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Commentary: Non-Payment Mandates Require Additional Study, Science

By Terrance J. Sheehan, MD
President & CEO

It is time to back-off, re-evaluate and shorten the list to one set of conditions for all payors that are clearly measurable, fully preventable and within hospitals’ and physicians’ control.

By now many of you have become aware of the decision by the federal government and many insurers to refuse payment for certain adverse health events that occur in hospitals and which are considered to be the result of medical errors or improper care that can reasonably be expected to be averted.

Medicare’s non-payment list includes eight conditions (see Box 1) while the insurers’ list includes all or part of 28 serious reportable events (see Box 2) advanced by the National Quality Forum (NQF), a voluntary consensus standardsetting organization for healthcare quality measurement and reporting.

In addition, in Vermont, all hospitals have adopted a uniform policy to not seek payment for eight of the NQF’s 28 events. Maine has created a statute that addresses hospital non-payment for all 28 NQF events and the New Hampshire Hospital Association has recently developed a set of guiding principles for identifying serious adverse events for which payment is not expected.

These hospital non-payment decisions are part of the shift toward pay-for-performance and are viewed as a necessary added incentive to improve patient safety. Medicare’s non-payment policy goes into effect in October 2008, but they are already seeking to add nine additional conditions (see Box 3).

In my opinion, these decisions have been made without a clear understanding of the consequences, either intended or unintended. The list includes, in some instances, conditions that are not clearly measurable and not fully preventable or within the hospital’s control. The May 14, 2008, edition of the Journal of the American Medical Association contains a commentary by Pronovost, Goeschel & Wachter titled, The Wisdom and Justice of Not Paying for Preventable Conditions. The authors wisely raise caution flags, stating that the ability to diagnose six of the eight Medicare conditions (central line associated blood-stream infections and retained foreign bodies are the exceptions) is error-ridden and there is limited-to-no-evidence about their degree of preventability. They further state, “In the end, Medicare must advance the science of quality improvement and measurement for its ‘not paid for preventable complications’ program to realize true improvements in patient outcomes. There is no shortcut.”

This issue is an important one that requires the full attention of hospitals and physicians in this country. It is time to back-off, re-evaluate and shorten the list to one set of conditions for all payors that are clearly measurable, fully preventable and within hospitals’ and physicians’ control. In the meantime, hospitals and physicians should develop and comply with evidence-based guidelines, policies and procedures that address the prevention of these events.

(Box 1)

Conditions for Which Medicare Will No Longer Pay if Acquired During an Inpatient Stay, As of October 1, 2008
Catheter-Associated Urinary Tract infections Pressure Ulcers Object Left in Patient during Surgery Air Embolism Blood Incompatibility Vascular Catheter- Associated Infections Mediastinitis after coronary artery bypass graft Falls

(Box 2)

National Quality Forum’s Serious Reportable Events
Surgery performed on the wrong body part. Surgery performed on the wrong patient. Wrong surgical procedure performed on a patient. Intraoperative or immediately post-operative death in an ASA Class I patient. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility. Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions ther than as intended. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility. Infant discharged to the wrong person. Patient suicide or attempted suicide resulting in serious disability, while being cared for in a healthcare facility. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility. Patient death or serious disability due to spinal manipulative therapy. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances. Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider. Abduction of a patient of any age. Sexual assault on a patient within or on the grounds of the healthcare facility. Artificial insemination with the wrong donor sperm or donor egg. Unintended retention of a foreign object in a patient after surgery or other procedure. Patient death or serious disability associated with patient elopement (disappearance). Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration). Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA incompatible blood or blood products. Patient death or serious disability associated with an electric shock or while being cared for in a healthcare facility. Patient death or serious disability associated with a fall while being cared for in a healthcare facility. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds

National Quality Forum’s Serious Reportable Events

Surgery performed on the wrong body part.
Surgery performed on the wrong patient.
Wrong surgical procedure performed on a patient.
Intraoperative or immediately post-operative death in an ASA Class I patient.
Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility.
Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions ther than as intended.
Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility.
Infant discharged to the wrong person.
Patient suicide or attempted suicide resulting in serious disability, while being cared for in a healthcare facility.
Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility.
Patient death or serious disability associated with hypoglycemia,
the onset of which occurs while the patient is being cared for in a healthcare facility.
Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates.
Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility.
Patient death or serious disability due to spinal manipulative therapy.
Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances.
Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility.
Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility.
Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider.
Abduction of a patient of any age.
Sexual assault on a patient within or on the grounds of the healthcare facility.
Artificial insemination with the wrong donor sperm or donor egg.
Unintended retention of a foreign object in a patient after surgery or other procedure.
Patient death or serious disability associated with patient elopement (disappearance).
Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration).
Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA incompatible blood or blood products.
Patient death or serious disability associated with an electric shock or while being cared for in a healthcare facility.
Patient death or serious disability associated with a fall while being cared for in a healthcare facility.
Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds

(Box 3)

Additional Hospital-Acquired Conditions Medicare is Targeting for Non-Payment
Surgical-site infections after total knee replacement, laparoscopic gastric bypass and gastroenterostomy, or ligation and stripping of varicose veins Legionnaire’s Disease Diabetic ketoacidosis, nonketotic hyperosmolar coma, diabetic coma or hypoglycemic coma Iatrogenic pneumothorax Delirium Ventilator-associated pneumonia Deep-vein thrombosis or pulmonary embolism Staphylococcus aureas septicemia Clostridium

Additional Hospital-Acquired Conditions Medicare is Targeting for Non-Payment

Surgical-site infections after total knee replacement, laparoscopic gastric bypass and
gastroenterostomy, or ligation and stripping of varicose veins
Legionnaire’s Disease
Diabetic ketoacidosis, nonketotic hyperosmolar coma, diabetic coma or hypoglycemic coma
Iatrogenic pneumothorax
Delirium
Ventilator-associated pneumonia
Deep-vein thrombosis or pulmonary embolism
Staphylococcus aureas septicemia
Clostridium