The following is a reader take by WhiteCoat, originally published on 4/7/2008.
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.
