In a move that could have significant implications for physicians and hospitals, the insurer Aetna has said it will not pay its network hospitals for care necessitated by certain preventable errors.
The announcement follows a policy shift by the Centers for Medicare and Medicaid Services, which has finalized plans to stop paying for eight preventable events as of October 2008.
Aetna, Inc. has incorporated language into its hospital contracts that calls for waiving all costs related to a number of serious reportable events. The language comes from the Leapfrog Group's “never events” policy, which includes a list of 28 events considered so harmful that they should never occur.
The list, compiled by the National Quality Forum (NQF), comprises events ranging from surgery performed on the wrong body part or on the wrong patient, to stage III or IV pressure ulcers acquired after admission to a health care facility.
The policy instructs hospitals to report errors within 10 days to the Joint Commission for Accreditation of Healthcare Organizations, state reporting programs, or patient safety organizations. Hospitals also are asked to take action to prevent future events and to apologize to the patient or family affected by the error. Aetna is the first health plan to endorse the Leapfrog policy.
“The major goal here is to get hospitals to focus on having the systems in place to prevent these events from happening,” said Dr. Charles Cutler, Aetna's national medical director.
Adopting the Leapfrog Group's never events policy is not about saving money, Dr. Cutler said. In fact, many of the never events carry no additional cost. Instead, Aetna is seeking to send a consistent message to hospitals ad health care providers about quality, he said.
“The intent here is not to be punitive,” Dr. Cutler added.
However, the Aetna announcement has nevertheless encountered some skepticism from the physician community.
The NQF list of never events is much broader than the eight preventable events selected under the Medicare policy, said Cynthia Brown, director of the division of advocacy and health policy at the American College of Surgeons (ACS).
One reason that many of those events were not included on Medicare's list is that they are difficult to measure with the current coding system, she said.
Another problem with the Aetna approach is that it's hard to affix blame to a hospital or a particular physician. “If there's a problem with blood incompatibility, is it the surgeon's fault?” Ms. Brown asked.
“It's hard to know how it's going to be operationalized,” she added.
When used properly, the National Quality Forum's never events list protects patients and directs a patient environment enriched with safety and quality, said Dr. Frank Opelka, who is the chair of the American College of Surgeons Committee on Patient Safety and Quality Improvement.
However, he cautioned that if payers drift from the intentions of the NQF never events, the specifications could be lost and overreporting could create unintended consequences.
For example, because of hospital overcrowding and limited resources in a rural environment, a frail patient may be admitted despite the lack of health care resources. If the patient has a pressure ulcer that progresses from a stage II on admission to a stage III, this should not be considered an NQF never event, he said.
Dr. Opelka also questioned whether hospitals would continue to report these types of serious preventable errors if they aren't being paid for the care.
“If the reports are generated from a hospital claims system and the payer no longer recognizes the events as payable, isn't the message to stop reporting rather than to prevent the never events?” asked Dr. Opelka, who also serves as the vice chancellor for clinical affairs at Louisiana State University Health Sciences Center, New Orleans.
The policy is likely to affect all of Aetna's network hospitals over the next 3 years as the company renegotiates its contracts, Dr. Cutler said.
Since Medicare announced its policy shift last summer, other insurers have considered changes to their policies. Officials at Cigna, for example, are evaluating how to implement a similar policy within their hospital network. The insurer plans to have a national policy in place by October 2008, said Cigna spokesman Mark Slitt.