When Insurers Say “Never” But Won’t Put a Penny Into Finding Solutions

Kevin M.D. has begun publishing op-eds from readers on his site www.kevinmd.com.

Below a “reader take” by WhiteCoat,  an emergency physician who blogs at WhiteCoat Rant.  I think he raises some good questions.

WellPoint and Aetna are now putting into widespread implementation a refusal to pay for what have been deemed "never" events.

The theory for payment denials is that if medical providers are not paid when certain unwanted outcomes occur, situations leading to those unwanted outcomes will be avoided.

Some events on the "never" list legitimately should "never" happen. I can’t think of any way to justify performing surgery on the wrong patient or performing surgery on the right patient, but the wrong body part. The flaw in the insurers’ theory is the determination on whether a "never event" has occurred is retrospective, not prospective. The insurers are focusing on outcomes rather than processes.

If it is so important to prevent these "never events" from happening, why have WellPoint, Aetna, CMS and the "National Quality Forum" refused to create "how to" lists showing health care providers how to avoid these outcomes? Where’s the clinical study showing us a practice model on how to prevent 100% of these "never events" in 100% of patients?

Medical providers may not be the brightest bulbs in the pack, but I for one am anxious to learn. In 2007, WellPoint was ranked as the 35th largest corporation in America and had revenues of more than $56 billion. In 2007, Aetna was 85th on the Fortune 500 with more than $25 billion in revenues. With such vast amounts of resources, why haven’t WellPoint or Aetna funded a study or created some guidelines for healthcare providers showing us how to prevent these "never events" 100% of the time?

Sure, we can minimize the chances of doing wrong site surgery by using a surgical marker to "cross out" the incorrect surgical site or by having surgical "time outs". But explain to me to prevent pressure sores in 100% of my patients. Show me how to prevent infections from urinary catheters 100% of the time. And how do I keep 100% of my elderly off-balance patients from falling and breaking their hips? Show me how to do it and I’m all over it.

There are two reasons why WellPoint, Aetna, and CMS haven’t published such how-to instructions. First, a set of instructions like this is just a fairy tale. Many of these "never events" just can’t be prevented. How would insurers look if they published "how-to" instructions, health care providers followed those instructions to the letter, and the "never events" continued to occur? The insurers would get vilified. They don’t want that. By focusing on outcomes rather than processes, the insurers can avoid the bad rap.

More importantly, insurers are concerned with profits over prevention. They can try to improve their public image by touting "patient safety", but actions speak louder than words. The reason that insurers aren’t paying for these events is because they can then charge patients more and more for insurance premiums, while using the guise of "never events" to pay less and less for the medical care that their patients receive.

By blaming the hospitals for events that some government-sponsored coalition says should "never" happen, they can increase their profits and vilify the "dangerous" health care providers. A win-win situation for the insurers and a lose-lose situation for the medical providers. It’s all about the Benjamins. WellPoint and Aetna didn’t crack the Fortune 500 by deciding to pay more for medical care.

I try to be on the cutting edge, though. If "never events" are going to become ingrained into our culture, I want to add a few of my own to the list. My mail should "never" be lost. Express Mail should "never" be delivered late. I should "never" wait in line to renew my driver’s license. Insurance companies should "never" refuse payments for legitimate claims. Customer service centers should "never" answer customer telephone calls on later than the third ring.

Where do I get in line for my refunds?


26 thoughts on “When Insurers Say “Never” But Won’t Put a Penny Into Finding Solutions

  1. I wonder if anyone has tracked the amount of money the insurers are spending (see Blue Cross Blue Shield Foundation of Mass) to fund campaigns that seek to limit patient and physicians treatment choices? Those dollars alone would put a big dent towards covering treatment costs they deny on a regular basis.

  2. Didn’t we just go through this with CMS, and their 13 “never” events? I remember one was nosocomial Staph. aureus infection. Some related articles suggested using older and cheaper antibiotics for Staph., such as clindamycin.
    The only problem was that nosocomial Clostridium difficile infection was also a “never”. What is the antibiotic most likely to cause this? Doh! Clindamycin!
    There have been some recent studies indicating that prospective cultures for S. aureus, at least in ICU, are cost-effective. Are these going to be reimbursable if the data supports this as an infection control measure?

  3. Maggie,
    You are a true talent in health care writing, with a voracious appetite for research, but I very strongly disagree with this post.
    You write: The reason that insurers aren’t paying for these events is because they can then charge patients more and more for insurance premiums, while using the guise of “never events” to pay less and less for the medical care that their patients receive.
    I have another theory. “Never” events constitute a fraction of one percent of medical expenses. For both providers and health plans, this is really small fry from an economic point of view. In 60 years of our current health insurance system, insurers have never denied “never” events until now. How could they have waited so long if it was really just about money all along? That would be a case of insurers being stupid instead of being clever.
    My alternative theory is that they’re doing it now because the debate over quality took this long to be able to frame “never” events as something that shouldn’t be paid for. This is partly the impact of “lean” and six sigma thinking, and it is partly a change on the part of providers themselves, who have increasingly come around to seeing these events in a new, more system-based light.
    The first mention I remember seeing about not paying for “never” events came from an integrated delivery system, Geisinger, which agreed not to charge for mistakes it made in its heart surgery program. This was done as a marketing move to focus attention to its higher quality and create the idea that Geisinger care came with a “guarantee.”
    Later came CMS with a more general and explicit rule about never events. Only then came the usual private FFS payers. Maybe there is a hidden history which shows them to be champing at the bit to do this for decades, and were only recently able to pressure Geisinger and Medicare to do it first as cover, with a plan to take that extra 0.05% savings and use it to pad margins rather than reduce the premium yield (the growth in premium year to year). That plan is improbable. Insurers have very limited ability to boost their low margins, and there is no evidence that they can do it in the long run (yet).
    Insurers want good press, and are always looking for opportunities to do things that will get it. Refusing to pay for “never” events is a way to be seen as doing the right thing at no cost, or maybe a slight and temporary gain. Not only that, but it actually is doing the right thing.
    I think the real story here, and a positive one, is the growing influence of system-thinking in medicine. The huge flap over the use of evidence-based checklists in Medicare, which was bizarrely barred on privacy grounds and then allowed, is another case in point. I disagree with your claim that “many of these mistakes just can’t be avoided.” Unless by “many” you mean “a very small minority.” There are numerous examples of hospitals now that have cut the rate of certain errors by 90-99%.
    As for why insurers don’t tell providers how to avoid mistakes….should that be their role? It’s not clear that providers want them to take that role. Or rather: it is clear that given the choice providers would prefer to develop their own evidence-based guidelines to reduce errors, rather than have insurers get too involved in developing or enforcing them.
    A new car is warrantied against defects…call them “never” events (wheel falling off when driving normally down the road, etc.). Is it my job, or Consumer Reports’ job, or my car insurance company’s job, to tell the manufacturer how to avoid the defects? I think each of us can play a role in dis-incentivizing the manufacturer from making cars with defects, but we are not close enough to the product to tell the manufacturer what changes to make in any detail. You make this very point, but then put a sinister spin on it as though our inability gives the lie to our refusal to pay for mistakes.
    Am I an asshole or hypocrite to expect the new car I buy to be free of defects, just because I can’t tell the car manufacturer in any detail how to avoid them?
    Final thought: when criticizing insurers it is very easy to scapegoat and make contradictory charges. Do insurers want higher medical costs or don’t they? If insurers don’t want lower medical costs (as you say, they don’t want prevention) because that will lower premium, then how is it that they simultaneously keep working to lower medical costs in order to make money? Either reducing medical expenses gives them more profit or it gives them less, but you can’t have it both ways.
    I think that both poles of that criticism are too simplistic, and probably you do too, but it didn’t come across that way in the post.

  4. Jd-
    First, thanks for the kind words about my posts.
    Secondly, here’s the good news: I haven’t let you down. I didn’t write that post.
    Look at the sentences in italics under the title: this is an op-ed from Kevin M.D.’s blog.
    I thought it was interesting mainly because I liked the idea that if insurers are that interested in quality, then perhaps they should make an investment in figuring out how to improve quality.
    In particular, I think it would be great if insurers made a serious investment in helping hospitals and doctors pay for health information techonology which would reduce errors.
    Insofar as health IT also reduces costs, the first benficiary would be the insurers, not the doctors or the hosptials. (Hospitals sometimes make money if they make an error, they can bill a new DRG and the patient stays longer.)
    I wouldn’t expect auto insurers to make an investment in figuring out how to make cars safer because the auto industry should be profitable enough to make these investments itself. (Okay, the U.S. auto industry isn’t, but other auto industries have been.)
    The hospital industry, on the other hand, is very labor intensive, which means that it is always going to be strapped for cash. (Unless it overcharges Medicare, bilks the uninsured, and knowingly provides unncessary care–which for-profit hospitals, in particular, have a history of doing.
    Finally, you write:
    “I think the real story here, and a positive one, is the growing influence of system-thinking in medicine. The huge flap over the use of evidence-based checklists in Medicare, which was bizarrely barred on privacy grounds and then allowed, is another case in point. I disagree with your claim that ‘many of these mistakes just can’t be avoided’ Unless by
    many’ you mean ‘a very small minority.’ There are numerous examples of hospitals now that have cut the rate of certain errors by 90-99%.”
    I agree completely.

  5. I’m sorry but I disagree with White Coat’s baseless complaints. It’s not incumbent on insurance companies to dictate how doctors practice medicine or how hospitals run their business. The insurance company has their own business to run, I’m really curious why you feel like they should be in the business of training and educating the health care profession? How are you harmed by your mail being lost and how is that damage costing a third party and society millions if not billions of dollars? If you complain loud enough, you’ll get your .42 cents back. If your priority delivery is late, you are entitled to a refund. What are you charging and collecting from a third party when somebody doesn’t answer on the third ring? You’re comparing the potentially permanent disability or loss of life of a human life to waiting in line for your driver’s license? What is your point? I work in construction, mistakes that cause delays or damages that require additional funding to correct, are charged directly back to the person who caused the damage, the plumber, electrician, roofer, whoever screwed up pays for it, it’s called a back charge. I think you’re missing the message being sent by “never events” and that is you need to look to your facility leadership and start investigating why these events happen, how you can prevent them and start cleaning your house up. Many, many people and organizations have dedicated their time and resources into helping you do this…and many many healthcare organizations don’t want to hear it and don’t want to help. It’s an alarming message that these events are occuring with enough frequency that CMS and private insureres have said “ENOUGH.” I for one am glad they have.

  6. Lisa, Howard and Sal,
    I basically agree that hospitals should not charge others for their mistakes.
    And that they need to do a much better job of looking at the system that lead to errors.
    Some of this stuff is expensive–it can require a lot of trial and error to figure what really works when you are talkinb about a procedure with 90 steps.
    This is where I think it might be in the enlightened self-interest of insurers to provide funding or bonuses to hopsitals who invest in this.
    Finally we do have to accept the fact that some “never” events cannot be completely avoided, and or some of the “never events” may be contradictory–as Howard points out.
    But the rate of errors in U.S. hospitals is way too high–especially when compared to some other countries.

  7. I think jd’s point about the emergence of system thinking is important in trying to get at the root cause for why some of the mistakes happen and how to prevent them in the future.
    My employer is in the heavy manufacturing sector of the economy. Our CEO has embraced workplace safety as one of his top priorities. He pounds on it constantly and it is one of the metrics that managers are evaluated on to determine bonuses. His leadership has made a significant positive difference in reducing accidents, both minor and serious, at our company. Every incident is investigated and analyzed in order to determine what changes, if any, we need to make to prevent a recurrence. That all said, in the first quarter of 2008 there were 11 fatalities across U.S. facilities industrywide including the death of a contractor at one of our facilities. While it may be impossible to drive fatalities and serious accidents to zero, leadership from the top and focus throughout the organization make a positive difference.
    I think hospitals are finally starting to realize this as well, but they have a long way to go. Posting results like central line infection rates and incidents of VAP publicly on their website can help to hold hospitals accountable, allow them to see how they compare to their peers, and push them to drive for continuous improvement. CMS and private insurers finally declaring that they will no longer pay for “never events” will provide an additional and needed “kick in the pants” to get hospitals and doctors to focus on improving their healthcare processes.

  8. Yea, ok, sure, insurance companies can offer financial incentives so hospitals can implement error-reduction procedures, or start spending the money on root-cause analysis. Which brings us full circle, that’s not where the hospitals are spending their money, one example is the very expensive construction projects. When the healthcare industry gets their priorities in order, maybe others, like insurance companies, will follow suit. I think “never events” are an example of outside influence trying to force much needed improvements…and that’s the only way it’s gonna come, by force. Show me a hospital that is desperate to find the money to fund root-cause analysis and I’ll show you their robotic technology used to develop new drugs. But most importantly Maggie, is there’s tons and tons of improvements that can be made, overnight, that cost next to nothing. Most of the “errors” resulting in harm or death to patients and extended care (more revenue) are a result of a lack of common sense and/or total communication failure… they’re easy to avoid, but families don’t realize it until it’s too late. It doesn’t take an army of researchers or expensive equipment to realize the benefits of a patient having an advocate. (Abolish visiting hours) Including a pharmacist during rounds. Reducing the layers and layers of administrators. Don’t use community items from patient to patient (blood pressure cuffs, stethoscopes, etc). Schedule a regular and consistent rotation of nurses per patient. Staff patients appropriately. Use visual clues (if you see the line on the wall, the pt’s head isn’t elevated enough, et al) Reduce resident required working hours. How about the one’s that do cost money? I know in South Carolina they’re now using simulators to train and teach on, as opposed to live patients. Finally somebody putting their money where their mouth is, and I bet those who are getting their act together won’t be affected by the lack of payment caused by “never” events because they won’t have any. General Motors has worked exhaustively for years trying to help the healthcare industry in their part of the country, they’ve even sent their engineers in to help design the hospitals. Look at the Leapfrog Group, Fortune 500 companies banding together to use their combined buying power in an attempt to improve care delivery and lower costs. All this tremendous effort has seen little success, the last time I talked to the GM guy he said for all their effort they’ve seen less than 1% gain on costs, that’s almost nothing, it’s negligible. If any hospital asked “please help us fix this” they’d have experts lining up to help them. They’re not asking for help, they turn their back when it’s offered…they’re too busy building their towers and counting their money while telling the world “there’s no problem here.”

  9. Maggie –
    First, thanks for linking to the piece. I wrote it to encourage dialog about this issue. From the posts here and the posts at Kevin’s site, it appears that some people just don’t understand the nuances in the health care industry.
    Let me again point out that I believe some never events are legitimate. Wrong site surgery. Wrong patient surgery. These are things that should probably never occur. The point of the op-ed piece was to show that the concept of never events is being taken too far. Widespread implementation of such thinking will cause an adverse effect on the ability of every American to obtain medical care in a hospital – either through avoidance of at-risk patients or through exponentially increasing the costs of screening to make sure that the potential for “never events” does not occur.
    JD –
    “Never” events constitute a fraction of one percent of medical expenses. I agree — for now — until the definition of the events expands again, and again, and again. We are already seeing health insurers expand the definition to include things that constitute a much larger proportion of health care expenses. First it’s wrong site surgery. Then decubiti, then falls, then UTIs. Exactly when do things stop being “never events”? Maybe insurers should cover nothing because technically everything could be considered avoidable. Soon insurers will refuse to pay for cancer treatment because hospitals didn’t provide enough warning about patient smoking. Where does it end?
    “Insurers have very limited ability to boost their low margins.” You’re kidding, right? Oh I forgot. My health insurance premiums haven’t gone up in years. Precertifications do nothing to impact whether insurers pay for care. Pre-existing conditions don’t exist. Tying reimbursement to Medicare rates (which are declining) actually reduces the margins further, right? Why, heck, with a little better margins, WellPoint would probably be able to oust WalMart on the Fortune 500 instead of being a lowly #35th largest corporation in the nation. Poor shareholders.
    “There are numerous examples of hospitals now that have cut the rate of certain errors by 90-99%.” Unless the error rates have been reduced by 100%, how can you consider them “never events”? They still happen. So you penalize the hospitals for the 1-10% of the things that can’t be prevented and keep the money to pad your bottom line? Sounds equitable to me.
    Let’s use your new car example for never events and let’s make you a car manufacturer. Because Consumer Reports comes out with a report that flat tires are “never events,” should you as the manufacturer be required to pay for all flat tires and any damage to cars or passengers that results from them – up to and including permanent disability to car passengers from accidents caused by blow outs? They’re “never events” right? What about breaks in the serpentine belts? What about windshield wiper wear? Look at your car warranty and you will see that there many exclusions to the “never events” as you apply them to the motor vehicle industry. Your analogy just doesn’t hold water.
    Lisa-
    If you work in the construction industry and I am both a physician and a health care administrator, what is the foundation for you labeling my observations about the health care industry as “baseless”? There’s just a little difference between pounding nails and starting IVs.
    You too are comparing apples to oranges. Buildings should never collapse, right? Your company should therefore be liable for all damages from building collapse because it is a “never event.” What happens when a tornado hits, or a levy breaks and there is a flood in the town, or high winds rip the walls off, or any one of a myriad of other unforeseeable events cause your “never event” to occur? You’re right – it will just encourage you contractors to make better houses. And contribute to an exponential growth in costs. And drive multiple contractors out of the business. And make it difficult to find someone willing to build a house for fear of the next catastrophic “never event.”
    What if you made the plumber liable for all damages due to flooding from a severe rainstorm that was only tangentially related to his indoor work? What if an electrician was required to pay for all damages related to a fire caused by a homeowner overloading a circuit? Make your subcontractors liable for these “never events” and you won’t have very many contractors willing to provide such work.
    The general public may think that expanding the list of “never events” is a “good thing,” but as the amount of never events expands, you will have less and less access to health care. If that is a good thing, you’re going about it in the right way.
    When you shock a rat for random events over which it has little control, it does not encourage creative thinking, it encourages apathy.
    Poorly thought-out policies such as this are going to cause a collapse of the health industry.
    You heard it here first.

  10. With regard to the car analogy, if enough flat tires were occuring (anybody remember Firestone?) or enough serpentine belts were breaking, corrective action would be taken, manufacturers don’t have an easy time getting away with selling defective products, especially auto manufacturers.
    WhiteCoat, are you blaming acts of God like tornadoes and floods for medical errors? That’s not the cause, the cause is human error. By the way, there are roof products that are warrantied to withstand high winds, if you purchase a product rated to withstand 100 mph winds and you have damage from 80 mph winds, guess what? You don’t have to pay for the repairs and neither does your insurance company. Right, buildings should never collapse if they’re built correctly and conform to code requirements, they won’t. That’s one of the reasons we have code requirements, to ensure public safety and consumer protection. Where’s the code enforcement in healthcare? There isn’t any. I can promise you if our products repeatedly failed as a result of human error on our part our insurance company would drop us like a hot potato and we’d be out of business anyway. By the way, our insurance on a project stays in place years after we’re done. If something goes wrong that is directly attributable to our human error, we’re still on the hook for it, same with all the subcontractors. Building owners have their own Act of God coverage. I have to tell you, WhiteCoat, during our hospital experience the physicians treating my husband had little clue what was happening at the bedside, they literally had no idea and told me to my face on several occasions “that doesn’t happen here” and I really think they believed it. I’m not trying to pick on you, but I think you suffer from the same blindness. “less and less access to healthcare” we’re already there, the healthcare industry is collapsing and, in my opinion is a total failure anyway. Let me ask you something, when the family of a patient tells every pt caregiver they come in contact with, and it’s noted in the chart, and the pt is wearing a bracelet saying they’re allergic to penicillin, but the pt gets penicillin anyway and dies as a result, in your world knowing all the nuances of healthcare, how was that unavoidable? How is that an Act of God? What about the caregiver who is starting an IV on pt X who is infected with MRSA, leaves that room and goes to tend to pt Y who does not have MRSA, well, they do now because the nurse didn’t wash her hands or follow infection control procedures. In your world, how was that unavoidable? In my world consistent caregivers and appropriate staffing ratios make both those scenario’s avoidable. I can keep going all day.

  11. Lisa-
    While you make some good arguments, I think you are missing White Coat’s overall point. If you study the NQF’s list of “never events”, it includes things like falls and decubitus ulcers.
    How one could argue that patient falls can be prevented 100% of the time, is beyond me. Having defended hospitals against patient slip & falls, I can tell you that no amount of preventative measures can reduce patient falls to zero. Elderly and infirm people fall, and with shocking regularity.
    Likewise, bed sores can occur whether or not a patient is provided optimal care. When patients are confined to beds for long periods of time, their skin begans to break down.
    I will concede that many of the “never events” are events which are generally preventable. That said, to classify common events, overwhich a hospital has little or no control, as “never events”, will help no one other than the insurance companies.

  12. White Coat, Lisa and
    InLimine
    First, In Limine is definitely right about patients falling. Unless you strap them to their beds, some patients will get up and try to walk to the bathroom on their own and won’t make it–particularly elderly patients, patients taking drugs etc. Somebody can’t be there every moment to catch them.
    On the other hand, I’ve seen studies showing that if you turn patients often enough, they don’t get bedsores. If I recall one study was experimenting with a system that alerted nurses as to when patients needed to be turned. Of course you have to have adequate staffing to do that.
    But bedsores are serious–and can lead to very serious infections.
    Lisa Medication errors could be greatly reduced with electronic medical records, electronic tags on patients and electronic tags on drugs. A warning signal would go off if a nurse tried to give penicillin to the wrong (allergic) patient.
    Without those computerized systems, medication errors will happen. Somebody turns right instead of left, goes into the wrong room, gives the wrong medicine to the wrong patient. Or two bottles look alike. Or the labels look alike . .
    Ultimately, I don’t think it shoudl be so much about who pays for hospital errors–it’s a matter of figuring out which errors are preventable–and developing systems that make sure they don’t happen.
    But I think we also have to accept the fact that health care is such a labor-intensive business that are millions of opportunitites for human error, and they will happen.
    I’m not talking about the person who doesn’t wash her hands–that type of sloppiness does just seem completely unprofessional. I’m talking about the person who, for one moment, loses focus and makes a mistake.
    Or the three people who each make one tiny mistake (putting something back on the wrong shelf, for example) which, compounded, hurt the patient. . .

  13. I agree, you can’t avoid all falls. Bedsores…”never” maybe not but they can and should be mitigated quite a bit. In general I’m still pleased by the refusal to pay for “never” events…it’s outside pressure brought to bear on healthcare to improve their service…that’s my point and in that respect it’s accomplishing it’s goal. And you’re right, medication errors can be corrected with IT systems…again, why isn’t this where the money is going? We’re back to the construction projects, et al again. Maybe the distaste of lost revenue caused by “never” events will force resources into avoiding them, as opposed to just avoiding responsibility for them, or just doctoring charts and records omitting their existence. I’m not saying I agree that everything on the list should “never” happen, what I’m saying is I’m glad CMS, Leapfrog and private insurers are taking action. Somebody has to.

  14. Some things on the list, as White Coat says, are unforgivable.
    But catheter-associated urinary tract infections, as mentioned in some Wall Street Journal and BizWeek eds on this topic?
    That’s not a sponge in someone. That’s ‘the most common hospital acquired infection’ (Cochrane Review). That’s not a ‘never event’. Moreover, while it is clear that leaving a sponge in someone is preventable, there is no clear sense as to how to prevent UTIs. If we knew how to prevent the most common infection acquired in hospitals, we would. But the ideas…well, antibiotic impregnanted catheters, silver catheters–all of these add cost and risk of reaction, toxicity, or other untoward events. It’s not so simple to just say ‘we won’t pay for this’ when it’s so common and so difficult to prevent.
    The same goes for falls. 93-year olds fall. They shouldn’t, but they do. As for the comment below that electronic medical records will fix everything, I beg to differ–bad programming makes EMRs prone to error, as well, though they are an improvement.
    Point is, quality is a laudable goal, but this is a difficult way to go about it. You can’t lump the most common nosocomial infection in with leaving a sponge in someone or cutting off the wrong foot.
    Brilliant scientists have dedicated their lives to nosocomial infections, and made improvements. But there is no way to categorize them as ‘never’ events, unless you’d like to just do away with ICU medicine.
    And I won’t even comment on holding hospitals liable for a suicide attempt.

  15. And another thing…I am a bit young and naive, but I’ve never seen a chart doctored to omit a critical value.
    I’ve seen mistakes. And universally, the doctor that made them was tortured by it, did everything he or she could to determine the cause, and attempted to improve.
    Some people might find this hard to believe, but many of us in medicine still do it to try and help people, not to grab our paycheck and run while our demented, UTI-infected, fallen, ulcerated, mis-ordered patients are assaulted, and their babies dischared to strangers. (Yes, those are all on the NQF list).

  16. And another thing (wow, I’m really fired up) the places where this has been tried include Minnesota. The Mayo Clinic reported multiple ‘never’ events.
    Often the sense is that any hospital that allows a ‘never’ event is totally suspect and you should get out as fast as you can.
    Yet, the Mayo Clinic does these things.
    If you are outside the industry, how do you explain the perception that Mayo is the best of the best, and yet somehow still makes mistakes that should prompt patients to make an immediate mass exodus?

  17. Maggie, thanks for correcting me on the author of this post.
    Whitecoat, there is a lot that you don’t know about how the managed care industry works. That is not a jab. Very few do understand the market dynamics.
    To start, what reason is there to believe that the things classified as “never” events will keep expanding until disaster strikes for providers? Hospitals have substantial bargaining power with insurers. If a hospital decides it isn’t going to put up with an insurer not paying for some “never” event that it thinks crosses a line, then that will become an issue in contract negotiations. Insurers cannot steamroll hospitals on these issues, because they can seldom afford to lose the hospital from the network.
    Insurers can’t even stop hospital spending growth from being roughly twice the rate of GDP growth, so what magic power will they wield to refuse to pay for an ever-widening sphere of medical mistakes?
    When I said that insurers have very limited ability to alter their profit margins, there is an enormous amount of data to back that up. Health insurance profit margins have fluctuated between 0% and 10% over the last 20 years, with an average around 3-5%. That makes it a low margin industry, unlike pharmaceuticals. In fact, health insurer margins are about the same as hospital margins. If health insurers are so good at beefing up profits, then why are health insurance profits less than most industries? And don’t say it all goes into executive salaries, because that isn’t true either. If you can find any large or medium-sized health insurer whose top 5 executives make more than 0.5% of total revenue, I would be surprised. If you add up the executive salaries for health insurers and hospitals in almost any city in the US, hospital executives will be far higher. I don’t have any problem with the claim that executive salaries on average are too high, but then so are physician salaries. Nobody except primary care physicians in community clinics comes out looking good on this one from an egalitarian point of view.
    But I really want to address this point about profits. Here is what few outside of health insurance understand: when an insurer first finds a way to reduce costs that other local insurers haven’t found, then it has a temporary competitive advantage and can profit from it. However, other insurers soon figure it out and duplicate it. When that happens, premium adjusts to reflect the reduction in medical expense and everyone is making the same margin as before. Only now everyone has to keep doing that utilization control (or whatever) because if you don’t you will start incurring higher claims than your competitors and will start losing money.
    I hope that point is clear. It’s subtle, but important.
    Insurers were very aggressive about cost controls in the mid 90s with the managed care boom. They actually controlled costs for a few years. But they did NOT make higher profits. In fact, they made lower profits because it was a highly competitive time (aggressive pricing) and by the mid 90s everybody was doing the same things (gatekeeping, discount contracting, etc.), hence no competitive advantage.
    Switching topics, you write: “Unless the error rates have been reduced by 100%, how can you consider them “never events”?”
    What’s the problem here? If the word “never” bothers you, we can call them “mistakes to be minimized.” The key is that they result from mistakes, and that they should not be rewarded. To err is human, but you cannot infer from that that error should not be punished. Errors occur in a context, and often what you want to “punish” is the context or system and not the individual.
    You didn’t address my comments on systems-thinking at all, but I really think this is the most important factor underlying the willingness of hospitals to accept non-payment for these events, and MORE IMPORTANT, it is a harbinger of a large reduction in the number of these events. If these errors are reduced from 1 sigma events to 4 sigma events (I’m not even contemplating 6 sigma for the hospital industry as a whole), that would be an enormous benefit to the people who are saved from suffering. Arguing that since we can’t reach 0 mistakes it isn’t fair to incentivize systems that avoid them better is a little bizarre.

  18. JD,
    These are interesting comments.
    No beef with the primary contention, just two little ones; first, connecting physician salaries to CEO compensation is about as ludicrous as connecting the pay for a mid-level programmer to Oracle’s CEO on the cover of the NY Times the other day.
    We have high median salaries compared to the overall US median, but our debt load is staggering. If you think I’m making CEO wages–i.e., multiple millions per year whether I do a good job or not–you’re sadly mistaken. We sure as heck don’t make a lot more than your average lawyer or stockbroker.
    I take your point about never events, but this still doesn’t explain urinary catheters; infections from them are not a ‘mistake’. Failure to treat one appropriately may be. But the infection itself is not. Something we need to reduce, just like pneumonia and all infectious disease in general.

  19. JD –
    – I agree that I don’t know about the inner workings of the managed care industry. Nor do I have insight into the inner workings of the insurance industry in general. But I have more insight than you can imagine about how these inane policies will affect the ability of every person in this country to have access to affordable health care. You’re arguing the wrong point.
    – You will not be able to convince me that insurers are victims with razor thin profit margins when so many insurance companies can be found in the Fortune 500. How does it feel when people look at your outcomes instead of your processes?
    – The issue with labeling anything as a “never” event is the idea a “never” event conjures up in the average layperson. A “never” event should “never” happen.
    You and Lisa both fall into this logical fallacy when you state that “the key result is that they result from mistakes.” Performing a wrong site surgery “results from a mistake.” Explain the “mistakes” that health care providers make that cause a patient to fall, or commit suicide, or elope, or develop a UTI. Go on. I dare you to try. I double dog dare you.
    You want to reduce the incidence of these events? Try asking someone that works in the field how to do so. Insurance companies have access to people who work in the field and obviously haven’t utilized their resources very well. Maybe they just chose to ignore their resources because the solutions would cost too much money. Instead, insurance companies have created Draconian rules that will increase their profits and will also prove the laws of unintended consequences as the rules go into widespread implementation.
    Lisa –
    Define “enough” in your response. How many flat tires are “enough” to warrant action? How many products have to “repeatedly fail” before they warrant action? That’s the issue staring you in the face. How many is too many? How many UTIs are too many? How many falls are too many?
    What “human error” causes a patient to commit suicide? To fall? To have a UTI? Lets hear it. Tell me how to practice perfect medicine. Until you answer these questions, your arguments have absolutely no substance. None.
    Your vendetta against the physicians caring for your husband have no place in this argument. If you aren’t happy with your physician, find another one.
    You’re right that patients with a documented penicillin allergy probably shouldn’t be given penicillin. But there are too many variables involved to determine whether there was something done wrong. What was the documented allergy? A rash or anaphylaxis? Was penicillin given or was it a cephalosporin? Was penicillin the only effective medication for the infection? Was the death due to an allergic reaction or due to the infection?
    Same with MRSA. A health care provider that doesn’t wash his or her hands should be reprimanded. But does every case of hospital-acquired MRSA necessarily mean that someone didn’t wash their hands? Show me some studies proving that one. And they can’t come from the construction industry, either.
    In your world “appropriate staffing ratios” make situations avoidable. Great. Who’s going to pay for them? Sure as heck won’t be the insurance companies. If you’re so gung ho on having appropriate staffing, hire your own nurse. Then you’d get one-to-one staffing and (presumably) outstanding care. If you want the best medical care someone else can pay for, it just isn’t going to happen. You can’t have it both ways, Lisa. See this post: http://whitecoatrants.wordpress.com/2007/11/05/pick-any-two/

  20. 2 million a year is enough, the CDC estimates 2 million people a year are affected by nosocomial infections, and 90,000 of them die. 90,000 is enough. It’s more than enough. Many people think we’ve had “enough” soldiers die since the war started. We have the same number of patients dying in one month than we’ve had soldiers killed in the war in 5 years. Somewhere on my computer at home is…I believe the State of Pennsylvania’s report on UTI’s and I will look for it tonight and accept your double-dog dare.
    I agree some of the items on the list may be misguided, as JD said, let’s call them “things that shouldn’t happen so frequently.” But with respect to cause and effect I think refusing to pay for “things that shouldn’t happen so frequently” is a step in the right direction. Eloping is on the list? My husband never fell in the hospital, the Occupational Therapists were quite thorough in educating me and him on how to avoid falls. He did fall at home a lot, though. Perhaps facilities with a high fall rate would benefit from more staff-patient training and education. Suicide is an interesting one. In our case my husband developed ICU psychosis and was depressed and suicidal. I saw this coming months beforehand and thought it was important to give him references to time and get him out of the room as frequently as possible…this was another battle I fought for a long time. Anyway, falls and suicides, in my opinion, are a result of neglect. Not EVERY SINGLE time. Somebody said I was mad at the doctors who took care of my husband. There was one I wasn’t too keen on, but overwhelmingly my frustration lays with the administration and those in charge of setting policy and procedures. It’s a “system failure” and improvements come from good leadership. I’ve said this for years, I said it in my book, I never pointed my finger at any one caregiver and said “it’s your fault” because overwhelmingly, it wasn’t their fault. You think I come on blogs like this because I’m mad at some doctor? Why should I pay for a private nurse when our insurance company is paying tens of thousands of dollars a day for adequate care…adequate care that wasn’t provided due in part, to inappropriate staffing. They can afford a 90 million dollar vascular institute but can’t afford to absorb another $1200 a day (at MOST) to add another body on the floor? It wouldn’t have cost anything to let my warm body stay on the floor overnight, that didn’t happen either. I crave feedback and information from industry sources, I have sought it out for years. I don’t think we’ll have good solutions until all the players come to the table. Myself and many other advocates have tried to get good dialog going with surgeons, private practice physicians, IT specialists, hospital administrators, etc. We’ve asked them for lists, we’ve asked them what frustrates them, what is it that’s so “complicated” about healthcare that we just don’t get it? We can’t get good conversations going, they won’t talk to us, they say things like we have a different perspective, we can’t understand, “keep doing what you’re doing” etc etc etc. Trust me we’ve asked “how can this be avoided” and we’ve offered solutions on “how this can be avoided” hell, that goes way back to when my husband was still in the hospital. What I heard was “that doesn’t happen here” “you misunderstood” “you have a different perspective” and that’s primarily what we STILL hear. Oh shoot the server crashed, more later. . .

  21. Here’s an interesting report on UTI’s re: double dog dare http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_028894.html
    Some interesting portions:
    “CMS announced that it intends to provide a bonus for superior outcomes to hospitals based upon hospital performance measures. While it is advisable to measure nosocomial infection rates to influence hospitals’ behavior by tying a portion of their payment directly to adverse reactions and quality, it is more urgent to remove the direct payments for adverse events under the Medicare DRG system…”
    “…Hospitals with higher nurse-to-staff ratios have a lower incidence of UTIs…”
    “The analysis showed that there is significant variation among hospitals’ nosocomial UTI rates”
    “…Finally, patients would benefit if CMS discontinued the practice of paying hospitals for hospital-acquired urinary tract infections through the presence of CC codes in the DRG payment system. Such a system discourages adoption of infection-reducing initiatives in America’s hospitals.”
    And finally, here’s one for you “young and naive”:
    “…The measurement does depend critically upon hospitals using similar criteria to code for UTIs. It is possible that the UTI diagnosis codes may be omitted from claims due to field limitation constraints or for nefarious reasons, such as to affect quality measurements…”
    And, “young and naive” you might be interested in John James, PhD’s book, “A Sea of Broken Hearts.” John is a scientist at NASA working on environmental issues on Mars. After his son died from wreckless medical care, he did his own research and his findings relating to “critical values” missing from medical records might be of interest to you, if you don’t want to take my word for it.

  22. PS, I never said I was looking for perfect medicine, I never said I knew how to practice perfect medicine or perfect anything. My point is the healthcare industry needs a lot, a LOT of improvement, they’re not self-motivated to do so, I’ve worked tirelessly for years to do my part in seeking said improvements and the problem is there’s no flexibility. There has to be give and take on both sides (pt-caregiver), I never asked for a trip to the moon or 5-star gold class service, I just asked for adequate, mediocre would have been fine with me. I recognize the element of “human error.” One of the most glaring errors in my husband’s case, and the one that result in all the subequent damage and extended hospitalization (test result reading error) never upset me, I was never angry or vengeful or disrespectful or critical or all of the other bullets I’ve had thrown at me over the years, I was never upset about that. I was GRATEFUL one physician listened to me and saved my husband, that’s the way it’s supposed to work. I’m still grateful to him, very much so. Now, it shouldn’t have taken a week and hundreds of phone calls and pleas to everybody to get that ear, but when I finally did get it, I was GRATEFUL.

  23. White Coat, I just read the link you posted. Ha ha we say the same thing in construction all the time, fast free or quality? Can’t have all three. This is not a new theory to me. I’m flexible, I’m not the one speaking in absolutes as you are. I’m not asking for free, fast and quality. I’ll take the quality followed by cost, since you asked. I didn’t say ALL infections are caused by a failure to wash hands, although this tops the list. Did you catch the March issue of Forbes? Manufacturing plants are more sterile than hospitals. When I refer to “medical errors” this is generally the umbrella term that covers the failure of healthcare to be patient-centered. Mistakes, carelessness, communication breakdowns, lack of attention to detail, etc. This statement of yours is telling:
    “You’re right that patients with a documented penicillin allergy probably shouldn’t be given penicillin.
    White Coat, let’s be friends, but seriously, “probably shouldn’t”…a pt with a documented penicillic allergy should not be given penicillin, PERIOD…unless you’re standing by with epi or whatever it is you use to counteract an allergic reaction. Why wear the warning braclet? “I’M ALLERGIC TO PENICILLIN” if they “probably shouldn’t” get it? And if they got it and died as a result, something went wrong, buddy, very wrong.
    Maggie said:
    “Ultimately, I don’t think it should be so much about who pays for hospital errors–it’s a matter of figuring out which errors are preventable–and developing systems that make sure they don’t happen.” I COULDN’T AGREE MORE and since this isn’t happening, outside pressure is brought to bear to force it to happen. I’m not going to nitpick about what’s on the “never” list or what they call the list, I’m just damn happy to see that outside pressure start to come. White Coat, back to the penicillin
    “But there are too many variables involved to determine whether there was something done wrong. What was the documented allergy? Penicillin. A rash or anaphylaxis? Anaphylaxis. Was penicillin given or was it a cephalosporin? Penicillin. Was penicillin the only effective medication for the infection? Don’t know. Was the death due to an allergic reaction or due to the infection? Allergic reaction.”
    This sounds like some RCA, but the beginning of your statement is more accurate “there’s too many variables to determine whether something went wrong.” The pt was given a medication they had a known allergy to, period. There should have been some RCA done and this death should have been a learning opportunity to improve procedures so it doesn’t happen again. That’s not what happens, for the most part, in healthcare. “Too many variables…doing the best we can…”complications from infection” is what goes in the chart. Human life lost, opportunity to learn lost, family knows pt was killed because they were given penicillin and are left wonderig WTF is going on here? By the way, I think you’re (or whoever said this) underestimating the layperson, nobody is going to run away from the Mayo Clinic because they’ve reported “never” events.

  24. “I wouldn’t expect auto insurers to make an investment in figuring out how to make cars safer…”
    Maybe they’re not making cars safer, but they’re certainly trying to mitigate their losses…and as a result have definately influenced auto manufacturers. Insurance Institute for Highway Safety. We tried to get the same type of organization going, Insurance Institute for Healthcare Safety, there wasn’t any interest. Maybe there’s interest now.

  25. Aaron–
    I don’t recognize your name, so welcome to the discussion. Your comments are very much on point.
    As regular readers know,
    I love it when commenters begin talking to each other.
    That turns the blog into one of those really, really good seminars you had in college–where students began talking across the table to each other.
    That’s interactive.
    As long as ocmmenters don’t attack each other in any personal way–which can be the downside of online interaction. People feel anonymous and so they
    say things that they would never say face-to-face. . .
    But by and large, that doesn’t happen often on this blog . . .

  26. Aaron–
    I don’t recognize your name, so welcome to the discussion. Your comments are very much on point.
    As regular readers know,
    I love it when commenters begin talking to each other.
    That turns the blog into one of those really, really good seminars you had in college–where students began talking across the table to each other.
    That’s interactive.
    As long as ocmmenters don’t attack each other in any personal way–which can be the downside of online interaction. People feel anonymous and so they
    say things that they would never say face-to-face. . .
    But by and large, that doesn’t happen often on this blog . . .