Defensive Medicine?

Some hospital leaders are concerned that CMS is moving too fast with never events.

The Centers for Medicare & Medicaid Services' newest proposed list of never events for which hospitals will not receive payment has left some facilities' senior leaders wondering: How exactly do you guard against Legionnaires' disease and delirium?

In April, CMS released the nine-item list that includes those two conditions, surgical-site infections following certain elective procedures, and Clostridium difficile-associated disease, among others. The list is the second round of never events offered by CMS in as many years. Last year's list, which takes effect Oct. 1, includes preventable events like objects left in patients during surgery, blood incompatibility, pressure ulcers, and hospital-acquired injuries. CMS will issue a final rule on or before Aug. 1 on the proposed additions.

The latest list has plenty of healthcare leaders concerned. Bob Wachter, MD, chief of the division of hospital medicine and the medical service at the University of California, San Francisco Medical Center, and professor and associate chair of the university's department of medicine, contends this latest list would create a new species of "defensive medicine" in which facilities will be forced to focus more on protecting themselves than improving quality. Wachter specifically worries about what he perceives to be a sense of unfairness in the second list—he wonders if CMS' list is really about patient safety or a way to save money. Additionally, Wachter says the never events will also create waste for hospitals trying to protect themselves and could sap the enthusiasm of patient safety and quality people.

"It's going to lead at best to wasteful spending and at worst to clinically inappropriate care to make sure that [the patient's] chart looks good," says Wachter.

Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, says a number of logistical, coding, and management challenges lie ahead with the new list. In some areas, there is no clear code; what's more, some conditions are not listed in medical records, and hospitals will have to work closer with other facilities, including nursing homes, to reduce incidents coming from outside facilities, she says. "It speaks to this notion that there is a growing expectation for hospitals to reach outside their four walls and work more broadly with the community."