Hartford health-insurer Aetna has adopted tough reimbursement policies that allow the company to withhold payments to medical care providers who make serious but preventable mistakes in patient care.
The new guidelines, which strengthen and add to similar policies Aetna adopted in 2008, require facilities, physicians and other health-care professionals to waive all or some charges directly related to 11 possible mistakes in patient care that can and should be prevented.
Those errors include eight “serious reportable events (SREs),” which are actions, such as leaving a foreign object in a patient after surgery or providing contaminated drugs that may lead to a patient’s death. The errors also include three “never events,” including performing surgery on the wrong person or wrong side of the body.
Elysa Ferrara, head of Aetna’s Provider Quality Performance Programs, said the goal of the new policy is to improve patient care and reduce unnecessary health care costs. It’s estimated that 98,000 people die each year from preventable medical errors, according to the Institute of Medicine.
“We don’t want our members left holding a bill for inappropriate treatments,” said Ferrara. “These kinds of errors should never happen.”
The trend of insurers not reimbursing medical providers that make preventable errors is relatively new. Mainly, it started last year when Medicare said it would no longer reimburse hospitals that treat conditions caused by wrong-side surgeries, transfusion with the wrong blood type, bedsores, and falls.
Since then, insurers, including Cigna, have begun adding those guidelines into some of their contracts, but Aetna’s latest policy enhancement may be the most stringent in the country.
Last year, Aetna began putting nonpayment language related to hospital errors in certain provider contracts, but now it will be added into the company’s overall reimbursement policy. That means it will carry more teeth and apply to all medical provider claims in Aetna’s commercial medical products and Medicare Advantage plans.
Ferrara said Aetna adopted the policies partly in response to members’ complaints about picking up the tab for unnecessary health care procedures. Members can end up paying for costly medical mistakes through higher premiums.
“We were hearing from members that they don’t want to be paying for these events,” Ferrara said.
The conditions no longer eligible for full reimbursement, and which medical providers may not charge for, are based on a list of 28 SREs first developed by the National Quality Forum, a nonprofit working to develop a national strategy for health care quality measurement and reporting.
According to the state Department of Public Health, there have been 967 “adverse events” at Connecticut medical facilities since July 2004.
The adverse events are similar to the SREs defined by the National Quality Forum. The most common mistakes in the state during that time period include falls resulting in serious disability or death (405), lacerations from open, laparoscopic, and/or endoscopic procedures (198), ulcers acquired after admission to a health care facility (124), and foreign objects left in a patient after surgery (68).
Eighty-six percent of the adverse events were from patients at acute care or children’s hospitals, according to DPH.
Aetna’s new policies will also require health care facilities to perform an in-depth analysis when a SRE occurs, as well as to identify improvements to prevent future mistakes.
Aetna medical directors will also review the event and discuss the appropriate payment given the circumstances.
In principal, Connecticut’s hospitals largely agree with the conditions set out in these new contracts, but they also have some concerns.
“Events that are truly caused by errors in the control of the hospital are events that we should not be reimbursed for,” said Brian Fillipo, a doctor and vice president of quality and patient safety for the Connecticut Hospital Association. “But we need to look at these events on a case-by-case basis. It is difficult to develop set-in-stone policies that determine which events should be reimbursed and which should not be.”
Fillipo said most medical providers agree that they should not charge patients if a “never event” occurs, but certain SREs may not preventable.
Patient falls is one area that can be up for debate. Fillipo said hospitals can take all the precautions to prevent a patient from falling, but that doesn’t mean it won’t happen.
Aetna’s new policy will not reimburse medical providers for the following mistakes: Three Never Events • Surgery performed on the wrong body part • Surgery performed on the wrong patient • Wrong surgical procedure performed on a patient Serious Reportable Events include • Patient death or serious disability from the use of contaminated drugs, devices or biologics provided by a health care facility • Patient death or serious disability associated with an electric shock while being cared for in a health care facility • Foreign object left in a patient after surgery or other procedure • Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances • Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility Source: National Quality Forum
Reader response:
“Further item for investigation: Does Aetna’s refusal to pay mean that the medial provider could then attempt to bill the patient or patient’s family directly? Or would the insurer’s policy also provide a protection to the insured individual or family?” — Tim Dwyer, Quasi-Peak Wireless
