Saturday, October 3, 2009

Government Won’t Pay for Medical ‘Never Events’. Sound Policy or Sound Bite?

A new term has been introduced into the medical lexion - Never Events. This refers to medical misadventures that should never occur, such as removing the wrong limb or leaving a pair of pliers in a patient’s abdomen. These terms can be confusing for ordinary folks who are not medical policy wonks. Words and terminology matter here. 'Never events' are not medical complications, which are blameless events that occur in a small percentage of cases. Complications, as purely defined, are not medical malpractice events as no negligence has occurred. Here’s a primer.

Medical Complication: A patient denies medication allergies. A physician prescribes penicillin and a rash develops. There is no culpability.

Medical Malpractice: A physician prescribes penicillin without inquiring about drug allergies. The patient has a known penicillin allergy. Penicillin is prescribed and a serious allergic drug reaction ensues. This is medical negligence. The physician messed up.

Never Event: A physician knows a patient is allergic to penicillin and prescribes it anyway. This should never occur. Of course, this still qualifies as medical malpractice, but it is a deeper level of negligence. A 'never event' means that fundamental safety standards and procedures were ignored or violated.

This is my personal definition of a 'never event', although I am a mere amateur wordsmith. The federal lexicographers in Washington, D.C. have issued an official definition and an actual list of 'never events'. Hospital administrators have memorized these events because, if they occur on their wards, then they will not be reimbursed for hospital care required to treat what should have never occurred in the first place. This certainly sounds reasonable. For example, if a hospitalized patient develops a bedsore, which should not have occurred, should the hospital be paid more for the extra days of hospitalization required? The government says no, and most of us would agree. Interestingly, the physicians who would treat this same bedsore would not be penalized, at least not for now.

Here’s my concern. This initial brief list of egregious 'never events' will surely metastasize. It will be fruitful and multiply and will soon encompass routine medical complications and expected side-effects of medical treatment, which may be unavoidable. Tomorrow's 'never events' will include outcomes that are less dramatic and shocking than wrong-sided surgeries. Expectations for medical performance may become unreasonable and unrealistic. For example, patients may come to expect that a post-operative infection should never occur, especially if this becomes classified as a 'never event'. Indeed, the Covert Rationing Blog writes that the public is foresquare behind the notion that no medical complications should ever occur and if they do it is somebody’s fault.

I am skeptical that the 'never events' policy will achieve its stated mission to improve medical quality. The policy will wander off track and end up where it doesn't belong. As in many quality initiatives, the initial policy is seductive, but the inevitable mission creep becomes the hangover. In addition, the 'never events' list will become a legal cudgel against the medical profession.

Others have voiced concern over the 'never events' policy. The Health Care Blog points out that the policy as written might paradoxically discourage hospitals from treating minor infections on the 'never events' list. Aggravated Doc Surg, a blog written by a surgeon, suspects that the goal is not improving care, but denial of payment. Aetna and other insurance companies are adopting their own 'never events' policies. Are they motivated only to protect patients' health? This industry doesn't enjoy pristine credibility for their devotion to serve humanity. Perhaps, the government should dictate to them that denial or delay of payment to physicians should be a 'never event'?

The medical profession must strive for the highest quality possible. Many physicians feel, and indeed we joke with each other, that we are expected to perform flawlessly. Sure, we’d all like it if every patient recovered fully. We want 100% patient satisfaction for our services. We wish we could stamp out medical complications in our lifetimes. These are goals that we aspire to, but we will never achieve. They are true 'never events'.


  1. Excellent blog! I visited here after fleeing one of the usually level-head Bob Wachter political rants, and this site is a breath of fresh air.

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