Thursday, January 7, 2010

Never Events: Cost Savings?

We're all familiar by now with the concept of "never events". These are the in-hospital complications (such as line infections, urinary catheter infections, DVT's, and decubitus ulcers) that the Center for Medicaid and Medicare Services has deemed entirely preventable and, thus, will not compensate hospitals for their treatments.

The idea behind such a mandate is twofold. Number one, it promotes safe practices that will hopefully improve patient care and in-hospital outcomes. If a hospital is being financially penalized because of high urinary tract infection rates, you can be sure that systemic QA review of how nurses and aides insert Foley catheters is just around the corner. That seems like a good thing to me. Unfortunately, not all infections or blood clots are preventable. (Try finding an article in the medical literature describing how one is supposed to reduce the incidence of DVT's to zero).

The other motivation of "never event" designation is to ostensibly bend the cost curve downward. Non-payment of "avoidable" events will, over the long haul, reduce overall health care spending. So they aver.

There's an interesting article examining the validity of this claim in the journal Health Affairs from last September. The study examined 767,995 acute inpatient Medicare discharges from 2006. Upon review of the charts, a so-called never event was idenified in only 828 patients. The savings from reduced payments for these events would have been about a hundred grand or so. Extrapolated nationwide, savings come to a little under $3 million---a pittance compared to Medicare's half trillion dollar annual budget.

The problem with "never event" non-payment is not that it is fundamentally evil and unjust but that it is irrelevant from a pragmatic perpsective (the cost reduction is negligible). The problem is with the inflammatory nature of the terminology. Never event. Think about it. If you were a patient and you saw on your hospital bill a charge that was deducted secondary to denial of payment by Medicare and then you found out that the reason it was denied was that it was a complication that is never supposed to happen, wouldn't you feel that you had been wronged to some extent? That something was inflicted on you during your hospital stay? If I'm a trial attorney, I love this terminology.

So it's simple---change the terminology. Call them "potentially avoidable complications". There are no "never events" in medicine. Absolutism is just as invalid and as damaging in medical practice as it is in politics, religion, and philosophy. As physicians, we ought always to strive for better practice but to insist on perfection is a pipedream doomed to end in disillusionment.


Anonymous said...

No "Never" events in Medicine??
Ever seen a Psychiatrist put in a Chest Tube??
Never gonna Happen

Unknown said...

Nowhere does Medicare call these "never events" - they are "Hospital Acquired Conditions".

Jeffrey Parks MD FACS said...

Really tgkobe?

Unknown said...

THANK YOU for that post.

Michael Kirsch, M.D. said...

For the time being, never events non-payment applies to hospitals, not to the physician who committed the act. This is a silly idea that looks great on a headline. Watch how the list of 'never events' multiplies in the months and years ahead. Soon, unavoidable complications will be defined as 'never events'. The public does not easily understand the difference between a complication and negligence. It would be easy to persuade my GI patients that a colonoscopy perforation should 'never' occur, even though this is a recognized, blamesless event.

rlbates said...

Just checking in. Hope you and your family are doing well.