Managed Care - August 2008 - (Page 6) LEGISLATION & REGULATION Payers Struggle to Find Approach to Never Events With physicians balking at CMS’s strategy, some health care plans are taking a less controversial route By John Carroll A t the American Medical Association’s annual meeting in Chicago in June, physicians voted to protest the Center for Medicare & Medicaid Services policy to reject payments to hospitals for conditions that Medicare considers reasonably preventable, including nine conditions Medicare was planning to add to the list this month. The AMA objected to a variety of hospitalacquired conditions — such as deep vein thrombosis, delirium, and Legionnaires disease — on Medicare’s list of current and proposed never events, says Rebecca Patchin, MD, an AMA trustee. “When you are providing appropriate care, delirium may occur, especially at the end of life,” says Patchin. But instead of focusing on ways to improve quality and reduce the number of instances that occur, CMS is likely to just force costs up as doctors run more tests to identify pre-existing conditions and thus delay needed care. Even if all doctors strictly adhered to evidence-based medicine, she adds, many of these conditions will continue to occur. The concerns voiced by the AMA and others must have had some merit for at the eleventh hour Medicare relented, slashing its list of additional no-pay conditions from nine to three on the last day of July. They are: surgical site infections after certain elective procedures, including certain orthopedic surgeries and bariatric surgery for obesity; certain manifestations of poor control of blood sugar levels; and deep vein thrombosis or pulmonary embolism after total knee replacement and hip replacement procedures. However, the AMA was still not satisfied. “To be a freelance writer, has been a contributJohn Carroll,reasonably preventable, there should be MANAGED CARE for six years. ing editor of solid evidence that by following guidelines, the occurrence of an event can be reduced to zero or near zero,” said AMA trustee James Rohack, MD, in response.“This is not the case for many of the now-banned conditions.” CMS, though, notes that the legislation governing never events requires the agency to select conditions that are reasonably preventable, not always preventable. While health plans have begun to migrate to the same basic approach — refusing to pay for what they have determined are incidents that should never occur to a patient in a hospital — several have moved forward while steering clear of the growing ruckus over Medicare’s approach to never events. And there’s a notable air of caution among some payers who say it will take some years to come to perfect a no-pay approach to never events. Choice of never events Two plans, Blue Cross Blue Shield of Massachusetts and Blue Cross & Blue Shield of Rhode Island, recently decided that they would refuse to pay for 28 serious reportable events (SRE) — also dubbed never events — listed by the National Quality Forum. Following the path of state agencies in Massachusetts, which recently adopted the NQF list, the two managed care companies are using a list that has an increasing number of events — and a declining number of defenders. “No one would disagree that these are egregious events,” says Audrey Shelto, vice president for health care services at Blue Cross & Blue Shield of Massachusetts. Shelto portrays the new move on never events as part of a wide-ranging set of quality and affordability 6 MANAGED CARE / AUGUST 2008
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