26 August 2009

Monkey See, Monkey Do


File this under utterly predictable:

Aetna tightens payment policies on hospital errors - Modern Healthcare (sub req)
Aetna has established new, tighter policies dictating when it will and will not reimburse for medical care related to errors made by providers.

Under the policies, Aetna has broken errors into two categories: “never events”—three events involving surgery: wrong patient, wrong site and wrong procedure—and 25 serious reportable events as defined by the National Quality Forum. Providers will not be reimbursed for a case involving one of the three never events, under the new payment policy. Of the 25 events, eight will be reviewed by Aetna to determine whether reimbursement should be withheld. The rest of the events will also be reviewed under Aetna's new policy, but they will not be considered eligible for adjustments to reimbursement, the spokeswoman said.

This of course follows on the heels of Medicare's decision not to pay for such events. The good news is that, as far as I can tell, Aetna has not extended the policy as far as Medicare has. Medicare, you may recall, also decided not to pay for certain (arguably) preventable conditions, such as foley-catheter-associated urinary tract infections, and surgical wound infections. Aetna, at least for the moment, is limiting its policy to the more black-and-white "never events" as defined by the National Quality Forum: items such as wrong-patient surgery or death due to contaminated medications.

I mention this not to rail against these standards or against the notion of incentivizing hospitals financially to avoid errors, but to highlight how rapidly and directly Medicare policies are aped by private insurers to the point that they become industry standards.

5 comments:

  1. I recently had ER admission for bradycardia and AMS ER doc while putting in Central Line puncutured rt lung. 7 days in ICU and this guy still sends me a bill for what insurance and Medicare didn't pay. Which list does that fall on. Most er docs say hasn't happened to them

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  2. I'd say it falls into a known complication of the procedure that is listed on the informed consent form. I've done very few as it doesn't fll into my clinical practice often enough to keep the skill up, but in talking to those who do, if you haven't dropped a lung at least, you haven't done enough.

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  3. Whose insurance pays for wrong patient surgery? The person who was operated on wrongly, or the person who didn't get the operation?

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  4. So I understand that the idea is that the hospital is supposed to pay for the errors, but what keeps them from just saying "oh, this wasn't covered, pay up" to the patient? This sounds like I'm being cynical or rhetorical, but I'm honestly curious. Is there some control to keep institutions from just passing the buck along?

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  5. A punctured lung is a known complication. It sucks when it happens. Bradycardia and AMS? Sounds like he was trying to save your life. be happy you are alive.

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