Managed Care - August 2008 - (Page 7) LEGISLATION & REGULATION initiatives that has been laid out by the Massachusetts plan. The NQF events are also rare. Instead of hospital-acquired infections, the NQF list leans toward incidents like patient disappearances, electric burns, medication errors, damage done by someone impersonating a physician or nurse, surgery on the wrong body part, and so on. By one estimate, there were about 70 of these NQF events in Massachusetts in the first five months of the year, says Shelto. There are other ways to tackle hospital-acquired infections than a no-pay rule, she adds. “We are working on a regional initiative to eliminate hospital-acquired infections,” she says, noting that any changes the plan makes to avoid paying for such infections would require changes in coding. Concentrating on the NQF list for nonpayment while working on new initiatives to eliminate the number of hospital-acquired infections is a logical approach, says Shelto. “It is going to take, both us and the state, some time to work out the implementation of this new payment policy on never events,” says Shelto.“Some may be identified through billing codes, some retrospectively through audits. That these events now have to be reported to the state will help a lot. Getting a shared definition of what is preventable in terms of infections still needs more work. In the meantime, local providers are doing a lot more to get to zero” on the CMS list of hospital-acquired infections. It’s hard for a plan to even know whether it is paying for these events, says Harold Picken, MD, MPH, the associate chief medical officer for Blue Cross & Blue Shield of Rhode Island. “It’s hard to tell from claims data, and that’s one of the issues hospitals are struggling with in terms of the CMS policy.” About a dozen states around the country require providers to report all or part of the NQF list. That may well expand as more payers as well as providers focus on new policies concerning never events. “Increased transparency and greater access to reported data present an important opportunity to learn and advance health care practices that improve safety and quality,” says Janet Corrigan, PhD, CEO of the National Quality Forum.“If we aren’t reporting these serious errors, we can’t learn from them.” While the Leapfrog Group is backing the NQF on its list of 28 events, Leapfrog CEO Leah Binder also said — in an interview before CMS’s decision to trim its list of new never events — that the quality group supported CMS’s refusal to pay for its slate of additional hospital-acquired conditions. Criticism of the CMS policy implies “a pessimistic view of the potential of the health system,” says Binder. “We have the finest system in the world,” fine enough to stop preventable errors from occurring. “It isn’t only the patient that should pay.” Payers want action — of some kind One reason the NQF list may be less controversial than Medicare’s is that like all NQFendorsed consensus standards, the SRE list reflects a consensus of representatives of all parts of the health care system. “We went for the larger list as we did our background reading,” says Picken. “It was hard to come up with objective criteria to draw a line between the last one included and the first not included. If you were a patient going into a hospital, is there anything on this list you would not expect to be protected from?” To get paid for treating the infections on the CMS list, says Picken, hospitals will have to prove that the patient had them at the time of admittance. And while it’s theoretically possible for some of those events to dwindle away to zero, Picken also believes that some hospitals will take a while to get there. “While we have more events than Medicare,” says Picken,“we are working to ease the hospitals in — in a more gradual way. “What if the alternative is no standards?” asks Picken.“Having national, commonly accepted standards is the goal, but you have to start somewhere. And if we all have to wait, we will never get off the dime.” MC AUGUST 2008 / MANAGED CARE 7
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