Defensive Medicine?

"There is a learning curve for the physicians at the beginning, a lot of querying and prompting them. They are ready for this. We have been getting them ready," says Lee.

Financial impacts?
In releasing the proposed changes, CMS suggested some potential cost savings associated with the added conditions. For instance, Legionnaires' disease cases in fiscal year 2008 averaged $86,014 per hospital stay, delirium cost $23,290 per hospital stay, ventilator-associated pneumonia was $135,795 per hospital stay, and deep vein thrombosis/pulmonary embolism cost $50,937 per hospital stay.

Although CMS views ending payments for never events as a way to save money, hospital officials expect minimal impacts on their bottom line. A larger issue, however, could be the information being used in public quality reporting and potentially harming the hospital's reputation because of unflattering results. Wachter contends that CMS did not take that into account when offering the latest list.

"Unintended consequences can shift the way we provide care," he says.

Rather than developing a list of conditions that hospitals cannot avoid because science has not found ways to prevent them, Wachter suggests additional research to test strategies to see what works. In addition, CMS should earmark payments for never events into research to improve quality, he says. "What bugs me about it is that it is a lot of time and energy, and I think it adds very little to the health of human beings."

Wachter is hopeful CMS will listen to the opposition raised and rethink some of the unintended consequences that will come if the most recent list takes effect. "Medicare went 50 years doing none of this. I don't think they have to go at 120 miles per hour to make up for lost time," he says.

The expanded list of conditions in the CMS rule:

• Surgical site infections following certain elective procedures
• Ventilator-associated pneumonia
• Legionnaires' disease
• Deep vein thrombosis/pulmonary embolism
• Extreme blood sugar derangement
• Staphlococcus aureus septicemia
• Iatrogenic pnemothorax
• Clostridium difficile-associated disease
• Delirium

Source: Centers for Medicare & Medicaid Services.

CMS has taken the lead in the avoidable hospital conditions movement, but a number of private health insurers are following the lead.

WellPoint, Aetna, and CIGNA are three insurers that will no longer pay for never events defined by CMS. Beginning Oct. 1, CIGNA will stop reimbursements for objects left inside a patient during surgery, air embolism, use of the wrong blood during transfusions, infections from urinary catheters, pressure ulcers, infections from central vein catheters, mediastinitis, and hospital-acquired injuries such as fractures and burns.

The Bloodfield, CT-based health insurance company says the move is consistent with CMS policy and the company's participation in national quality organizations and initiatives, including the National Quality Forum and Leapfrog. CIGNA Medical Officer Douglas Hadley, MD, says the insurer sees the CMS changes as a way to gain a national consensus to improve hospital quality.

Hadley says CIGNA customers are supportive of the changes. "Many of the employers for whom health insurance is very costly are concerned about some of their money going for mistakes that really aren't their problem," he says. Hadley says the changes will not cause much of a financial impact, adding that CIGNA is following CMS' lead for more than just financial reasons. "I don't think we're trying to promote this policy because we're trying to lower medical costs. We're trying to improve quality."

Hadley says CIGNA will include hospitals' never events record on its Web site so consumers can make educated choices on hospital safety, complications, and participation in the Leapfrog program. "We think that's the kind of thing that we want to encourage people to do where they have choices," he says.

Some providers are concerned that health insurers will follow CMS' lead and also refuse to pay for the second round of never events. Hadley says the insurer is waiting to see what CMS decides about the recently announced list before potentially adding hospital-acquired conditions.