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By David
Brown
Larry Becker, the director
of benefits for Xerox Corp., remembers his aha! moment.
Two years ago this month he
attended a meeting in Washington where a General Motors executive talked
about the Institute of Medicine's 1999 report "To Err Is Human."
The report estimated that as many as 98,000 Americans die each year from
medical mistakes.
GM has no small interest in
the matter, the executive, Bruce Bradley, told the audience at the Washington
Business Group. The automaker is the largest private purchaser of health
care in the country, covering one out of every 200 Americans.
If the Institute of Medicine's
numbers were right, he said, then 1.3
GM employees, retirees or dependents died every day from medical mistakes.
If accidents were killing people in GM's plants at that rate, Bradley
said, the outcry would have closed them down long ago.
"I really sat up and took
notice," Becker recalled recently. "I said, 'I could do the
same numbers for Xerox.' These numbers have real magnitude."
He wasn't the only one who
was impressed. Sitting next to him was Renee Brownstein, at the time Eastman
Kodak's benefits director. "It just kind of blew your mind,"
she remembered. When the meeting was over, the two shared a cab to the
airport and talked about the numbers the whole way.
Today, Xerox and more than
100 other large corporations (along with a few labor unions, nonprofits
and government agencies) are embarked on a campaign to reduce medical
errors, increase patient safety and enhance the care of hospitalized Americans.
They've drawn up a short list of specific goals they want the country's
hospitals -- or at least the big ones -- to meet in the near future and,
in effect, have nailed the list to the institutions' doors.
For starters, it's unusual
for industrial companies to give advice directly to hospitals and doctors.
It was always assumed that corporations making cars or photocopiers didn't
have the expertise to engage in such meddling.
Furthermore, the campaign is
premised on the idea that while the companies wield big sticks, they probably
won't have to use them as they step into the touchy marketplace of medical
care and treatment choice. Instead, they hope to achieve the goals of
safer, better and more efficient hospital care by sponsoring what amounts
to a Patients' Crusade. They want to get their employees to walk away
from from poor-performing institutions.
Perhaps most important, the
campaign potentially offers a more palatable way to control -- or at least
slow -- increases in health care costs in the United States, which are
rising steeply again after a brief lull in the mid-1990s. Against that
apparently unstoppable trend, this strategy is the Sleeping Giant -- powerful,
slow to wake and so big it's been overlooked by nearly everyone.
The
'Recommendations'
The main embodiment of this
strategy is an organization launched two years ago called The Leapfrog
Group, a collection of the country's biggest corporations that have agreed
to promote and publicize three specific hospital practices:
- Computer software systems
that replace paper-based ordering of drugs and medical tests. "Computerized
physician order entry" (CPOE) technologies eliminate errors that
result from misread handwriting and can help prevent overdoses, incorrect
doses, drug interactions and allergic reactions arising from medications.
The more sophisticated systems also offer physicians advice on diagnostic
testing.
- Limiting intensive care
unit (ICU) staffing to physicians specially trained in intensive care
medicine. Research has shown that ICUs with so-called "closed staffing"
have substantially lower mortality rates than ones in which primary
care doctors manage the treatment of critically ill patients with experts
providing consultation when asked.
- The limitation of certain
high-risk procedures to hospitals that do lots of them. The relationship
between high volumes and good outcomes in coronary artery bypass surgery
and numerous other complicated therapies has been evident for years.
The Leapfrog Group calls this goal "evidence-based hospital referral."
The founders of The Leapfrog
Group chose the three goals carefully. They consulted many health services
and outcomes researchers, says Suzanne Delbanco, executive director of
the Washington-based organization, and in effect asked: "If you were
to come up with the seat belts, air bags and anti-lock brakes for the
health care system, what would they be?" The three agreed upon are
backed by overwhelming and incontrovertible evidence of benefit.
The value of the three "leaps"
(as their proponents call them) may be beyond question, but that doesn't
mean they're being eagerly embraced by the nation's hospitals.
"I think it's safe to
say that the majority of our constituency is uncomfortable with Leapfrog,"
said Richard H. Wade, senior vice president of the American Hospital Association.
"They are holding out a set of standards that it would be impossible
for all but the most sophisticated hospitals to meet."
Only about one-third of hospitals
are in a position to make the investments necessary to buy CPOE systems,
which cost between about $2.5 million and $10 million, Wade said. (About
one-third of hospitals break even and one-third lose money, he added.)
Many have other high priorities intimately related to quality and safety,
such as hiring more nurses and replacing aging facilities.
There's also more than a touch
of resentment that, after a decade of what appeared to be single-minded
focus by employers and insurers on controlling hospital costs, "they're
now saying, okay, let's look at quality," Wade said.
The Leapfrog Group doesn't
argue with a lot of that, which is why so far it has directed its campaign
to a few urban areas and has avoided any threatening language.
As the Leapfrog effort begins,
statistics show plenty of room for improvement. Only
5 percent of American hospitals have CPOE systems. Only 10
percent of them meet the closed-staff ICU standard. The number of institutions
meeting the volume standards depends on the procedure.
About half of coronary artery
bypass operations and two-thirds of carotid endarterectomies (operations
that remove blockages in the arteries supplying blood to the brain) are
now done at what the group considers "low-volume hospitals."
Getting
the Word Out
At the moment, The Leapfrog
Group is promoting the three goals mostly by publicizing them. It has
created a survey and focused on getting hospitals in six regions -- Atlanta,
California, East Tennessee, Minnesota, Seattle and St. Louis -- to fill
it out. (A list of 10 additional target regions is to be announced next
month.) The survey results are posted on the organization's Web site,
www.leapfroggroup.org,
as are explanations of why consumers should care about such things.
The notion that medical errors
waste money "was one of the few business propositions one could take
to senior management and they would accept without proof," said Charles
R. Buck, who until retiring last year was head of health care quality
initiatives at General Electric. "They know that when you're error-free
from the customer's point of view, money just seems to fall out of trees."
In
Reality
The economic pressure The Leapfrog
Group's members are exerting on hospitals and doctors is subtle and will
take years to bear fruit. It's not like the sudden arm-twisting that insurance
companies engaged in a decade ago to get the price concessions those same
employers demanded.
Consider, for example, what's
happening in New York, Atlanta and Seattle.
Five companies in the New York
City area, with a total of about 100,000 employees and dependents in their
health plans, have agreed to pay small bonuses to hospitals meeting the
first two Leapfrog goals, CPOE systems and closed-staff ICUs.
They will add 4 percent on
top of whatever the hospital is reimbursed for a person's care. Of the
148 hospitals in the region served by Empire Blue Cross and Blue Shield,
10 have signed up for the program.
The companies -- Xerox, IBM,
Pepsi, Verizon and Empire itself -- expect to pay a total of about $2
million in bonuses over the next three years. That would buy one hospital
an entry-level CPOE system.
Maimonides Medical Center,
a 755-bed hospital in Brooklyn, has CPOE and is acquiring a totally computerized
patient-record system that will go into use later this year. The hospital
had revenues of $512 million in 2000. It expects to receive between $15,000
and $25,000 in bonuses this year.
In the Atlanta area, Delta
Air Lines has 75,000 health plan members, almost all of whose inpatient
care is provided by 21 hospitals. All the institutions have filled out
the Leapfrog survey, most at the request of Delta officials who met with
executives of about a dozen hospitals and hospital chains.
None of the 21 has CPOE systems.
None has closed-staff ICUs.
"We have indicated that
these are the things that we will value in our purchasing decisions in
the future," said Miles Snowden, a physician and director of health
services for Delta. "We have told them that it is our goal to provide
whatever incentives are necessary to have more than half of our hospital
discharges occur from facilities that meet all three leaps by the end
of 2004 in urban areas."
What
sort of incentives?
Snowden said it begins with
good publicity, and may move on to lowering co-payments for patients who
choose hospitals that meet the goals. Ultimately, institutions that don't
meet the goals "within a reasonable period of time" may be dropped
from preferred networks of reimbursement.
"We don't believe that
the system is short of money for these investments. The issue is deciding
where the investments go," Snowden said.
In Seattle, a delegation from
Boeing and the International Association of Machinists and Aerospace Workers
has met with 18 hospital systems that run, in all, about 25 hospitals.
As with Delta, the delegation's main purpose was to convey a message to
the hospitals' executives that they may want to consider the Leapfrog
goals when mapping out long-term budgets.
All the Seattle hospitals have
filled out the survey. About half provided commitments to install CPOE
systems in the next two years, and some others have said they will have
them by 2004 or 2005, said Greg Marchand, Boeing's senior manager for
health and welfare operations. A few meet the ICU standard, and others
are working on it.
About 70 percent of Boeing's
employees make their health-plan enrollment selections online. The company
is promoting the campaign on its Web site.
Washington
Post March 26, 2002; Page HE01
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