On behalf of patients, purchasers, and the public, the Leapfrog Group is a leading voice for safer, higher quality, and more transparent health care. The impetus for its formation was the Institute for Medicine’s urgent call to action and report, To Err is Human. Published in the American Journal of Medicine in 1999, it made it perfectly and publicly clear: medical mistakes are a top cause of preventable harm and death in the United States.

Leapfrog's advocacy started with a simple three-question survey of hospitals. If implemented, each recommendation represented a potential giant leap forward for patient safety. So straightforward and obviously important from today’s lens, it’s hard to understand the pushback that was initially received, with hospitals discrediting the “science” and boycotting the survey. Leapfrog knew all too well that what is was asking was expensive and that the technology was not perfect. Yet, it also understood that the technology would not get better until it was used and that the cost of not acting was both expensive and harmful.  

Leapfrog's first three leaps are still included in its annual, voluntary hospital questionnaire. With results available publicly online, patients, purchasers, and providers can all ask if their hospital has:

(1) Computerized Physician Order Entry (CPOE)
With federal financial support, more than 95% of hospitals have implemented Electronic Health Records (EHRs). Few would consider going back to the old ways of handwritten orders. One report suggests that medical errors have decreased 52% as a result of online ordering, and three times as many physicians reported that their EHR prevented a potential medication error rather than cause one. Yet, there is more to be done. A November 2021 report finds that 7,000 to 9,000 Americans die due to a medication error each year. The total cost of looking after patients with medication-associated errors exceeds $40 billion each year, with over seven million patients affected. 

(2) ICUs staffed with intensivist physicians during daytime hours (can be partially met with telemedicine)
The benefit of having patients cared for by physicians trained in critical care has been well-researched and found to reduce ICU mortality and spending. A recent study published in the Journal of Thoracic and Cardiovascular Surgery found that 24-hour intensivist coverage was associated with lower mortality, lower rates of cardiac arrest, and shorter durations of mechanical ventilation. Interestingly, the practice of a trained intensivist physician assuming responsibility for ICU patients' care has been the mainstay in Europe for decades. According to a 2016 report, only about half of hospitals in the US meet this criteria, and practices vary widely by state.   

(3) Enough surgical volume to safely perform certain high-risk procedures
Unknowingly, patients are often at greater risk of death and complications because their surgical teams do too few procedures (even common ones) for doctors, nurses, and technicians to maintain their skills. For 10 high-risk surgeries, Leapfrog asks hospitals to report their case volumes annually. In 2015, knowing that patients in the hands of low-volume surgeons or hospitals tend to fare worse, a group of leading academic institutions asked all hospitals to “Take the Volume Pledge” to improve surgical outcomes. Johns Hopkins, a leader in this initiative, explains the importance of surgical volume to its potential patients and lists the frequency of 11 procedures performed at its hospitals on its website. 

The evidence that volume matters to surgical outcomes is strong. This 2015 US News and World Report article discusses the issue from a variety of perspectives and provides examples of the importance of volume for surgical cases, including for common surgeries such as a knee replacement.  

The takeaway: a low volume surgeon or hospital may provide a good outcome, but overall patients are likely to have fewer complications and better outcomes in the hands of an experienced surgeon and facility. While it would be nice, we do not have to wait for hospitals to take the volume pledge. Don’t be shy about asking a surgeon directly, or the physician that refers you to a surgeon, for the number of times that they completed this surgery at the recommended facility in the past year. 

Leapfrog was founded to shine a light on hospital performance so that employers and patients could use their purchasing power to reward the top achievers and foster a marketplace for high-value care. Leapfrog reporting has expanded. Today you will find a letter safety grade for every general hospital in the US, as well as measures of infection rates, Cesarean section rates, and health equity. 

Leapfrog’s success depends on all of us using information to seek the safest and best quality care. The BHC is proud to support this effort as a Leapfrog Regional Leader in the St. Louis area. We will continue to highlight Leapfrog advancements and support employer members and the public in accessing and understanding the information. Please let us know how we can assist as you explore the available data.

Warm Regards,

Louise Y. Probst

BHC Executive Director

A recent headline grabbed my attention: the National Institute for Health and Care Excellence (NICE) recommends the United Kingdom’s National Health Service (NHS) cover the new weight loss medication, Wegovy. Given that England’s NHS review process was characterized as a “death panel” by some in the US not long ago, I was eager to understand the details of this recommendation. Both countries recognize obesity as a top driver of poor health and high health care spending and report that more than 60% of their populations are either overweight or obese. 

By way of background, Wegovy is a once a week injectable semaglutide, a medication that mimics the GLP-1 hormone (glucagon-like peptide-1). Released after eating, GLP-1 suppresses appetite and slows gastric motility, making people feel full longer and eat less. Clinical trial data show that participants lost on average 12% more of their body weight compared to a placebo over a 68-week period. Weight loss was found to be higher when combined with a supervised weight loss program. Studies have shown that weight returns, though, when the medication is stopped, suggesting this would be a lifelong treatment. Since its June 2021 US Food and Drug Administration (FDA) approval, Novo has experienced supply chain issues which have limited the drug's availability and postponed its marketing efforts to physicians. Supply chain issues are expected to be resolved in the coming months. Early indications suggest that patient success and physician acceptance is favorable and that product awareness and use are beginning to pick up.

The FDA approved Wegovy for use, in addition to a reduced calorie diet and increased physical activity, for patients with at least one weight-related ailment and a body mass index (BMI) of 27 kg/m2 or greater, as well as for people with or without an obesity comorbidity at a BMI of 30 kg/m2 or greater. Weight-related conditions include high blood pressure, type 2 diabetes, or high cholesterol. 

NICE’s independent appraisal committee recommended that Wegovy be considered as an option for weight management when offered alongside a supervised weight-loss program for a maximum of two years. Patients must have at least one weight-related condition and a BMI of 35 kg/m2 or greater. With exception, patients with a BMI of 30.0 kg/m2 to 34.9 kg/m2 may be considered if they meet certain additional criteria. Individuals from a South Asian, Chinese, and Black African or Caribbean background (known to experience higher rates of preventable premature death) were recommended for consideration at a lower BMI (usually reduced by 2.5 kg/m2).

But what about the price differences?  

Novo has set the list price for Wegovy in the US at $1,349 for a four-week supply. Rebates are generally understood to be about 20% to 22% of the list price. This means that net of rebates, Wegovy will cost over $13,000 per patient per year in the US.   

In the UK, not so much. Wegovy has a list price of about $99.08 (£73.25) for a four-week supply, or just under $1,300 per patient per year. So before any negotiations off of the list price, the annual cost in the UK is less than a one-month, after-rebate supply in the US.

We all know that the US has a very different and cumbersome supply chain, especially when compared to a single-payer system like that in the UK. So I was prepared for a price that was double, triple, or maybe quadruple – but not ten times or more.  

Why is it priced so much higher in the US? Well, it seems that it is the usual answer…“because it can." Wegovy is but one example of a problem we see often in the US pharmaceutical industry. 

The Institute for Clinical and Economic Review (ICER), the US' non-profit, private-sector response to the UK’s NICE, has announced that it will undertake a review of Wegovy this fall. Using an open, transparent, and independent consensus-based process, ICER reviews medications and establishes a fair price for use in the US. ICER leaders have been giving a lot of thought to how employers in the US could leverage this work to achieve better value for their investments in pharmaceuticals. Several possible solutions in their forthcoming Purchaser Playbook hold appeal. BHC members can get a sneak peek at these recommendations, and we look forward to receiving your feedback. Let’s not despair. Let’s take action.

Warm Regards,

Louise Y. Probst

BHC Executive Director

The 2021 No Surprises Act provisions to protect the public from the most painful of surprise bills, air ambulance transport, will take effect January 1, 2022. Yet, the controversy over establishing a process to identify a “fair” payment rate remains under dispute. 

Congress directed federal agencies, including the U.S. Department of Health and Human Services (HHS), to establish a federal Independent Dispute Resolution (IDR) system to be available for use after thirty days of unsuccessful negotiations between a payer and air ambulance provider. Under the proposed IDR system, an approved arbitrator entity would receive information about each party’s claim, additional requested information, and the “qualified payment amount” (QPA) or the plan’s median in-network payment. Modeled after the “baseball-style” arbitration, the IDR entity selects one offer, which becomes binding on both parties. The losing party must pay the fees associated with the IDR process.

Recognizing that billed charges can be inflationary and that public program rates are significantly lower than commercial payments, Congress barred the IDR arbitrators from considering: (1) a provider or facility’s usual and customary charge or the billed charge; or (2) reimbursement rates paid by public payers. The law lists the QPA as a must-be considered factor and gives the IDR the authority to determine how other factors influence their determination. These other “additional factors” likely include geography, market share, service expertise or level, etc. The IDR entity is also required to explain their decisions when selecting an offer that is higher than the QPA.

Both the Association of Air Medical Services (AAMS) and the Texas Hospital Association have filed suits in federal court challenging the proposed rules. According to a December 6th Health Affairs blog post, both suits claim that the agencies have given priority to the QPA, and as such, the new federal IDR process favors insurers. The lawsuits claim that the rules are not consistent with what Congress intended because of the heavy weight placed on the qualifying payment amount in the arbitration process.

Administration officials, purchasers, plans, and patients believe that the agencies did what Congress instructed. Their goal was for the IDR process to help to lower health care spending, and they find that many of the provisions are necessary to encourage the parties to work together in earnest to resolve their dispute, rather than relying the arbitration process. If QPA is not considered, they fear that patients, employers, and public insurance programs could face higher premiums. 

Hotly debated and lobbied political issues are a strong indication of the amount of money on the table. Operating as an “out-of-network” provider has brought price-setting power to air ambulance companies and hefty profits. Research from the USC-Brookings Schaeffer Initiative for Health Policy revealed that by 2017, two private equity firms controlled nearly two-thirds of the national Medicare market for both fixed-wing and helicopter air ambulance transports and that transports delivered by private equity and publicly-traded firms were the most expensive, often reimbursed at 50 percent more.  

According to Heathcare Dive, Congress is also weighing in on the rules, with 152 lawmakers signing a letter on November 5 stating the latest rules "do not reflect the way the law was written, do not reflect a policy that could have passed Congress…” Besides stating the obvious, since these issues were debated for months in Congress, before the details were assigned to the federal agencies to determine, their letter seems to value the financial interest of the private equity firms above that of the American public. The Healthcare Dive article links you to the letter and 152 Congressional signors. Take a look and see what you think.  

Stay tuned. Resolution of these pending lawsuits is expected in early 2022. 

Warm regards,

Louise Y. Probst

BHC Executive Director

St. Louis, Missouri, November 10, 2021 – The Leapfrog Group, a non-profit representing hundreds of the nation’s most influential employers and purchasers of health care, and supported by the St. Louis Area Business Health Coalition (BHC) as a regional leader in Missouri, announced today the fall 2021 Leapfrog Hospital Safety Grades.

The independent grading system assigns an “A,” “B,” “C,” “D,” or “F” grade to general hospitals across the country based on over thirty national measures of preventable errors, injuries, accidents, and infections. The fall 2021 Hospital Safety Grade represents the largest set of hospitals ever graded, with grades assigned to 2,901 facilities across the country.

In the St. Louis and surrounding region, twenty-six (26) hospitals were graded, and ten (10) earned an “A,” five (5) earned a “B,” eight (8) earned a “C,” one (1) earned a "D," one (1) earned an “F,” and one (1) was not graded.

The local hospitals that earned an “A” include HSHS St. Elizabeth's Hospital, Mercy Hospital Jefferson, Mercy Hospital South, Mercy Hospital St. Louis, Mercy Hospital Washington, OSF Saint Anthony's Health Center, SSM Health St. Clare Hospital – Fenton, SSM Health St. Joseph Hospital – Lake St. Louis, St. Luke’s Des Peres Hospital, and St. Luke’s Hospital.

The Leapfrog Hospital Safety Grade is the only hospital ratings program based exclusively on hospital prevention of medical errors and harms to patients. The grading system is peer-reviewed, fully transparent and free to the public. Grades are updated twice annually, in the fall and spring. 

“The Leapfrog Group thanks the health care workers in St. Louis and nationwide who work so hard for their communities. It’s important we recognize excellence, especially in times like these. But it’s also important to know when hospitals fall short, because lives are at stake,” said Leah Binder, president and CEO of The Leapfrog Group. “We see every day how hospitals can and will improve their safety when patients make clear it’s important to them.”

For more information about the Leapfrog Hospital Safety Grade, as well as individual hospital grades and state rankings, please visit HospitalSafetyGrade.org.

About The Leapfrog Group
Founded in 2000 by large employers and other purchasers, The Leapfrog Group  is a national non-profit organization driving a movement for giant leaps forward in the quality and safety of American health care. The flagship Leapfrog Hospital Survey and new Leapfrog Ambulatory Surgery Center (ASC) Survey collect and transparently report hospital and ASC performance, empowering purchasers to find the highest-value care and giving consumers the lifesaving information they need to make informed decisions. The Leapfrog Hospital Safety Grade, Leapfrog's other main initiative, assigns letter grades to hospitals based on their record of patient safety, helping consumers protect themselves and their families from errors, injuries, accidents, and infections.

About the St. Louis Area Business Health Coalition

The St. Louis Area Business Health Coalition (BHC) is a non-profit organization representing over 70 leading employers, which provide health benefits to thousands of lives in Missouri and millions nationally. For 39 years, the BHC has worked to achieve its mission of supporting employer efforts to improve the well-being of their employees and enhance the quality and overall value of their investments in health benefits. To accomplish these aims, the BHC centers its work on providing pertinent research, resources, and educational opportunities to help employers understand best practices for the strategic design (and informed use) of benefits to facilitate high-quality, affordable health care. To learn more, please visit www.stlbhc.org or follow the BHC on Twitter and LinkedIn.