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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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.
“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.
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.
“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.
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 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.
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.
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.”
“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
there are a lot of lawyers who get the degree but don’t work.
WhiteCoat,
This post has been recognized on redscrubs.com’s Honorable Mention list.
Nice job!
Sincerely,
Dr. Incognito
Accountants practice medicine about as convincingly as doctors teach calligraphy.
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.
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.
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