At “Healthcare Renewal” (hcrenewal.blogspot.com) Brown University’s Dr. Roy Poses recently posted a thought-provoking piece about the Leapfrog Group, an employer group that has made its reputation pushing for higher quality care. Poses points out that nearly 30% of the members of Leapfrog are healthcare corporations, and notes that this might skew their view of healthcare’s goals:
“One would expect that companies who make money by providing health care goods and services may have different ideas about health care costs and quality than companies who do not do any health care related business” said Poses in his post.
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The Leapfrog group includes, “some well known large companies, such as Boeing and IBM,” Poses acknowledges, “But what is most striking about its membership is the prevalence of health care corporations. A full 14 of 49 members (28.6%) are health care corporations. These include pharmaceutical companies, e.g.
- Boehringer Ingelheim,
- Eli Lilly
- Sanofi-Aventis
“These also include health care insurers and managed care organizations, e.g.,
- Aetna Inc,
- Blue Shield of California,
- HCA,
- UnitedHealth
- Wellpoint
…as well as hospitals and hospital networks, e.g.,
- Greenville Hospital System
- Heartland Surgical Specialty Hospital
And other health care companies, e.g.
- Milliman (purveyors of care guidelines)
- Thomson Healthcare (providers of health care information resources)
Finally, Poses notes, Leapfrog “includes companies that, while not being purely in health care, have significant health care businesses, such as General Electric.”
Does this bias the group’s definition of “quality” care? Perhaps.
Two weeks ago, when Leapfrog released a list of the nation’s 41 top hospitals, quite a few of the benchmarks for quality depended on whether or not the hospital had been able to invest in expensive health care technology, such as computerized medical records and neo-natal intensive care units. Hospitals were not rewarded for low-tech care—such as having smoking cessation centers or palliative care counselors.
As Web M.D. explained, “To score well” in the Leapfrog survey, hospitals had to win points in four categories: “having intensive care units staffed by specially trained doctors, having computerized order-entry systems for medications and other orders with error-prevention measures, performing procedures such as cardiac catheterization and caring for certain high-risk neonatal conditions, and performing safe practices such as those designed to control hospital-related infections and cut down on medication and treatment errors.”
Overall, Leapfrog judged hospitals on two criteria: “Safety Practices and Top Performance in High-Risk Procedures” [my emphasis]. And while “safety” included low-tech procedures such as hand-washing, the emphasis on “high-risk procedures” meant that Leap-Frog was saving its gold stars for hospitals that offered the most expensive, intensive care –which in turn, usually requires the most expensive, cutting-edge technologies, drugs and equipment.
Now, I completely agree that computerized systems for ordering drugs are needed to prevent errors and save lives. According to Leapfrog, only 10% of the hospitals they surveyed use computerized systems to keep track of doctors’ orders. Clearly, this indicates the need for more widespread use of electronic medical records—though it far from clear as to who will pay for them.
When it comes to neonatal intensive care units, however, there is some evidence that we have too many in some regions of the U.S. and have reached a point of diminishing returns. At that point, additional ICUs are not saving more infants lives but may be leading to over-use which can, in fact, threaten a baby’s health (See The New England Journal of Medicine, May 2002).
Perhaps if a different group were rating hospitals, it might focus on hospitals that excelled in safety and Top Performance in Preventive Care. In that case, the winners might well be poorer hospitals that cannot afford a high volume of expensive technology, but make an all-out effort to open neighborhood clinics and offer counseling and preventive care like OB/GYN exams and Pap smears.
Finally, let me stress that Roy Poses is not suggesting that Leap-Frog’s quality standards are necessarily biased, but he is suggesting that quality assessment is yet another area where we need more transparency regarding possible conflict of interest. As he puts it, while “it is the truth that the Leapfrog Group is an organization of employers, it is not the whole relevant truth. In fact, it appears that the Group includes significant representation of companies who have vested interests in health care being done in certain ways. Thus, its ideas about how to improve quality and lower costs may have been influenced by the vested interests of its members, which may not represent just the interests of employers who provide health insurance to their employees. At least, the organization should make clear that it includes ‘employers’ who also sell drugs, sell health insurance, manage care, and market health care information [my emphasis].
“This seems like another example, in a somewhat different dimension, of conflicts of interest in health care, and of the failure of such conflicts to be clearly disclosed. This also seems like another demonstration that things are rarely what they seem in the complex and not always honest world of health care, particularly in the US.”
To read Poses’ entire post, with links to other posts, click here.