The most recent Health Wonk Review includes a particularly interesting article about “never events” written by Dr. Rich of The Covert Rationing Blog. “Never events” are complications that – according to the Centers for Medicare and Medicaid Services (CMS) – should never occur. A few years ago, CMS came up with a list of several “never events” and stated that hospitals and doctors would no longer be reimbursed for costs associated with treating these complications. Basically, they were saying that the complications should never have occurred in the first place, were the result of provider error, and that the hospitals and doctors would have to remedy the problems without being compensated for doing so. CMS has now added several new conditions to the “never events” list, and Dr. Rich picks apart the underlying motives and implications that go along with the “never events” list and the refusal by CMS to pay for care provided to treat these conditions.
The “never events” list reminds me of zero-tolerance policies that are sometimes enacted by schools and other organizations. Both tend to generate strong public support at first glance. After all, shouldn’t we expect doctors and hospitals to strive for mistake-free work? Shouldn’t we do whatever it takes to prevent drugs and weapons from being taken into schools? But then we end up with 6-year-olds being suspended for bringing camping utensils in their lunch boxes, and all of a sudden the zero-tolerance policies don’t seem to make as much sense. Perhaps there’s a similar grey area with “never events.” As Dr. Rich points out, certain high risk populations (the elderly, those with some chronic conditions, the obese, people with clotting disorders, etc.) are more likely to suffer complications on the “never events” list. In some cases, even the best possible care cannot prevent all “never events.” Of course, there are also plenty of times when “never events” do occur because of provider error or negligence. But to lump all “never events” into the same category seems like a mistake akin to equating a first grader with a camping utensil to a 15 year old with a switchblade.
If the goal of CMS is to reduce the number of “never events” – but not to discourage doctors from treating high-risk patients who may be more likely to suffer complications – it would seem to make more sense to evaluate reimbursement for “never events” on a case-by-case basis. Zero-tolerance policies rarely make sense when you consider all of the possible scenarios, and the “never events” list basically amounts to a zero-tolerance policy.