Op-ed: Medicare’s mistake

The following op-ed was published on January 14th, 2009 in the USA Today.

Every patient’s worst nightmare is going to the hospital for a procedure only to have a surgical instrument left in his body, the wrong limb or organ operated on or, worse, dying from a medical mistake. These types of mistakes should never happen.

So when Medicare recently instituted a plan to deny hospital payments for catastrophic medical errors or “never events” its initiative received widespread acclaim.

“When you enter a hospital,” says Herb Kuhn, deputy administrator of the Centers for Medicare and Medicaid Services, “you don’t want to leave with something else. Let’s get it right the first time.”

Medical errors, though rare, contribute to nearly 100,000 deaths a year in the U.S., according to the Institute of Medicine. These mistakes are ultimately paid for twice “” once for the error and again for the subsequent treatment to fix it. The result is almost $10 billion in annual excess charges.

Preventive action

Medicare deserves to be lauded for modifying its payment system to promote healthy outcomes over the quantity of care and, in the process, reducing unnecessary excess charges for errors that should never happen.

Where Medicare goes wrong, however, is by extending the no-pay rules to include “reasonably preventable” complications. These currently include patient falls and hospital-acquired infections. Temporary changes in mental status, known as delirium, also will be added this year.

Despite impeccable care, some hospital complications cannot be prevented. For example:

* No studies exist that show how infections can be cut to zero.

* The government acknowledges that there are few effective guidelines to reliably halt the onset of delirium.

* The AARP reports that one in three seniors older than 65 falls each year.

Penalizing hospitals for events that cannot be prevented is counterproductive and leads to unintended consequences, including driving up the cost of care by exposing patients to more testing, thereby decreasing access to medical care.

Who is at fault?

When a hospitalized patient develops an infection, for instance, it can be difficult to determine whether the fault lies with the medical staff or with a predisposed condition. This is a crucial distinction because Medicare will punish the former scenario but pay in the latter.

Hospitals might be motivated to order tests, without clear medical symptoms, to show that any infection caught from within its walls was already pre-existing.

The American Medical Association shares this concern, saying that the aggressive expansion of no-pay events can “drive up costs by requiring more tests upon admission.”

Furthermore, some institutions could decide not to admit or perform elective procedures on high-risk patients, particularly the elderly, out of fear of being denied payment for complications it cannot prevent.

Robert Wachter, professor of medicine at the University of California-San Francisco and an authority on hospital medicine and patient safety, cautions that the rapid expansion of the no-pay idea looks like a “cost-cutting effort clothed in the garb of patient safety” that is “nowhere near ready for prime time.”

While withholding payment for inexcusable medical mistakes is a sensible concept, Medicare’s decision to penalize hospitals for more nuanced complications raises the bar too high. You cannot regulate perfection.