Medicare targets hospital errors

Leave a scalpel in a body during surgery? Medicare paid to get it out. Get an infection from a catheter? Medicare paid to treat it. Same with problems caused by a transfusion of the wrong kind of blood.

No more. Starting this week, Medicare has announced it will no longer pay for 10 preventable conditions that patients acquire because of poor hospital care. Patients won't pay either because hospitals will be required to bear the costs of their own mistakes.

Blue Cross and Blue Shield of Florida and Humana are following suit, and other insurers may follow in a move that experts hope will improve the quality of care and lower costs.

South Florida hospitals generally support Medicare's action, although some have reservations about the details.

"I truly believe our national healthcare system is really in a quiet revolution," said Lisa Rawlins, director of quality and performance at Broward Health.

Supported by both Republicans and Democrats, "transparency initiatives'' have led to the gathering of medical data, Rawlins said, and that information turns into knowledge, and now it's turning into action. . . . I applaud what's happening."

The 10 situations covered by Medicare's latest move do not include the so-called "never events" -- happenings in hospitals that should never occur, such as amputating the wrong leg or operating on the wrong patient.

"Medicare doesn't pay for those events now," spokeswoman Ellen Griffith said, "on the basis that Medicare doesn't pay for anything that's not medically necessary."

The Leapfrog Group, which consists of large businesses dedicated to improving healthcare quality and lowering prices, has encouraged its members to refuse to pay for never events, and the American Hospital Association suggests that its members not bill for such catastrophic mistakes.

Some private insurers, including Humana and Aetna, also are refusing to pay for never events.

The 10 conditions in this Medicare announcement, however, are of a different type -- ailments caused by lack of quality controls that result in complications, such as serious bed sores or infections that occur at the site of surgery.

Unlike the clear-cut example of wrong-leg amputation, Medicare is saying it believes these conditions are "reasonably preventable" with the right hospital care.

That kind of qualification concerns Thinh Tran, chief quality officer for Baptist South Florida, who says the system strongly supports the idea of not paying for mistakes the hospital makes.

"Wrong-site surgery or a foreign body left in after surgery -- absolutely we should not receive payment," Tran said. ''But on the flip side of that, sometimes, regardless of what we do, there is going to be a clot in the leg of the patient," which is another of the 10 Medicare conditions.

"Sometimes people are prone to clots, no matter what you do. . . . Or a urinary or bladder type infection. If a patient came in from a nursing home, how can you tell if the infection started there or in the hospital? It's going to be a challenge."

Medicare officials have said they're not expecting to save much money with the new program -- perhaps $21 million a year of the $110 billion spent on in-patient hospital care annually.

But officials at the federal insurance program for the elderly hope their move will pressure hospitals to improve quality, thus yielding a much larger savings by reducing unnecessary treatment caused by mistakes.

"This is really a natural progression of using whatever levers are available to encourage continuing efforts of quality and safety," said Bill Donelan, vice president for medical administration at the University of Miami. "Medicare is working to reward good performance with incremental payments. This the old carrot-and-stick analysis."

Medicare's lastest move is the "stick part of the initiative," Donelan said.

"Medicine is not an exact science. . . . There will be, without doubt, a very small percentage of times a penalty is applied where there would be a very good reason for it not to be applied," Donelan said.

"But trying to sort that out is very difficult to do," he added.

The UM administrator called Medicare's 10 conditions "not terribly complex. I think [Medicare] is doing the sensible thing."

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