WhiteCoat: Never say never

The following is a reader take by WhiteCoat.

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?

WhiteCoat is an emergency physician and blogs at WhiteCoat Rants.

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  • Anonymous

    If I hire a tree trimmer to take down the pine tree and he takes down the maple instead, I’m not paying him. He will be lucky if I don’t sue him.

    If my tree trimmer correctly takes down my pine tree but accidentally drops it onto my house, I’m not paying him. And I will sue him.

    If my tree trimmer thinks he should be paid for doing the wrong thing, then he’s an idiot.

    It doesn’t matter whether or not my tree trimmer is a highly profitable business or how quickly he answers his phone when customers call.

    I think it is astounding that anyone would expect to be paid for doing something that is NOT what they were contracted to do. Doctors included.

  • Anonymous

    I respectfully disagree with Anonymous 8:55. Some of these “never events” are things that cannot be prevented unless you are Spiderman and can catch every single old lady who is about to fall down and break her hip. Likewise, you cannot prevent all car accidents from occurring. Sure, you can take a defensive driving course and reduce the odds that you will get into a car accident but the odds don’t become zero.

    The refusal by insurance companies to pay for “never events” has a trickle down effect. The hospital has to somehow cover the costs of caring for these patients. Think of that the next time you visit the hospital.

  • Anonymous

    my solution is don’t take those patients. If you have to have a catheter for a long time, then I won’t pick you up as a patient. And to the guy who doesn’t pay the tree trimmer, that’s fine, but what happens when you can’t find a tree trimmer.

    So no bed sores are allowed, that’s fine, I won’t take any patients that can get bedsores. If you are forced to stay at bedrest and have comorbidities, I will say that I can’t be your doctor.

  • Anonymous

    8:55: Seriously, this is one of the worst arguments by analogy I have ever seen. The problem is that the things in your “example” are always preventable by exerting proper caution. Why, one might even call them “NEVER” events!

    How the hell could anyone with even the most basic knowledge of medicine compare that to the development of BED SORES? You know, the things can that happen in people when they’re in bed a lot, whether you treat them perfectly or not. The insurers have made a brilliant realization — they get pilloried in the press for refusing to pay for things to save themselves money. But if they refuse to pay for things and claim it’s because every patient should always have a good outcome and therefore any bad outcome should be paid for solely by the hospital, they’re heroes! Brilliant! Somewhere a marketing executive just got his wings.

  • Anonymous

    I take it that bed sore minimization is not a part of modern medicine.

    It amazes me that hospitals are going to have trouble paying for this or anything else. My local hospital seems to have lots of money for expansion, elaborate landscaping requiring elaborate maintenance, wood paneling and wood furniture in many of the administrative offices, and very healthy salaries for the administrators. And yet, when my wife needed some assistance one afternoon after spinal surgery, it took almost an hour for her to get a nurse. Bedsores indeed. It’s negligence.

  • Michael Rack, MD

    I do a little inpt psych, but am mostly an outpt doc. If a pt covered by one of these insurers has a never event, it appears that the hospital won’t be paid. Is the attending physician paid for the evaluation and management billing codes that he submits? What about other docs who are brought in as consultants? This is a genuine question, inpt billing for med patients is something I know little about.

  • Edwin

    That’s the trick, Anonymous 11:12 — sometimes these events will occur no matter if the hospital was negligent or not!

    Of course, we want to avoid poor care and negligent doctors and nurses… but for THEM to give the best possible care, they also have to be supported by management, have enough material and human resources, time, and so forth.

    From an outside perspective, given the task of “removing negligence” from hospital care, what does one do?

    It sounds like they have targeted outcomes that are likely results of negligence and made them anathema.

    The PROBLEM is from a lack of understanding; some of these things that are now anathema do not solely arise from negligence.

    Sure, bad nursing can lead to bedsores, and you want to eliminate bad nursing, so penalize bed sores! Can bed sores also be a natural consequence of some disease presentation, no matter how good the nursing is? I don’t know, but it sounds like this may be the case.

    Some of the “never events” may be reasonable… I don’t want a doctor removing bits of me in surgery that don’t need removing, for example… but it sounds like they got all excited by the idea of a list of things they don’t have to pay for and got a bit overextended.

  • Stark Raving Med

    It never ceases to amaze me what insurance companies concoct to deny service – when there’s plenty of unnecessary services provided to patients by their physicians already out there crying out for rejection! Coverage for a baseline mammogram at age 35? Not only has that been completely rejected by every major organization as unnecessary, it’s been shown to drive up the cost and morbidity of breast care more than it helps. Yet some insurance companies still cover it (and some docs still order it). As a radiologist I had a request for an MRI of the ABDOMEN AND PELVIS to evaluate an ovarian cyst. The patient waited a week to get it pre-approved…AND IT WAS! Why go through the rigamaroll of pre-certification if the crap is still getting through? Incidently we called the referring doc and and only did the pelvis, satisfactorally answering his question.

    Who’s making these decisions and why are they completely devoid of medical rationality? Insurance companies could really cut the waste without harming too many people if they had competent, medically savvy people instituting policy.

  • LD

    I agree w/ the theoretical construct of the ‘never event’, but I am for damn sure that the practical application will be a CF. If a surgeon amputates the wrong limb —– he should be sued, his licensed should be suspended (pending review), and he SHOULD NOT GET PAID for removing a ‘good’ limb. The rub is in how ‘never event’ is defined, and the likely slippery slope into a ‘catch all’ for any bad outcome / error. If an ER doc is running a code and he omits a single dose of eip (a dose determined to be part of ‘the standard of care’ — assume that the ACLS algorithms are ‘the standard of care’) then should he forfeit his ‘pay’ if the patient expires? (NO)

    It is the insurance companies’ role to call for the development of a ‘never event’ list, but the AMA should be charged with identifying the ‘events’ themselves (if the lawyers could decide which events qualify then perhaps they should be medics)

    The principal is sound, provide a financial disincentive for poor performance, but I am sure it will become distorted where the rubber meets the road.

    Kevin is a bit off base. His argument that a bunch of lawyers, actuaries, and admins should provide a set of ‘how to’ instructions is entirely without merit. The whole idea is to use financial pain to motivate medics to generate their own safeguards. If the lawyers could create such a set of instructions (for highly specialized arenas of practice) then perhaps they should be medics.

    ‘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.’

    Patients (and insurance companies) are customers and they are (rightly so) only concerned with outcomes. The ‘never event’ items must be incidents which could NEVER happen (ex: administer the wrong blood type) if the standard of care is followed; bed sores and infections from a catheter SHOULD NOT be on the list as they can occur even if top notch care is practiced.

  • SeaSpray

    You know what they say…never say never!

    While some providers may have the God Complex (I am kidding!) try as they might…they aren’t omnipotent.

    I certainly don’t want a bedsore, UTI or broken hip that could have been prevented through better provider responsibility and accountability and so I am glad there are standards that have to be met. We all know about the preventable negligence stories.

    No surgeon should ever lob off a healthy breast or remove the wrong kidney. These things are no brainers. But to penalize the providers when certain things may very well be out of their control is just wrong.

    This so obviously seems to be a gain for the insurance companies.

    There should at least be an inquiry/evaluation to determine the cause and then pay accordingly and not some blanket decision that penalizes everyone.

    What are providers doing to counter these things?

    And then there is the trickle down theory…these things will affect insurance companies in the end too.

    Eventually what goes around -comes around.

    Sadly…the patients are caught in the middle.

  • Anonymous

    I can’t believe the insurance industry has turned on you guys when you were such close bedfellows a few years ago.

    Glad to see Kevin still blaming physicians’ conditions on everyone but the physicians though. That’s how things get done – never taking responsibility for your situation!

  • Anonymous

    There is definitely a distinction to be made between events which absolutely can be prevented with faithful adherence to safety procedures and communication (i.e., wrong site surgery) and events which can be minimized through professional practices but never 100% controlled (like bedsores and infections). I’m all in favor of denying payment for the former but not the latter.

  • Anonymous

    just drop any patient who could possibly get these complications and that takes care of the problem.

    funny how the people complain about the docs still want to come see us when they are sick. go down to mexico you can get anything you want from the pharmacy and you can treat yourself.

  • Anonymous

    I see a huge gaping gulf between wrong site surgery and bedsores, UTIs and broken hips. Am I the only one?

    The comments depress me. There’s no excuse for amputating the wrong limb or breast, period.

    I hope and pray that I don’t make the mistake of choosing the doctor that will drop me as soon as I develop a condition he might not profit from.

    Frankly, Doctors, it seems to me it’s high time to stop complaining about Aetna, United and the like and do something about it. I know you will all disagree, but Drs. are still one of the highest paid professions in the US. Why don’t you buy up the health insurance companies or start your own, or even more radically, take a look at some form of universal healthcare that doesn’t leave you penniless and doesn’t leave us back in the Middle Ages?

  • Michael Rack, MD

    “Why don’t you buy up the health insurance companies or start your own,”
    not sure, but there is probably some federal Stark/anti-kickback/anti-collusion rule against this. And there is no way to compete with Medicare

  • Anonymous

    So would this be an easier pill to swallow if the “never” list started with just two or three things, e.g. wrong-site surgery or transfusion of the wrong blood type?

    I agree that many things on the list can be hard to prevent. I’m not sure how the list was selected nor what criteria were used. I think it would make much more sense to start with the low-hanging fruit and give hospitals a chance to achieve some results before hitting them with a penalty.

    But let’s not throw out the baby with the bath water.

    There’s a fair amount of literature on how to prevent wrong-site surgery, yet it keeps happening. Since reporting is mandatory in only a few states, we don’t even know how often it occurs, although it’s probably pretty safe to assume that what’s actually reported is only the tip of the iceberg.

    Hospital CEOs, hospital staff and, yes, many physicians, seem to have every excuse in the book as to why they can’t do better. Save your breath because I’ve heard them all.

    Maybe creating a financial penalty for some of these mistakes is the only way to get health organizations to take it seriously.

  • Anonymous

    So for every “never” event, a patient is “injured” and the insurance company gets to keep the money. I have a suggestion. Have the insurance company award that money to the patient. By this act, we know that the insurance people are truly concerned about the patient and not just the profit.

  • Anonymous

    >>go down to mexico you can get anything you want from the pharmacy and you can treat yourself.

    I had one in the ICU who did exactly that.

    GI bleed. Had the family get all the medicines. Sure enough, from Mexico, a combination medicine of indomethacin and prednisone. Patient didn’t tell me about that drug. Made regular trips to Mexico for the medicine you couldn’t find in the USA. I couldn’t believe such a combo drug existed, but there it was.

    Patient found it helped arthritis.

    I bet it did.

  • Anonymous

    Decubitus ulcers are “never events”?

    Why is it OK to develop heart failure or renal failure, but skin failure is unacceptable? A decubitus is skin failure. In a debilitated patient in bed, it is as inevitable as any other organ failure. But renal failure or CHF or COPD is a consequence of the natural history of disease, yet skin failure can only happen because some LPN didn’t turn the patient at precisely 2-AM last year.

    Complications of decubitus ulcers killed Christopher Reeve. Even a multi-millionaire, with all the healthcare resources available at his disposal, STILL got a decubitus bad enough to kill him. I don’t care if you’re rich as Croesus. You’re confined to bed or a wheelchair long enough, you’ll get a decubitus.

  • Anonymous

    You don’t have to talk to too many people with aged/dying relatives to find resentment towards mistakes that happen in hospitals.

    While the profession may see downsides to these policies I think they have great public sympathy and support because people feel so angry and frustrated at the care their relatives receive.

  • Anonymous

    12:51: The point of the post saying that the insurers should provide a guide for how to prevent bedsores 100% of the time (since it should “never” happen) is that it is literally impossible. It is impossible for them to write standards of care that make bedsores never happen, yet they’re claiming somehow this should magically be the case. If they can provide me a how-to manual for making bedsores a “never” event I’d absolutely love to get my hands on it.

  • Anonymous

    >>While the profession may see downsides to these policies I think they have great public sympathy and support because people feel so angry and frustrated at the care their relatives receive.

    And they will also find fewer and fewer doctors willing to cover these places, because of those unrealistic expectations.

  • Anonymous

    The insurance company does not get to “keep the money” — they make a margin above their costs. What they get to do is reduce some of these 15-25% annual rate increases so that small businesses like mine can continue to afford health insurance. Call me disrespectful, but I’m not paying you guys to amputate the wrong limb. There are legitimate “nevers” and you know it.

  • Ladyk73

    Many anony-mouse-s here!

    First, Doctors are not one the higgest paid professions. I wonder how family practice docs pay off their student loans!

    Bed sores a never? So when you have a patient who is 356 lbs, wouldn’t you risk hurting both the patient and the staff to move them as frequently?

    On the falls: So you will get into trouble for using “seat belts” for the happily confused elderly, and you cannot keep side rails on a bed cause someone might get their head caught…..
    oh my

    I hope I NEVER have to be in an emergency and all of the hospitals are closed.

  • Anonymous

    It must be nice to be in a profession where you get paid for your errors. I’m an engineer. If I tell a client “I’m sorry, but I solved the wrong problem” or “the project failed because I botched the calculatons” or “I’m sorry, but the machine won’t be delivered in working condition,” then I’m not only not paid — I’m unemployed.

    Furthermore, my clients are not expected to provide me with engineering standards. That’s what my profession provides me. And if I don’t follow them, I can lose my license.

    Oh yes, I have malpractice insurance too. But if I violate certain codes and standards it won’t matter much because it will be a criminal issue, not a civil one.

    As for “we want to avoid poor care and negligent doctors and nurses… but for THEM to give the best possible care, they also have to be supported by management”:
    Welcome to the real world. Works the same way in every field. But management can’t support you if you don’t even set standards like what is a “never” and what is not. Maybe there are bed sores in part because there’s a nursing shortage — what have you ever done about it? What? That’s what I thought.

  • Anonymous

    United healthcare profit last year was 4.6 billion. I think that’s a pretty substantial margin. That’s a billion a quarter. You might want to call and see if you get some money back.

  • Ladyk73

    “Anonymous said…
    The insurance company does not get to “keep the money” — they make a margin above their costs. 7:21 PM”

    I am so sorry, but you should request a copy of your insurances or HMOs tax filings an see how much money they have in their fund balance. And then make a analysis between their opearting budget.

    Keep the money? Yes, yes they do.

  • Anonymous

    United serves 70 million Americans, so that $4.6 billion is only about $66 each. $66 a year. I’m not impressed with your logic. Besides, it’s a publicly traded company (NYSE: UNH) — buy the stock if you think they’re making huge profits.

  • Anonymous

    “It must be nice to be in a profession where you get paid for your errors. I’m an engineer…”

    So was I. Not sure how to point this out to you, but things are different here. Structural components (or circuits, or chemicals) are assumed to be possessed of known quantities. With a patient, you never really “know” what you have, because there is no way to quantify it. As an example, patient outlook matters, though there is no way to quantify it. So do genetics, and we’re just beginning to quantify that. Tying compensation to outcome is appropriate, when the outcome results from less than optimal care. Otherwise, your argument does not hold. It is not possible to perform at a level greater than optimal (you want miracles?), and to be held responsible for a bad outcome after optimal care is irrational. Thus the objections.

  • Anonymous

    the whole idea behind health insurance is to spread the cost over multiple people so that one person who is healthy pays more than he costs and one person who is sick pays less. Just like Taxes.

    So the idea is you shouldn’t make money on everyone.

  • Anonymous

    Anonymous 7:48 PM claiming to be an engineer.

    Let’s try again. Decubitus ulcers (bedsores) are not preventable events. Decubitus ulcers are skin failure, like renal failure, pulmonary failure, heart failure.

    Decubitus ulcers can happen despite the best possible care. Christopher Reeve is the best example. Complications of decubitus ulcers lead to his death.

    Yes, engineers do not get paid for failure or error. They also have the ability to turn away work where the risk of failure is unacceptably high.

    You are seeing fewer and fewer medical students going into geriatrics. Unrealistic expectations on the part of families is one major reason doctors stay away from the field.

  • dr. bean

    The point is some of these “never events” are not 100% preventable or even close. How anyone, medical or non-medical could think that wrong-site surgeries and decubitus ulcers are in the same category is beyond me. So it seems disingenuous to say the least. Find some other way to reduce bedsores than by lying and saying that they are always due to malpractice.

  • Anonymous

    Or, more to the point, pressure ulcers are not necessarily preventable.

    Reichel’s Care of the Elderly 5th edition. Chapter 41 “Pressure Ulcers”:

    “Although the development of a pressure sore in a high-risk patient is not necessarily associated with poor care, this is often assumed to be the case. There are more than 17,000 lawsuits a year related to pressure ulcers, with settlements as high as $4 million”.

    “Although much is yet to be known about the prevention and treatment of [pressure ulcers], we do not know enough to prevent or heal the majority of pressure ulcers.”

  • Anonymous

    “First, Doctors are not one the higgest paid professions. I wonder how family practice docs pay off their student loans!”

    Actually, they are not “one of”, they are THE highest paid profession according to the US Dept. of Labor

  • Anonymous

    there are a lot of lawyers who get the degree but don’t work.

  • Dr. Incognito

    WhiteCoat,
    This post has been recognized on redscrubs.com’s Honorable Mention list.

    Nice job!
    Sincerely,
    Dr. Incognito

  • EthnicRedneck

    Accountants practice medicine about as convincingly as doctors teach calligraphy.

  • Anonymous

    Last February I was speaking to a nurse who told me her ER had over 20 holds (its a ten bed ER). The hospital was full with patients in the halls. She had been working 12-16 hour shifts everyday as had everyone else. They tried diverting patients but every hospital was the same. The elective surgery schedule was canceled and ambulatory surgery turned into an inpatient unit. It was Flu season. Hopefully no one got a decubiti while lying days on a stretcher in the emergency room.

  • Anonymous

    Maybe smoking should be a never event and insurance companies could refuse to pay for any smoking related disease. Doctors and hospitals could also refuse to treat anyone who smokes.