Medicare Won't Pay for Medical Errors ... NY Times October 1, 2008

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http://www.nytimes.com/2008/10/01/us/01mistakes.html?_r=1 & hp & oref=slogin Medicare Won’t Pay for Medical Errors By

KEVIN

SACK NY Times October

1, 2008 ST. PAUL — If an auto mechanic accidentally breaks your windshield

while trying to repair the engine, he would never get away with billing you for

fixing his mistake. On Wednesday, Medicare will start applying that logic

to American medicine on a broad scale when it stops paying hospitals for the

added cost of treating patients who are injured in their care. Medicare, which provides coverage for the

elderly and disabled, has put 10 “reasonably preventable”

conditions on its initial list, saying it will not pay when patients receive

incompatible blood transfusions, develop infections after certain surgeries or

must undergo a second operation to retrieve a sponge left behind from the

first. Serious bed sores, injuries from falls and urinary tract infections

caused by catheters are also on the list. Officials believe that the regulations

could apply to several hundred thousand hospital stays of the 12.5 million

covered annually by Medicare. The policy will also prevent hospitals from

billing patients directly for costs generated by medical errors. Because Medicare is the largest insurer

in the country, its decision to refuse payment for preventable conditions has

already influenced others — public and private — to set similar

criteria. Over the last year, four state Medicaid programs, including

New York ’s, have

announced that they will not pay for as many as 28 “never events”

(so called because they are never supposed to happen). So have some of the

country’s largest commercial insurers, including WellPoint,

Aetna , Cigna and Blue Cross Blue Shield plans in seven

states. A number of state hospital associations,

including here in Minnesota, have brokered voluntary

agreements that members will not bill for medical errors. In April,

Maine became the first

state to ban the practice statutorily. The Congressionally mandated Medicare

measure is not projected to yield large savings — $21 million a year,

compared with $110 billion spent on inpatient care in 2007. But it carries

great symbolism in the Bush administration’s efforts to revamp the

country’s medical payment system, which has long been criticized as

driving up costs through perverse incentives that reward the quantity of care

more than the promotion of health. The real money, many health economists

believe, may come from reorienting the payment system to encourage prevention

and chronic disease management and to discourage unnecessary procedures. The

two major-party presidential candidates support such a realignment, a rare

point of consensus in a polarized health care debate. “This is a specific case of the

larger pay-for-performance trend, the idea that you should pay more for quality

than lack of quality, or in this case pay less for defects,” said Dr.

M. Berwick, president of the Institute for Healthcare Improvement.

“This whole trend is like a juggernaut, and it is not going to

stop.” Pay-for-performance makes use of both the

carrot and the stick. Medicare now grants bonuses to doctors and hospitals that

report quality measures. It is experimenting with rewarding physicians who

follow protocols for treating diabetes, coronary artery disease and congestive

heart failure. The Medicare Payment Advisory Commission, an arm of Congress,

recently recommended reducing payments to hospitals with high readmission

rates. Three years ago, HealthPartners, a

Minnesota-based health maintenance organization, was first in the country to

refuse payment to hospitals for never events. Company officials said the policy

has yet to save much money. But at Regions Hospital in

St. , which is owned by HealthPartners,

the change has reinforced a new focus on reducing medical errors. “Historically, there’s been

some acceptance that these things happen,” said Brock D. , the

hospital’s president. “We’ve come to now accept that

they’re avoidable. And that’s a sea change.” Some improvements have been

technological, like an electronic prescribing system that has helped cut

medication errors in half. Others are breathtaking in their obviousness, like

diligent hand-washing. Nurses have been trained to provide more

information during shift changes about whether patients are prone to falls.

High-risk medications like heparin are now marked with pink labels to ward

against mix-ups. Shortly before A. Kehborn’s

recent ankle fusion surgery, her orthopedic surgeon, Dr. A. Cole, checked

records and asked her repeatedly whether he would be operating on her left leg.

He then took a sterile marker and signed his initials on her left ankle. As they prepared for surgery, technicians

tallied sponges and blades so they could later be sure that none were left

behind. Before taking up his scalpel, Dr. Cole was reminded by the

“Time-Out!” towel covering his surgical tray to call for a brief

break. “We have here for a left

ankle fuse,” he announced. “Does everybody agree?” After all

in the room chimed their agreement, he made his incision. In pre-op, Ms. Kehborn, 48, said it had

never occurred to her that patients might be charged for a medical error. “It should be the hospital’s

and doctor’s responsibility to step up to the plate and own up to their

mistakes,” she said. “I’d be livid if we had to pay for

it.” The patient safety movement picked up

steam in this country in 1999, when the Institute of Medicine, a prestigious

advisory group, estimated that 44,000 to 98,000 Americans died each year from

preventable medical errors. In response, at least 20 states have

passed laws requiring hospitals to report mistakes or preventable infections

publicly, according to the National Conference of State Legislatures. The

federal Centers for Medicare and Medicaid Services now requires hospitals to

report on 42 quality measures. Hospitals that do not fully report may be docked

up to 2 percent of their reimbursement. In 2002, the National Quality Forum, a

standard-setting consortium for the health care industry, compiled a list of 27

largely preventable adverse events, a list that grew to 28 in 2006 with the

addition of “artificial insemination with the wrong donor sperm or

egg.” In 2003, Minnesota became the first state to require reporting of all errors on the list, and last

year the state’s hospital association became the first to announce that

its members would not bill for them. The number of never events in

Minnesota reported to

the state has been low — 106 in 2004-5, 154 in 2005-6 and 125 in 2006-7.

The most frequent errors have been bed sores, retained objects and wrong-site

surgeries. Regions Hospital had six or seven

reportable errors in each of those years, including one death, a suicide. Because individual hospitals may report

only a few serious errors a year, they have started collaborating to look for

common threads and propose solutions. Some of the innovations were initially

greeted with rolled eyes, but hospital officials say that has lessened.

Nonetheless, studies by the University of Minnesota found that some

of the safety procedures, like the pre-surgery time-outs, have largely become

rote. Clear trend lines are not expected for

several years. Some states have found through audits that not all errors are

being reported, but Minnesota officials believe that compliance is high. “There’s been an

understanding by hospitals that we’re not trying to get them, that

we’re really focused on what we can learn from these events,” said

Diane C. Rydrych, the state health department official in charge of reporting. E. , vice president for

quality and patient safety at the American Hospital Association, said hospitals

had generally accepted that many of the 28 adverse events should never happen,

like giving a patient the wrong type of blood. But she said other areas could

be gray, like an injury caused by a malfunctioning device. “Anyone — I don’t care

who they are — always finds it a little provocative to be held

accountable for something that is not within their control, especially when you

have dedicated yourself to doing the right thing for your patients,” Ms.

said. Such unforgiving standards, she said, can “set an

expectation among patients that staff will be closer to perfect than they

actually can achieve.” Even

America ’s Health Insurance

Plans, the leading industry trade group, has questioned whether some of the

conditions on the Medicare list are always preventable. But V. Lee, executive director of

the Pacific Business Group on Health, based in

San Francisco , said occasional inequity was a

price worth paying to send the message that careless medicine will not be

tolerated. “I don’t worry about that 1-in-100 case that can’t

be avoided,” he said, “because the benefit of not paying for the 99

that shouldn’t happen means a far greater focus on avoiding harm. What we

want is to encourage doctors and hospitals to get to zero.”