Leah Binder on How Price and Transparency help patients and employees
Leapfrog Group president and CEO Leah Binder talks with Harry about data transparency and how it helps inform healthcare decisions by putting the right information in the hands of patients and employers.
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Harry Glorikian: Welcome to the Money ball medicine podcast, I’m your host Harry glory camp. This series is all about the data-driven transformation of the healthcare and life sciences landscape. Each episode we dive deep through one-on-one interviews with leaders in the new cost-conscious, value-based healthcare economy. We look at the challenges and opportunities they’re facing and their predictions for the years to come.
So, my guest today is Leah Binder, Leah is the president and CEO of the Leapfrog Group. The Leapfrog Group represents employers and other purchasers of health care who call for improved safety and quality and hospitals. She is a regular contributor to forbes.com, The Huffington Post and The Wall Street Journal expert forum. She was named on Becker’s list of the 50 most powerful people in healthcare in 2014, and consistently cited by modern health care among the 100 most influential people and top 25 women in healthcare.
She has served on numerous national boards and councils including the Institute of Medicine collaboration on patient engagement, the Health Care Financial Management Association Leadership Advisory Committee, but Corey healthcare systems advisory panel, AARP champions for Nursing strategic advisory council and the national priorities partnership board. Prior to her current position, she spent eight years as vice president at Franklin Community Health Network an award-winning rural hospital network in Farmington Maine.
he previously worked as a senior policy adviser for the office of mayor Rudolph Giuliani in New York City and started her career at the National League for nursing, where she handled policy and communications for more than six years. Thank you very much for joining me today, good to have you here.
Leah Binder: Well, thank you for having me, it’s a privilege.
Harry Glorikian: So, we had spoken quite a bit back when I was putting together the book Money ball medicine but for those people who are not familiar with the Leapfrog Group, can you tell us a little bit about the group its mission and what you feel the biggest impacts are it’s made to date?
Leah Binder: Sure and I want to congratulate you by the way on your book, I really thought it was fantastic. I’ve been giving it out to a lot of my colleagues I strongly recommend it. So, congratulations on an excellent book, I think it really captured some very important issues about where we are in healthcare right now. So, it’s a great contribution.
Harry Glorikian: Thank you so much.
Leah Binder: The Leapfrog Group is a non-profit, we were national. We were founded in the year 2000 by a group of senior executives in large companies, who were concerned about healthcare quality and costs. They were particularly concerned about a report that came out from the Institute of Medicine, right around that time that was called to air is human. Which said that, upwards of a hundred thousand people were dying of preventable medical errors in hospitals every year.
And they were astounded by that number not only because that’s a lot of people dying and when they did the numbers on their own covered lives, for many of them that meant one of their people were dying you know every day or every other day, because many of these executives such as companies like GE covered a lot of people. And they were not only were they just devastated to think that, their people were experiencing this kind of loss but also that they didn’t know anything about it, that in spite of all of their efforts to try to improve healthcare and get their cost down and manage their health benefits well.
They had no idea that this was going on and this had such an impact, and so they wanted to change that, so they decided that it was time to have a more transparent marketplace in health care. They would through leapfrog this nonprofit, they would start to publicly report on the relative safety of every hospital in the country. And they would encourage their employees in the American public to shop for their hospital care to think about safety, before they walk in the door of a hospital. And in so doing not only would they protect their employees, but hopefully drive a market for improvements in safety and throughout the country and improve the quality of care nationally.
So, that’s the goal, we publicly report on hospitals and now we’re moving into other settings as well. But our goal is to collect information using the leverage of large purchasers, large companies typically a purchasers of health benefits, using their leverage to suggest to hospitals and other health systems that they give us information, that’s otherwise not available. And then we publicly reported in the interest of giving consumers what information they deserve to have about how the health care system is doing.
Harry Glorikian: So, when I was writing the book, I found that even when patients were armed with data and information tools designed to help them decide between you know different healthcare providers. They don’t seem to be using the tools you know to the degree that they can. Are patients ready to fully you know activate their emerging role take advantage of it or can we make technology easier to use for them in some way?
Leah Binder: Well, yes to both. Yes, consumers are increasingly using information but not anywhere near the level that they should, but that will change. We are in a very fast changing environment not only in healthcare but in general. I think consumers even five years ago shopped very differently for almost everything, and now that’s changing as well in healthcare and it’s been changing. And so, I think we’re seeing those changes in the way consumers are using technology to make decisions about their own healthcare and when the Millennials get a little bit older just a little bit and they start to recognize their own mortality and need health care more. I think that’s when we’re going to see the real explosion in the change in healthcare.
Because they just aren’t, there to intolerant of the idea that they cannot use a smartphone for instance to access pretty much any information they could possibly need to make it an important decision like a healthcare decision. So, I think that we’re going to see a major shift in consumer use of technology. But I think that one of the big changes we’ve seen with this newly transparent environment and the is not as much on consumer behavior yet, but on how the healthcare industry itself functions, in anticipation of consumers increasingly using information to make those kinds of decision. And that’s where we’ve seen I think some very significant shifts in the healthcare industry already.
Harry Glorikian: So, can you give me an example of where you’re seeing that? I’ve seen a lot from CMS seems to be really pushing, you know wanting information to be transparent or putting information out there. But you know, what do you see happening really on the ground and can you give me a couple of examples?
Leah Binder: Sure one thing we’re seeing with hospitals is an unbelievable focus on their own metrics. I’ve been out visiting a number of hospitals and I’m struck by how many of them have on their walls, information about how they’re doing on a whole variety of patient safety metrics like, how many Falls and how many you know infections and etc. And many of them are putting this on walls that are accessible by patients but they’re all over the place. I see metrics everywhere; this is a very different. I never saw that five years ago or very rarely saw that five years ago.
So, they’re within health systems, they are communicating to clinician to clinician, how they’re doing and they’re looking at real card data to do that. And so there’s just that level of internal transparent see that we’re seeing, that does have a big impact I think on performance. And I think also there’s a whole new job title in healthcare, and if you’ve seen this, I think this came about really it started about five years ago we started to see this, but now it’s become much more ubiquitous this new brand new job title. Chief, usually called the chief engagement officer and so it’s usually a c-suite title.
So, chief engagement officer reporting to the CEO of a health system, this person is usually responsible for patient engagement, how patients are experiencing the health care system. So, you think, well health care should have been doing that from the very beginning of course that should have been all about patient engagement, right. That’s what everybody should be doing but you know for whatever reason and there’s lots of reasons we could go into her an hour, they have not put the patients at the center of absolutely everything that goes on in healthcare, that’s not the tradition in health care.
So, the fact that they’re now seeing these new chief engagement officers emerge is another sign that health systems are truly changing their orientation to their work and recognizing that they have to pivot around new priorities, and the new priority is the patient. So, we’re seeing a real shift.
Harry Glorikian: So, now do you believe that’s driven by how the system is being compensated or is it competition or technology? What do you think is the driver?
Leah Binder: I wish, I could say it’s driven by how they’re paying, because how they’re being paid because that would mean that where we’re seeing what I would say is the most sustainable kind of change. If we were really paying healthcare and we had a different kind of economic infrastructure of our healthcare system, I would say that’s a very long-term change that will benefit all of us. And I think many of, both within the healthcare system and outside of it, would like to see that happen and are pushing for that to happen and we’re seeing certainly some inroads around that in. For example, in the notion of value-based payment etc., and we’re seeing that happen, however I would not say that that right now is the driver.
I still think right now probably the majority of health care is paid fee-for-service with some significant inroads and other models, but still fee-for-service really does dominate the landscape in terms of the payment of health care, where I see it’s driven though is that those who are paying is shifting and shifting in significant ways. Right now most large employers and many smaller employers have shifted toward high deductible health plans which are typically three-thousand-dollar deductible, for example for families or more for families and about 1,500 or more for individual plans and in that, underneath that deductible.
So, before you hit that deductible every dime has to be spent by the employee or the covered person, including drugs and other kinds of services that in more traditional health plans were already covered, even if you hadn’t already spent it ductile. So, I’m not trying to give a boring lecture on insurance policy or anything, but the point is that for many people who are covered by health insurance they’re actually paying most of their health care if not all of their health care in a given year out of their own pocket. And that is about one in three American workers now covered by one of these plans, that’s a gigantic shifts happened over the past ten years.
It’s gone from zero, covered by one of these to a third of all workers that’s a major transformation of our health care system. It’s been cited in lots of reports and research studies as a change in our thinking about health care. So, the people paying the bills and health care now is changing, and when consumers are paying out of their own pocket it does change the way they behave in the marketplace. As opposed to, for example paying just the standard copay, they’re actually wanting to know what is that doctor going to bill me for this visit, and that changes how they think about their choice of that doctor and that service.
Now there’s lots of debate about whether it’s good or bad or whatever, but beyond that is just simply the fact that, that’s changed the economics of health care. Which in turn has gotten the attention of health care providers at least, who recognized that they had better become more responsive to consumers because it’s the consumers directly paying a lot of their bills.
Harry Glorikian: So based on that, what should have done senior healthcare IT leaders, you know startup companies you know we’re hearing about Google and Amazon delivery. What can they do to sort of help the providers that are on the ground, you know clinicians, operational people you know improve healthcare delivery, you know on the ground you know. How to get them to think about it differently and how to get them to implement it?
Leah Binder: I think that for startups, one of the first pieces of advice I would have for any startup is, not to approach the healthcare market without someone on your team and in a very significant position on your team, who is from the healthcare system and very familiar with it and how your product or service integrates. I say that because, I see some startups that come into the market and they don’t necessarily have a person who’s that integrated who has that knowledge of the healthcare system. And they come in and they say, well I have this product and it will for example improve patient safety.
I can look at all the numbers and say that patient safety is nowhere near where it needs to be, and this product solves all problems in patient safety or many problems in patient safety. So, obviously it’s going to be very popular, and we’re going to do extremely well in the marketplace. They don’t necessarily understand some of the barriers that have existed in the market and why great ideas around patient safety have not always sold the way they should in theory sell. And it takes really someone from within the healthcare system to understand some of the frankly insane nuances of the health care system.
There are things about the health care system there just don’t make any sense in a normal market, so you have to have someone in the inside who understands that else. You can easily go down a road that sounds logical but doesn’t make just don’t work in healthcare. So, that’s my first piece of advice for startups, but in terms of technology I think that technology that is easily accessible by consumers, is always going to be a good start for anyone. But it isn’t necessarily going to be immediately impactful and usable in healthcare.
It’s a longer-term play, as I mentioned I think Millennials as they come more into the market as consumers are increasingly demanding that level of accessibility in the healthcare system. The new enterprises, we’re seeing like CVS and Caremark and the work that we’re seeing certainly with Warren Buffett etc. Amazon the entries in the marketplace of traditionally consumer focused, extremely innovative organizations into the health care system suggests that it’s coming but it’s not immediate. So, don’t expect immediate overnight results, but it is something that will definitely be a tipping point soon. So, it would be great to be positioned in that marketplace.
Harry Glorikian: So, speaking of those of that trend is you know, what do you see is the top healthcare technology trends that are around the areas that you’re really working in sort of transparency information. I keep thinking of like you know your smartphone knows exactly where you are and can give you pricing nearby or something like that. and then you know of course the big hot button right, AI machine learning and where is that playing a role. And what do you see happening in those areas, and who might be some of the companies that are driving in that area?
Leah Binder: I see a lot of work around AI for administration of claims data for purchasers and attempts to, I think one of the first efforts around AI with regard to purchasers was to try to see if you could predict who is going to need the most health services in the future. So, to try and look at claims and patterns of use of healthcare benefits to see if you can, you know identify those people who were most likely to for example have a heart attack in the next five years or something, and so to be able to intervene with them earlier.
I think that that has largely not yielded quite the results. I think everyone hoped for and I think now there the effort is really around at least that I’m seeing for purchasers is to really look at how can we identify the best practices, the best possible providers and help guide employees toward, or steer them toward those higher performing, more efficient providers. I’m seeing increasing efforts by purchasers for instance to give their employees services like second opinion services or other kinds of support, so they can navigate the health care system. And I think they’re using AI a little bit to try and form the right kinds of networks and develop the right kinds of expertise that they need. Because even though leapfrog provides a lot, I mean for example my organization leapfrog provides a lot of quality and safety information, we don’t pretend to provide enough of it.
And I think that employee and really the market, our information on quality safety transparency cost is really still at an early stage. And I think that employers are starting to use their claims data in more sophisticated ways to get at information that they can use right away as opposed to waiting for the rest of the country to catch up on quality and safety. So, I’m seeing a lot more aggressive efforts to help people navigate the health care system by employers.
Harry Glorikian: Obviously you are talking to the leaders of these employer led health plans and so forth -. What should they be doing more of or what could they be doing more off to drive this?
Leah Binder: Well, the first thing that they should really be doing is accessing or expecting their plans to access all of the data that’s available. So, as I mentioned I don’t think, we ever can say we have quite enough we’re still in the early stages in some respects of getting as much data as we need, but there is good data that’s out there. So, asking and insisting that their employees can access the best possible data, so they can make good decisions about where they’re going to seek care and then use that data in innovative ways, and put money on the table for that.
There’s companies like Ingersoll Rand for instance, who are actually providing incentives, financial incentives for employees to use their services that they provide to help employees navigate the system, so to give them information on you know which are doing a better job of and where they can get second opinions etc. So, when their employees use it, they actually get money in their health savings account. That’s a really good and innovative way and I think that it’s a simple way too. It’s not all that complicated for employers to just say, we want you to just talk to them try to get a second opinion make sure you know what you should know about the performance of the providers, you’re considering and then use it.
I think where we’re going to see more technology come into play and I’m hopeful, but I haven’t seen it happen yet but I would suggest it’s a good idea. So, I’m hopeful that somebody’s going to do it is, where we see employers able to connect their claims from their health benefits with other kinds of health care that they invest in, but they tend to think of as separate. So, like worker’s compensation or disability, short-term or long-term disability benefits they’re all connected to the health of the same people. But they often see them as totally separate enterprises and in fact they’re connected and the company’s paying for both.
So, the more we can see longer-term and more integrated assessment of the overall spending around individual patients, and how individual people are impacted by a whole variety of things that happen to them in the healthcare system, that’s when we’re going to start to see more nuance in purchasing behavior. So, an example would be, we’ve had employers start to try to really understand how errors and accidents, infections in hospitals are affecting their own employee population. These things don’t appear on standard claims, typically sometimes they do but not typically.
Typically, if there’s let’s say and medication error made, there’s no particular bill, there’s no line on your claim that says you know you paid for this error. It’s kind of buried inside the claim, if it’s even noted in the claim and it’s hard for employers to detect it, and yet these are very common. All the literature on errors and accidents is that they are extremely common, that as many as one in four patients admitted to a hospital or experiencing some kind of harm. So, it’s very common and employers are paying for that, so they really do want to understand where it’s happening and most often and in so doing be able to try and prevent it.
And there are ways to use AI as well in exploring claims and to look for things like excess length of stays, that don’t match a diagnosis or things like that help them to be able to at least trigger a closer review of a claim and to begin to observe patterns that are troublesome. So, I think that what we’re seeing with for technology at least from the employer perspective is an ability to be much more nuanced and much more sophisticated in really looking at the experience of their employees. And then using that in more effective ways to help their employees get the right kind of care.
Harry Glorikian: Jumping back to Leapfrog. So, what will be happening at leapfrog in the next couple of years where is the, where are you taking the organization and what would you like to see the organism and develop and/or produced to help this, in this long goal?
Leah Binder: Our goal is to save people’s lives and on a fundamental level, so that you are protected when you go to a hospital or any kind of health system. But that your well-being is a primary consideration which will protect your life. It is a, you know five hundred people a day, upwards of 500 people a day die preventable errors in hospital. So, it is a major issue for people to be protected from that. So, we want to change the market, so that that’s not happening anymore and so that people can better protect themselves by making the right choices.
And so we continue to focus on patient safety and using all of the technology that is available to us and to our members, our purchasers to try and do that. Whether it’s find the errors and publicly report them, which is what we do at leapfrog for employers as a group nationally, or find them in your own claims for one in particular purchaser which we simply, we advocate that they do and we help connect them with the resources to do it.
And then what we’re focusing on right now is hospitals, but we are also in 2019 moving toward ambulatory surgery centers, as well as outpatient surgery. 60% of all surgeries are now done on outpatient basis or in ambulatory surgery centers. So, we’re going to be looking at safety and quality there as well. And in addition to what we do in reporting this data ourselves, we also advocate with CMS to make sure they report it, and we’ve been strong advocates since our inception and in many respects why CMS currently reports so much data is, a lot of the work of people at leapfrog and are continuing very strong efforts to make sure, not only that we can get the information but also that it’s made publicly available to everyone.
So, we continue to be needed believe me to get that information available to people, and to get it used to make it easy for purchasers to use it and in sophisticated ways and to get, to drive that market for better care.
Harry Glorikian: Are there any, I guess stories that you could share where this information really made a difference with either an individual or a group, whether it’s the cost impact or anything of that nature that you could share? You know just going back to Moneyball medicine, which is all about you know how data is changing practice of medicine or how patients look at their care and how they manage themselves and how that affects. Obviously what we all look at is is price or cost or you know combination of those two things.
Leah Binder: Right and we definitely have had a number of successes that we do think are important, and that you mentioned price and cost and I just want to make a little comment about that, they’re different. The cost of care to the purchaser is one thing, the cost to the provider is another thing. Those are two different things, but for purchasers they’re very interested in price transparency. They want to know how much each provider is charging their employees and then that’s the price and then they want people to be able to compare among prices.
That’s really important, but it’s not the only thing and the example that I give around that is that, you can know the price that a particular, say Hospital is charging for childbirth. Let’s say for a normal vaginal delivery and for a C-section etc., you could find out the pricing. But what you also want to know is what is the rate of C-section, because that varies tremendously. We see variations in our data you know some hospitals will have upwards of 40 or more percent of all births via C-section, others will have you know below 20 percent C-section.
So, a C-section is roughly twice the cost to an employer and to consumer, it’s twice the cost of a vaginal delivery. So, if you’re going to a hospital that has a much higher propensity for C-section births you’re going to pay more and that’s not a price issue they may charge a slightly lower price for their C-sections that is a cost issue and that’s a quality issue. So, quality and cost and price are all integrated and it’s not enough just to pull out one. You have to look at all of them together and so our examples of what we’ve seen with leapfrog have to do with that integration.
An example would be, there’s a hospital, we publicly report as I just mentioned C-section rates by hospital where the only source that information we ask hospitals through the Leapfrog Hospital survey to voluntarily report to us on that. It is a standardized rate, so it’s adjusted for all of the factors that can go into differences among hospitals in their C-section rates. We try to adjust for those things and it’s a rate, that’s used by Joint Commission for example which is accrediting body for most hospitals and other, it’s endorsed by the NQF it. So, it’s a good measure of C-sections that you can use to compare among hospitals, and again we do find major variation.
So, one Hospital which we wrote up in a case study which is on our website leapfroggroupe.org and available anyone if you want to take a look at it is, they recognized through doing a leapfrog survey that their rate was higher than others and it did not meet the Leapfrog standard. And they as a result launched a campaign and they lowered that rate, significantly another meeting to standard. Simple example maybe, but that is saving a significant amount of dollars to the people, the women who are using that hospital as well as their employers who are paying for much of their care.
So, that is an example when we’ve seen reductions, and we’ve seen improvements in maternity care for everything that we’ve been reporting. And in some cases dramatic, we were reporting on early elective deliveries. These are deliveries, they’re done without a medical reason early it too early in the pregnancy of 37 to 39 weeks as opposed to 40 weeks, which is when mother nature typically decides time to give birth. And so they’re scheduled anyway and to try and actually get a jump on mother nature, so that I guess you can get the right doctor or there’s various reasons it’s just more convenient to schedule it.
But it’s not safe, it’s not a good thing to do. It’s not safe for the baby, it’s not safe for the mother and often results in a NICU stay which are very expensive as well as just not safe and not healthy. So, those went from a rate when we first started reporting them publicly, again we are the only source of that information. Back in 2010, we were reporting a rate of about 17% and now the rates down to about 2% nationally. So, that’s a massive decline a major change in the delivery of maternity care and it has definitely saved, probably hundreds of thousands of babies from a stay in the NICU and saved a lot of costs as well.
So, in maternity care we can definitely see the impact of the transparency movement. And we are not doing the work by the way, we’re not a critic for the enormous amount of work it takes to reduce you know your rate of early elective deliveries or your rate of C-sections. That’s some pretty substantial leadership and hard work by providers, but transparency and markets work and that’s what we see when we start publicly reporting on a measure like that.
Harry Glorikian: Yeah, know I mean, we all know that you know transparency changes a lot of markets. It’s when things are not transparent and opaque that strange things happen, either people comparing themselves to others because they have no idea what the other person is doing or just the patient being informed. And you know I always thought to myself you know once this information is available, and you can make some pretty interesting apps and analytics to identify different things either to the providers themselves or to the patients.
Leah Binder: Right and the providers when see their own performance in comparison with others, it does help them to understand what they can do better. And and it usually motivates and galvanizes changing, that’s a key aspect of everything.
Harry Glorikian: So, is there anything that I haven’t asked you that, you would love for the listeners of today to hear about, either changes in the marketplace technology or you know things that leapfrog is working on itself?
Leah Binder: Well, one of the areas of technology that we put a lot of emphasis on is the safety of technology used by hospitals, and specifically how safe it is, how well it protects patients from common errors. So, an example of what we have classically looked at is computerized physician order entry or provider order entry, depending on who you talk to, but it’s CPOE, computerized order entry. It’s used for medications and the prescriber enters an order in to the system the CPOE system.
They enter the medication order in for a specific patient, it connects to the patient record and if that order would cause an allergy problem with the patient or it’s a drug interaction with something else that the patient is taking, then the CPOE system fires an alert at the physician. Typically, it says you know this the patient’s allergic, do you want to change the order etc. And that has really reduced errors in the hospitals the most common error made in hospitals by far our medication errors. And so the CPOE systems have had an impact on that.
So, what leapfrog has done is, we actually give a test to hospitals. They can, it’s a web-based time test where they can assess whether their system is alerting the way it should and not alerting too much. You want to avoid frivolous alerts so that physicians start ignoring all the alerts. So, it’s actually kind of a balancing act, but we look for systems note that alert when there’s a really terrible medication error that’s being made. So, if doctor enters or prescriber enters something that would definitely cause the patient significant harm or even kill the patient, we want to make sure that system alerts to them and we test for that.
So, we’ve found that about a third of the orders we’ve tested do not alert properly, and so there’s definitely work that needs to be done. So, what I think is the take home message that we’ve learned from this work with CPOE and I think a lot of hospitals have shared with us is that, technology in hospitals is not plug-and-play. You don’t just buy it off the shelf and plug it in now they all sort of know that. But in theory but in reality technology is something you have to monitor constantly.
You have to be vigilant about it, you have to make sure it’s constantly working to the benefit of the patient, and you can’t assume that technology replaces all of the other kinds of efforts you make to keep your patients safe. It augments what you do to keep your patients safe, but it doesn’t replace it. And I say that too because I think when CPOE especially when it first came around, a lot of hospitals thought well. We’ve got this technology now so we can skip a step, we cannot have the nurse check the order at the bedside or something like that. They would skip a step and that’s not safe either, we have found as I said a lot of orders are not alerted properly so that step shouldn’t be skipped.
And also it actually just doesn’t protect the patient enough, but when it’s combined with the systems that are already in place and checks and balances around order entry or any other kind of safety issue, you do find that technology can vastly improve the safety for patients. So, we’ve looked at that, we’ve looked at barcode medication administration and we’re very interested in continuing to monitor. Not just whether hospitals have good technology in place but whether they monitor it and they use it most you know as effectively as possible. And both of those things have to be combined for technology to be effective.
Harry Glorikian: Well, I want to thank you for your time today. This was wonderful and it’s great you know continuing our conversation over time. I’m sure they’ve all talked many times in the future on many different things and I can only wish you guys extreme success, because I’m also getting a little bit older. So, you want the system to work as well as it can.
Leah Binder: Right, we all have a role to play and making sure that happens, and I really do appreciate your book. So, thank you for writing it and for making it available. It’s been a great resource.
Harry Glorikian: Thank you very much for your time, really appreciate it.
Leah Binder: Thank you.
Harry Glorikian: And that’s it for this episode hope you enjoyed the insights and discussion. For more information, please feel free to go to www.glorycamp.com. Hope you join us next time, until then farewell.