Mark B. McClellan, M.D., Ph.D., the Administrator of the Centers for Medicare & Medicaid Services (CMS), announced that CMS is investigating ways that Medicare can help to reduce or eliminate the occurrence of “never events” – serious and costly errors in the provision of health care services that should never happen. Such action is part of the Agency's ongoing efforts to pay for better care, not just more services and higher costs. “Never events,” like surgery on the wrong body part or mismatched blood transfusion, cause serious injury or death to beneficiaries, and result in increased costs to the Medicare program to treat the consequences of the error.
According to the National Quality Forum (NQF), “never events” are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility. While the exact number of “never events” is not known, they result in many deaths and additional health care costs. In 1999, the Institute of Medicine (IOM) estimated that as many as 98,000 deaths a year were attributable to medical errors, and recommended that error-related deaths be decreased by 50 percent over five years.
Even with incomplete estimates, it is clear that, while there has been improvement in some areas of quality and safety since the IOM report, our health care system still has not reached the IOM’s goal of a 50 percent reduction in the number of deaths due to medical errors. Consequently, working with provider associations and other public and private groups, CMS is taking further steps to prevent “never events.”
Clearly, paying for “never events” is not consistent with the goals of Medicare payment reforms that would adjust payments based on quality and efficiency of care. Reducing or eliminating payments for “never events” would mean more resources could be directed toward preventing these events rather than paying more when they occur. The Deficit Reduction Act represents a first step in this direction, allowing CMS, beginning in FY 2008, to adjust payments for hospital-acquired infections.
CMS is reviewing its administrative authority to reduce payments for “never events,” and to provide more reliable information to the public about when they occur. CMS will also work with Congress on further legislative steps to reduce or eliminate these payments. CMS intends to partner with hospitals and other healthcare organizations in these efforts.
A fact sheet on “never events” is available through the link below.
|
Email
Print