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Medicare (and now other Insurers) will no longer pay for "Preventable Hospital Errors"

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Previously, I wrote about a Medicare proposal scheduled to take effect October 1, 2008, in which the government insurer would no longer pay for "preventable hospital errors." These include errors, injuries, and infections that could "reasonably have been prevented." (The New York Times article is here. The large pdf file of Medicare reimbursement rules is here; see page 290 for the new guidelines.)

The conditions that will no longer be covered include infections from urinary catheters, infections from central venous catheters, pressure ulcers, objects left in the body after surgery, air embolism, injuries from blood incompatibilities, mediastinitis as a complication of heart surgery, and falls.

Other conditions that could be added to the list in the future include surgical site infections, ventilator-associated pneumonia, Staph aureus bacteria, methicillin resistant Staph aureus infection, deep venous thrombosis, and Clostridium difficile colitis.

According to the Wall Street Journal, two other insurers, Aetna Inc., WellPoint Inc., will also refuse to cover care resulting from the most serious errors (like operating on the wrong limb and leaving an object in the body after surgery). Other insurers are expected to follow along by denying payment for errors, and the list of uncovered "preventable hospital errors" is anticipated to increase with time.

I am of two minds about this. On the one hand, I've written previously about the potential of medical checklists in preventing errors and hospital acquired infections, like intravenous catheter infections. Most hospital systems could prevent a percentage of errors and complications through the use of simple measures like checklists. I think that the new Medicare rules will encourage the widespread adoption of hospital safety rules, and this could potentially save lives.

On the other hand, these complications are only potentially preventable. Even after following best practices, there are certain conditions -- like lower extremity blood clots, intravenous and urinary catheter infections , and C. Diff colitis -- that are likely to happen in the sickest hospital patients. Viewed another way, these rules are just another way of reducing payments to hospitals that are already on shaky grounds financially. Invariably, the list of uncovered medical conditions will grow to include many situations that may not "reasonably have been prevented," but for which insurance companies would simply prefer not to pay.
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About the Author


MD, FACP, FASN

Dr. Schwimmer's blog explores the intersection of medicine, new technologies, and the Internet.

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