“Never Events” are Pay-for-Performance in Disguise

On October 1, 2008, Medicare announced its first list of “never events.” A never event is something that Medicare believes should never happen and it refuses to pay hospitals when such events occur.

Some of the items on the original October 2008 never event list make sense – surgery on the wrong patient or the wrong body part is obviously inexcusable. So is leaving a surgical instrument in a patient.

Unfortunately the list has expanded to include relatively unlikely but routine complications with the result that Medicare’s “never events” policy has the potential to skew clinical decision making in a way that does grave harm to patients.

For example, making Clostridium difficile infections a never event is preposterous. As part of a larger discussion of the folly at the heart of the never event targets, the WhiteCoat blog notes that Clostridium difficile is a “never event” normally present in the stool of 3% of healthy adults and up to 80% of healthy newborns and infants. Patients with inflammatory bowel disease, or irritable bowel syndrome, or renal failure often have C. difficile.

Classifying C. difficile as a never event when acquired in the hospital vastly increases the risk for hospitals willing to treat people who may be C. difficile carriers. The sensible course for hospitals is to test every entering patient for C. difficile infection. One commercial test kit costs $823.56 for 20 kits or about 40 dollars a patient plus labor. Since there were more than 40 million hospital admissions in the U.S. in 2006, that would cost more than $1.6 billion annually. Alternatively, hospitals could elect not to treat C. difficile carriers or to skimp on the free treatment that Medicare requires them to provide to people who develop C. difficile during their stay.

Medicare’s decision to classify delirium, bloodstream staph infections, surgical site infections, collapsed lungs as a result of medical procedures, and deep vein thrombosis following hip or knee replacement as never events also poses significant risks for elderly patients dependent on Medicare. Outlawing deep vein thrombosis is the same as outlawing blood clotting. Even in the best managed cases, the rate is 1 to 3 percent. An incidence of 1 to 3 percent is not a “never” event, and the insistence on preventing clots ignores the fact that too much clot suppression can cause fatal hemorrhages.

For a more detailed discussion of the dangers of the never event classifications, and of how they endanger patients, see the Buckeye Surgeon blog in August 2008.

The harm posed by never events is one of a number of problems that arise when bureaucrats who often know relatively little about the balancing of various harms that inform treatment decisions for individual patients set treatment targets. In the process, they shift decision-making power from physicians to hospital managers.

In the National Health Service, which has been setting targets longer than Medicare and which gives managers much more power, clinical decisions are routinely abrogated by hospital managers trying to satisfy government quality targets.

To meet targets, managers move medically unstable patients from emergency departments to acute care over the objections of physicians. Hospitals discharge patients too early, with a plan of readmitting them in order to record two successful “clinical encounters.” Physicians are forced to divert attention from treating seriously ill patients to those with minor ailments when waits in Emergency Departments close in on the four-hour target.

Overruling medical staff to meet government targets also creates havoc in patient care. As previously reported at this blog, an estimated 400 to 1,200 people were killed by substandard care at one NHS hospital emergency department.

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