Never events: Medicare won’t pay, but you will

Medicare, like all health insurers, is constantly looking for way to avoid paying for medical care. The latest attempt sounds perfectly reasonable, until you consider who will bear the burden.

As of October 1, 2008, Medicare will no longer pay for what it claims are “never events,” events that should never happen. The purported rationale of this new rule is that by refusing to pay for “mistakes,” Medicare will reduce the number of medical mistakes that occur. There’s precisely zero evidence that refusing to pay reduces mistakes, and there is reason to believe that refusal to pay will hurt patients in ways that have not truly been considered. Don’t have Medicare? This still affects you, since Medicare payment rules are usually adopted in short order by private insurers.

What is a “never event”? Medicare claims that a “never event” is a mistake so easy to prevent that it never should occur. Which events are “never events”? According to the Center for Medicare and Medicaid Services, these seven conditions are in the initial group characterized as “never events”:

•  pressure ulcer stages III and IV;

•  falls and trauma;

•  surgical site infection after surgery for obesity, certain orthopedic procedures, and heart bypass surgery;

•  intravenous-catheter associated infection;

•  bladder catheter-associated urinary tract infection;

•  administration of incompatible blood;

•  air embolism; and

•  foreign object unintentionally retained after surgery.

The first problem is that of the eight stated “never events,” only three are medical mistakes. No instruments or sponges should ever be left behind after surgery, no one should ever receive blood that has not been properly typed and cross-matched, and no one should ever have air introduced into the bloodstream by way of injection or IV. Instituting appropriate hospital procedures can and should be able to prevent all incidents of foreign objects left behind, incompatible blood transfusions and air embolus.

The other five events are not “never events.” They are known complications of hospitalization or illness. They are going to happen anyway, despite best efforts to prevent them. Since they cannot be prevented 100% of the time, Medicare plans to save money by simply refusing to pay for them. That’s not where it ends, though. Someone is going to pay and that someone is going to be the patient.

The burden on patients is going to be far greater than simply being forced to pay for the treatment and extended hospitalizations that result from infections, pressure sores or falls. Consider the case of falls. Elderly people are prone to falling. Often, they are in the hospital because of a fall. Nothing can be done to make those individuals less likely to fall, so the only recourse of the hospital is to prevent the falls from occurring. The most reliable way to do this is to prevent them from getting out of bed without supervision. In the case of the incapacitated elderly, the most reliable way to prevent them from getting out of bed is to tie them into it.

How about procedure related infections? We know that those are who most ill or most frail are more likely to suffer infections. If the hospital knows it will not be reimbursed for infections that are impossible to prevent, it will simply refuse to care for patients most likely to get infections. It will accomplish this by refusing to admit those patients, by denying them the procedures, or by transferring them to other facilities. If all else fails, it will simply bill the patient personally for the treatment that is needed to cure the infection.

Considering pressure sores as a “never event” creates a Catch-22 situation for the hospital. Pressure sores occur when patients are so sick or so weak that they can no longer move themselves in bed. They lie for long periods of time in one position, and the skin in areas under constant pressure begins to break down.

There is one and only one way to prevent pressure sores, and that is by constantly changing the position of the patient in bed. The repeated cutbacks in Medicare reimbursement have made it impossible to staff hospitals with enough people to provide the level of care that prevents pressure sores. Now Medicare is insisting that it will not pay for the unintended results of its own cost cutting measures. The hospital will have only one choice, and that is to refuse to admit patients who might develop pressure sores.

As Roy Poses, MD, president of the Foundation for Integrity and Responsibility in Medicine writes:

“Thus is appears that the surest way to avoid incurring CMS’s proposed financial penalty … it to avoid admitting sicker patients… This, of course, is a perverse incentive that could make care less accessible for those who need it most, and would violate hospitals’ fundamental mission to care for the sick…

Paying physicians for the time it takes to gather information, think about it and thoughtfully come up with the best possible plan for each individual patient would do a whole lot more to improve quality and patients’ outcomes than penalizing hospitals … for events that they could not have prevented.”

The ER doctor who blogs at WhiteCoat Rants predicts:

1 You’ll get diagnosed with a lot more illnesses so that it is very difficult to determine what care is for a “never event” and what care is for the “never event.” Then when you have to stay in a hospital longer because of a “never event,” the hospital can allege that the extended stay was really due to a problem that was not a never event. That will mean more testing, more procedures, and higher costs.

2. If you develop a “never event,” you’ll be more likely to get transferred to another hospital. CMS won’t pay for never events if they develop in a hospital, but they will pay for treatment if you present with a pre-existing never event. Hospitals will develop unwritten agreements that certain specialists at each other’s facilities are better suited to treat a certain patient’s “never event.” More transfers mean more redundant testing, higher costs, and more complications from the testing.

3. Testing and diagnosis of never-event conditions will diminish where feasible. That bedsore isn’t a Grade 3 – it’s only Grade 2. CMS will pay for those.

4. Say hello to the Advance Beneficiary Notices. Medicare won’t cover preventative care, so you are going to have to pay for it out of your pocket. If you’re prone to falls or bedsores, you’ll have to pay for a personal nurse to wait on you hand and foot so you don’t develop these never events. If you don’t pay for a personal nurse 24 hours around the clock to keep a never event from happening, you’re personally responsible for paying the costs of treatment if the “never events” occur. You had the opportunity to prevent the events but you were just too cheap to pay for it. I think that ABNs are less likely to catch on, but eventually I think they will become commonplace.

Medicare’s refusal to pay for “never events” is simply the latest iteration of paying for performance (P4P). However, by refusing to pay for complications that cannot be prevented, Medicare will merely shift the burden to the patients themselves, in particular, the oldest and sickest among us.