January 2008
In this issue
Zero Tolerance: Health Plans Refuse to Pay

In an effort to increase patient safety, several large-scale private insurers are moving toward refusing to pay (or let their members be billed) for hospital-related errors. Following Medicare's lead, Aetna and WellPoint, the third and first largest health plans in the nation, respectively, as well as Blue Cross Blue Shield Association, Cigna and UnitedHealth Group, are exploring some variation of refusing to compensate hospitals for up to 28 "never events" that are taken from the National Quality Forum (NQF) endorsed list of adverse events, which was released in 2002 and updated in 2006.

The NQF list of "never events" includes: Foreign objects left behind after surgery; death or serious disability due to medication error, being given the wrong blood type, embolism, falls, electric shock and burns; artificial insemination with the wrong donor sperm or egg; surgery performed on the wrong body part or on the wrong patient; and, wrong surgical procedure performed on a patient. In total, the NQF endorses 28 "never events."

Medication and surgical errors have been under extreme scrutiny ever since The Institute of Medicine's (IOM) initial report that indicated as many as 98,000 serious injuries or deaths in America each year are the result of medication or surgical errors - which is greater than the annual number of deaths due to automobile accidents, breast cancer and AIDS. In addition to the IOM report, The Centers for Disease Control and Prevention (CDC) estimates as much as $4.5 billion in health spending each year is the result of hospital-acquired infections. This item is on Medicare's list of "never events" being considered as something it will not reimburse for in the future. However, it is not on the NQF endorsement list, though that list does include "death or serious injury due to contaminated drugs, devices or biologics," which seems to infer death due to infection. The CDC also estimates that hospital infections result in as many as 99,000 deaths each year.

"It's not a matter of not paying for them. It's about getting them not to happen in the first place," said Thomas Granatir, director of policy and research at Humana Inc., in a January 2008 Wall Street Journal online article.

Other "never events" for which Medicare may refuse to reimburse include injuries due to objects left inside patients during surgery; surgical-site and urinary tract infections; injuries due to wrong blood being administered; bedsores and injuries sustained in a fall at hospitals.

Click here for the complete NQF endorsement list.

Copyright 2008
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