Medical malpractice is the eighth leading cause of death in the United States. Yet it is estimated that less than 15% of all victims of medical malpractice ever file a lawsuit. Most malpractice causes more injury which then causes more medical care. National costs for preventable medical errors exceed 29 Billion dollars by some estimates. That expense is paid for by all of us through higher insurance or through bills to Medicare and other tax payer funds. This leads to the ironic and depressing result that many times hospitals and physicians make money from their own malpractice by billing for medical care that they cause and, worse yet, we the taxpayers and employers often foot the bill.
Medicare got the message that malpractice costs taxpayers money. To try to improve the health care and and reduce the costs associated with medical malpractice historically paid for by the taxpayers, the Centers for Medicare and Medicaid Services (CMS) developed a plan to reward good care and penalize negligent or preventable medical errors. Part of that plan began in October 2007 and is called the Never Event Rule.
The program uses both a carrot and stick methodology to improve medical care and to cut costs. Part of the plan looks at reducing common and preventible Hosptial Acquired Conditions (HAC) An HAC is a medical condition or event caused or acquired at a hospital. Some HAC are so prevalent and so preventible that Medicare deems them to be "Never Events," meaning that they never should happen without negligence. When Medicare finds a Never Event the hospital is, under law and as a condition to allow participation in Medicare, to report the Never Event and the hospital is required to pay themselves for the cost of the care caused by the HAC from a Never Event.
Medicare identified 10 categories of hospital acquired conditions that were Never Events based on three criteria:
High Cost and/or Volume of the medical event
A higher bill to Medicare than would be billed if there were no HAC due to the event
The medical event could have been reasonably avoided by attention to standard medical accepted practices.
The 10 Never Events in a Hospital are:
1. Retained Foreign Object After Medical Procedure (example: sponge or tool left in patient).
2. Air Embolism
3. Blood Incompatibility
4. High Stage decubitus or skin pressure ulcers
5. Certain Falls and Traumatic injuries in a hospital that are preventible such as
· Broken bones
· Dislocated joints
· Internal brain Injuries
· Impact and crush traumatic injuries
· Hospital Burns
· Electrocution and shocks injuries
6. Injuries caused by negligent diabetic care
7. Urinary Tract Infections related to Catheters
8. Vascular infections related to Catheters
9. Surgical Site Infections in certain surgeries, including:
· Laparoscopic Gastric Bypass surgery
· Orthopedic surgeries to:
10. Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) related to surgeries involving:
· Total Knee Replacement
· Hip Replacement
The point of the Never Events Rule is to make it clear that no longer will taxpayers foot the bill for conditions that are reasonably preventable if evidence-based treatment guidelines are followed.
The system works through the use of medical coding. Medicare requires a code for all medical care in a hospital. The bill is based in part on what codes are listed. Medicare tracks conditions that are hospital-acquired by comparing what hospitals report on the Medicare claim forms as conditions that were there when the patient is admitted to the conditions that are there when the patient is discharged. If it is a new condition first obtained while in the hospital then the condition is considered hospital acquired.
If a Never Event condition is an HAC (it was acquired during the hospital stay) instead of making a profit for that additional HAC related care, the hospital must pay itself for some of the cost of that care. Medicare does that by no longer reimbursing hospitals for the higher billing for the increased costs of care caused by the hospital acquired condition. Hospitals must now eat the cost for treatment of the patient caused by the Never Event. Some private insurance companies have followed the lead of Medicare. Additionally, the hospital can not only not bill Medicare for the increased care cost, it cannot bill the patient/beneficiary for the increased cost.
The purpose of the Never Event rule is to use economic principles of responsibility to allocate the cost of care. Now, instead of perversly making a profit from their own negligence, hospitals must bear the economic burden of their errors. But be careful to make sure the hospital does not ignore the law and instead bills Medicare or the patient in violation of the law.