A growing number of hospitals across the country are making promises to stop billing patients and payers for care related to certain medical errors, but the efforts appear to be more of a public relations move than a substantive change.
State associations that have or are looking at nonbinding, voluntary limits on such billing include those in Colorado, Massachusetts, Michigan, Minnesota and Vermont.
But hospitals say they lack a system to track this kind of care, so little is known about how much hospitals might loseand patients and payers might gainfrom such a change. Moreover, some hospitals say they already have been declining to ask for payment on procedures done to rectify mistakes made by the hospitals. Creating a policy on the matter is merely formalizing the process, hospital industry executives said.
Nevertheless, some quality experts said the change is significant. Raising the question of how this type of care should be paid for is a manifestation of the prominence of patient-safety issues, said Diane Pinakiewicz, president of the National Patient Safety Foundation. It is an inevitable evolution of the issue, she said.
Minnesota hospitals have been following the nonbilling practice for years; the timing of the associations announcement was motivated by the CMS statement on its reimbursement changes, said Bruce Rueben, president of the Minnesota Hospital Association.
Nonbilling was already common practice; it only makes sense to not bill for these events, he said.
Minnesotas formal policy does not have a huge impact on practice, but it tells consumers that hospitals take concerns about medical errors seriously, according to Debra Boardman, president and chief executive officer of 187-bed RiverView Healthcare Association, Crookston, Minn. It makes a public statement, she said.
Based on the National Quality Forums list of 28 adverse events, including wrong-site surgery, wrong-patient surgery, contaminated drugs or medical devices, and infants discharged to the wrong person, the nonbilling policies will take separate shapes in Minnesota and Massachusetts, the two states that have formally announced their plan. Minnesota will stop billing for all 28 events, but does not have an implementation schedule in place. Massachusetts, which will stop billing for nine of the 28 events while assessing the others, expects to initiate its policy by the end of January.
Neither plan is mandatory for member hospitals; however, the associations said they expect full participation, based on their hospitals historic push for greater quality.
Medical errors came into the national spotlight in 1999, when the Institute of Medicine released its report To Err is Human, in which it called attention to an estimated 44,000 to 98,000 deaths per year from medical errors costing between $17 billion and $29 billion. National groups like the Leapfrog Group and Institute for Healthcare Improvement have used the IOM information to help form their agendas to push for change in the healthcare industry. NQF modeled its list of events after the IOM report as well. Much of the IOMs data are nearly two decades old, however, and there are no updated estimates available.
The CMS also relied in part on the IOM report in formulating changes to its reimbursement policy next year, an issue that is potentially contentious for hospitals that will have to submit data in yet another structure to receive payments. The CMS, the largest payer in the U.S., will no longer pay for eight specific problems, deemed hospital-acquired conditions. Three of the NQFs adverse events appear on the CMS list. Taking their cue from the federal agency, insurance companies have begun announcing they will no longer pay for certain care as well (Sept. 3, p. 20).
At this point, however, there is no way to account for care related to mistakes, according to the hospitals. Because they say theyre already not billing for these events, they dont keep track of the costs involved.
Hospitals are keeping track of the events themselves for reporting requirements, but not the costs involved for that care; the expenses are difficult to predict, and the events are rare and do not have a large impact on the bottom line, said Andy Whittemore, chief medical officer of 746-bed Brigham and Womens Hospital, Boston. Formally adopting a policy creates a palpable change in culture, but we need more time to work out the details of some of the events, he said.
Helen Darling, president of the Washington-based National Business Group on Health, which focuses on employers interests, isnt buying it. That hospitals are already leaving out some payment requests doesnt ring true, she said.
There is no evidence to show hospitals do leave out certain components of care; If anything, Ive heard the opposite, said Darling, who ranked 74th on Modern Healthcares list of 100 Most Powerful People in Healthcare for 2007. Because parceling out each specific part of treatment is so difficult, it might not be done, she said.
Even health insurers dont seem too concerned about the potential impact of adverse events on the bottom line. HealthPartners, one of the largest insurers in Minnesota, works with hospitals on each bill if there is an issue, said Babette Apland, senior vice president. From Oct. 7, 2005, to Oct. 6, 2006, the state saw only 154 adverse events occur out of 8 million total admissions. The money is a small percentage, she said.
But part of the issue is financial, said the National Patient Safety Foundations Pinakiewicz. Historically, the medical payment structure has been to pay for all care, regardless of outcomes. We are not incenting the provider system toward the best care, she said.