To err is human, not on insurers’ dime anymore

If a surgeon left a piece of medical equipment inside you during an operation and you had to be opened up again to get it out, would you expect to have to pay for that mistake?

I’m guessing you’d say no – perhaps rather emphatically – but more often than not the patient ends up paying for that boo-boo. Oh, usually not directly but the patient’s insurer does pay for it, whether that’s Medicare or private insurance.

But those days are coming to an end, at least for those insured by Medicare, on Oct. 1. That’s when new rules adopted by the federal Centers for Medicare and Medicaid Services to deny payment for eight specific events that can happen within a hospital setting go into effect.

In addition to leaving an “object” inside the patient during surgery, the events include: causing an air embolism; giving the patient a transfusion of the wrong blood type; infections caused by urinary and vascular catheters; bed sores; surgery site infections after coronary artery bypass surgery; and injuries from falls.

Additional medical errors, including ventilator associated pneumonia, staphylococcus blood poisoning and deep vein thrombosis (blood coagulation), are being considered for addition to the “no pay” list in 2009.

The Medicare action is aimed at saving the program money – estimated at a minimum of $20 million annually – and to encourage hospitals to improve patient care.

“The primary purpose of this provision is to give hospitals a financial incentive to adopt policies and practices that will avoid such errors in the future,´ said Ellen Griffith, a CMS spokeswoman.

Some private insurance companies are already taking the same approach as Medicare, and others are expected to follow in an effort to improve medical care and reduce health care costs. Aetna is one company taking a leading role, according to spokeswoman Rachelle Cunningham.

The ‘never event’

Cunningham said Aetna was the first private insurance company to adopt the Leapfrog Never Events policy, a list of actions they will require hospitals to take whenever a “never event” – defined as one that should never happen to a patient – occurs.

“What Aetna has done is include language into all our new and renewed contracts that would require the hospital to report the event to the appropriate agency and include corrective action to prevent the error from occurring again, and to waive the charge related to that error and to apologize to the family,” she said.

The Leapfrog Group is a health-care advocacy organization, founded in 2000 by the Business Roundtable, dedicated to improving health care and making it more affordable.

Cunningham said Aetna is embracing the never-events policy.

“Patient safety is something Aetna has always had a strong commitment to, so this fits into that philosophy,” she said.

Susan Pisano, vice president of communications for America’s Health Insurance Plans, said the organization representing 3,000 private health insurers generally endorses Medicare’s rule changes.

“What Medicare has done with respect to never events is consistent with the overall direction in health care where incentives are becoming aligned, because you don’t want to be paying as much for poor quality (health care) as good quality,” she said.

Others follow suit

Pisano said AHIP is not taking a formal position on the change – leaving it up to individual companies’ business decisions – but predicts many will follow suit.

“There was already some movement in the private sector toward it, and this new rule will mean others are likely to follow,” she said.

John Bender, M.D., president of the Larimer County Medical Society and president-elect of the Colorado Academy of Family Physicians, said he believes the new rules are a good thing.

“I think this is something that physicians, in the long term, will be glad came out because it’s going to help us with some of the malpractice reform and bring some quality control measures to medicine that are kind of hard to implement because of the historical culture,” he said.

Bender said nurses and doctors have been generally loathe to say much about medical errors for legal and other reasons, but – with some tort reform on the state level that would focus on transparency and hold blameless those who spoke up – much progress could be made in creating better systems to avoid medical errors.

“The days should be gone when nurses and doctors are afraid to talk about medical errors,” he said. “The public is demanding transparency but (medical personnel) need to have tort reform to help that come about.”

Steve Porter covers health care for the Northern Colorado Business Report. He can be reached at 970-221-5400, ext. 225, or at sporter@ncbr.com.

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