes. We have sought a short list of specifications from subject matter experts such as David Lansky (Foundation for Accountability) and Judy Hibbard (Univ. of Oregon). Based on those specifications and rigorous consumer testing with enrollees from a member company, The Leapfrog Group prepared a succinct "plug 'n play" enrollee communications package for purchasers, consisting of updated "key messages" and a suggested strategy for disseminating them among Leapfrog purchasers' enrollees. The Leapfrog Group will periodically update the package as new research and materials become available.
"Educating and informing" refers to stimulating consumer awareness of the importance of comparing performance ratings of providers and provider networks. Based on psychology research, this implies the need to use vividness, simplicity and personal relevance in conveying core messages about the safety and quality implications of provider selection.
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III. Substantial Incentives
Q What does it mean to incentivize?
A The published literature on provider incentives is not precise about "what works." The Leapfrog Group has discussed with a sample of provider leaders what incentives they require to make the investments (financial and non-financial) needed to achieve big leaps in overall customer value and to implement Leapfrog's safety practices. Based on these discussions, we have developed a "plug 'n play" set of provider incentive options for purchasers to implement directly or via their health plan intermediaries.
We will also encourage employers who prefer a custom approach to have similar discussions with their major providers. A website-based Leapfrog Purchaser toolkit includes:
- A basic Incentives and Rewards toolkit for Leapfrog members.
- An actuarial model developed by Towers Perrin for understanding the cost/benefit of Leapfrog adoption.
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Q How will The Leapfrog Group determine if purchasers are fulfilling their commitment to Leapfrog's Purchasing Principles?
A Leapfrog staff will perform an annual survey of members to: assess their progress in implementing the Purchasing Principles and gather their feedback on how Leapfrog can better support them in implementing the Purchasing Principles.
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IV. Purchasers and Leapfrog's Recommended Quality and Safety Practices
Computer Physician Order Entry (CPOE)
Q How can a purchaser know if a hospital's CPOE system meets the Leapfrog standard?
A The current CPOE specifications are performance-focused and get at the essence of what we seek. They require that a hospital report publicly if:
- It has achieved a minimum intercept rate of 50% of serious prescribing errors and what its intercept rate actually was, using a nationally standardized case-based testing protocol developed by the Institute for Safe Medication Practices (ISMP) and First Consulting Group;
- It has achieved routine use by all prescribing physicians and
- Its physicians are required to acknowledge an intercept before overriding it by documenting it.
First Consulting Group, which has special expertise in this area, has worked with Institute for Safe Medicine Practices to select the most valid test cases using LDS Hospital's uniquely rich empirical database on the consequences of prescribing errors. They are currently developing a CPOE evaluation tool for hospitals that will designate:
- The most critical CPOE functionalities and subsystem interfaces (e.g., laboratory results and pharmacy data) necessary to achieve a high rate of intercept and
- How to be a savvy purchaser of CPOE systems.
If and when a viable direct measure of hospital adverse drug events develops that is connected to a controlled public reporting system, we will use it to expand or replace our current structural specifications. Since it may take several years for a significant number of hospitals to meet this standard, we are using an interim approach in which hospitals would report their progress on the precursors to establishing CPOE and other important medication safety process improvements that have been documented to improve medication safety.
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Q How can intermediaries get the physician community to buy into this?
A Intermediaries should review the evidence on "what works" in physician behavior change (Cabana et. al. in JAMA 1998) and blend it with the opportunities and barriers they discern in each area.
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Q How can intermediaries work with purchasers to get hospital, physician, and physician organization (e.g., medical society) buy in?
A The Regional Roll-Outs (intermediaries) will test and report on different "best practice" approaches. Leapfrog's "Points of Leverage" paper suggests potential starting points. Embracing Leapfrog's new health plan contract language and standard RFI questions will also help increase buy-in.
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Intensivist Physician Staffing in Intensive Care Units (IPS)
Q Are the standards applicable only to tertiary care hospitals?
A No. The standards apply to all general acute care hospitals in urban and suburban areas operating adult or pediatric ICUs.
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Q It is difficult for plans to dictate hospital staffing, response time, etc. Can you help us with this?
A Dictating to providers is inconsistent with the Leapfrog principles. The principles call for using market mechanisms effectively to reinforce comparative provider performance and/or capabilities. Leapfrog purchasers who delegate this responsibility are committed to using intermediaries who are effective in this role.
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Q If it were a national priority, could enough intensivists be provided (or mobilized from ambulatory care) for urban hospitals within the next 4 years?
A If it were a national priority, it is possible. Critical care fellowship training extends for either one or two years. History suggests that physicians' choice of specialty is sensitive to the job market.
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Q How will the Leapfrog Group address the shortage?
A We will (1) create demand via our standard, (2) encourage specialty boards and the Association of Academic Medical Centers to convey the anticipated new demand and (3) sensitize federal officials who set physician training and loan forgiveness priorities.
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Evidence-based Hospital Referral (EHR)
Q Where will purchasers get performance information for high risk procedures in the EHR practice?
A We invite hospitals to participate in the voluntary online hospital patient safety survey.
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Q How can we verify physician behavior?
A In the future, Leapfrog may seek warranties on its website from physicians regarding whether or not they commit to referring relevant patients to hospitals meeting the EHR (and other Leapfrog) standards. However, health plans may be best positioned to verify physician adherence.
Accordingly, in developing future health plan RFP/RFI questions, we may (1) include a question about the plan's willingness to verify physician behavior by claims analysis and (2) recommend to Leapfrog purchasers that health plans' responses to this question be assigned a significant weight. The latter is recommended especially if the plan's response to a related RFP/RFI question examining the plan's aggregate evidence-based referral pattern adherence is unfavorable.
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Q Plans in some areas have no leverage with hospitals (census penetration is small) or physicians - even if they all band together. How can they work with purchasers to increase leverage on this issue with hospitals? Physicians?
A Intermediaries specialize in reconciling consumer/purchaser preferences with the healthcare industry. Accordingly, we expect that when necessary, they will collaborate with other intermediaries and recommend helpful purchaser behaviors, such as enrollee education or plan design modifications.
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Q In areas where plans have little leverage with the hospitals, attempts to refer specialty care selectively to other hospitals can lead to the hospital refusing to do any business with the plan. If that is the only hospital in the geographic area, what can plans do?
A Intermediaries are only expected to exercise Leapfrog's market-based approach in urban areas where there is typically competition among hospitals.
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Q How can plans work with purchasers to educate local/regional/national hospital associations on the issue?
A Strategies for cooperation might be most easily developed in areas where Regional Roll-Outs are planned. This will offer intermediaries a packaged multi-employer entity as a partner.
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V. Cross-Cutting Safety Leap Questions
Q What should we do if a hospital won't provide necessary information?
A We will set a deadline for hospitals' initial website warranties and for annual updates. To sway non-reporting hospitals, we will use e-mail links among Frogs and Leapfrog-supportive health plans to:
- Identify Leapfrog purchasers and Leapfrog-supportive health plans who provide a significant volume of admissions to the non-reporting hospital and
- Solicit volunteer regional "Leveraging Frogs" to assume accountability for leveraging all Leapfrog purchasers with hospital CEOs and, if necessary, hospital trustees. (See items 3-7 in "A Frog's Summary of Key Accountabilities.")
The Leapfrog website will house a continuously refined "Points of Leverage" paper to summarize proven purchaser tactics. The website will also identify successful Leveraging Frogs to enable other Leveraging Frogs to seek their advice. To set a motivational floor for hospitals to cooperate with reporting in our national effort to notify hospitals about Leapfrog and associated hospital warranties, we will specify the adverse language to which the website listing will "default" for hospitals that do not provide a warranty. (See Answer #1 in Section A.)
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Q Is it important to consider the context for safety Leaps, such as hospital location, size, or collateral hospital features?
A Other than exclusion of rural hospitals, our subject matter experts feel the safety Leaps are reasonable to expect of all hospitals. Some urban hospitals may find it difficult to meet the Leapfrog safety standards and may push for better methods of comparing hospitals. We welcome such a dialog. The hospital industry could rapidly accelerate progress in hospital performance comparisons.
We are now seeking additional expert input on whether we should exclude from the ICU standard hospitals that do not treat sicker patients. We will invite rural hospitals that meet one or more safety standard to report their status on the website, but we will not portray them adversely if they do not. Each of the safety standards assumes that certain systems/processes are either already in place or must newly be put in place.
First Consulting Group will spell this out for CPOE, as we described in Section D. Because such specification is resource intensive, we will seek funding to develop specifications of the necessary co-factors/functionalities for the other two safety Leaps. The Leapfrog Group hopes to be helpful to hospitals in this way when feasible.
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Q Should Leapfrog's safety leaps focus on structural improvements (i.e., CPOE) or actual performance?
A The Group will always place greater value on actual performance than on structural improvements. The most common impediment to the former is the lack of well-developed and trusted systems of comparative performance measurement and reporting. Such systems always require substantial provider cooperation and investment, which are difficult to achieve. We will:
- extend an open invitation to the health industry and its performance measurement organizations to develop and apply performance measurement systems that experts in evaluation methodology judge to be more valid than an existing Leapfrog safety standard; and,
- defer to such systems as soon as hospitals use them. (For example, the Society for Critical Care Medicine has a risk-adjusted hospital reporting program for ICU mortality and complications, but few hospitals participate. However, if a participating hospital can demonstrate superior performance, we will "deem" it equivalent or superior to meeting the ICU staffing standard.)
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Q How can purchasers verify the presence of the safety standards in hospitals?
A We will primarily rely on providers' public warranties on the Leapfrog website. Some insurers and the AAHP have expressed interest in assisting us with onsite verification. We will encourage this assistance and explore other audit methods, but not depend on them, since legal counsel has confirmed that false public warranties carry substantial liability for providers. We will encourage provider warranty through health plans, the AHA, and, as a last resort, direct employer leverage.
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Q What is the final definition of rural vs. urban?
A Urban is defined as within federal Metropolitan Statistical Areas (MSA) boundaries.
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Q Will we make available to purchasers the list of hospitals falling outside of MSAs?
A Yes. We will pursue a source (or contractor) to gather this for all Leapfrog purchasers and post the list on (or link it to) our website.
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Q Is the Leapfrog considering new safety leaps for services outside the
hospital?
A After refining existing hospital Leaps during 2002, the Leapfrog Group's next focus will likely include physician offices. Our primary partners will be AHRQ/CMS, JCAHO, NCQA, NQF, and physician quality leaders. The current focus of our physician office Leap exploration is e-prescribing and e-retrieval of lab results, as well as physician participation in robust, national quality benchmarking programs. Exploratory collaboration with our primary partners is underway.
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