Medicaid Adopting “Never Event” Payment Rules

Medicaid is following the lead of Medicare and will stop paying for about two dozen “never events” in hospitals, according to a final rule published in the Federal Register on June 1. The rule nationalizes a nonpayment policy already implemented in 21 states, preventing funds from being used to pay for services that “result from certain preventable health care-acquired illnesses or injuries,” Centers for Medicare & Medicaid Services (CMS) officials said.

Never events are identified as situations where misadventures or poor outcomes befall a patient while hospitalized that could have been prevented. They include operations on the wrong body part or patient and post treatment infections. They also include blood incompatibility, serious pressure ulcers, falls, embolisms, burns, electric shocks, and comas caused by a number of means. Injuries to a patient’s spine, neck, shoulder, and elbow, and cardiovascular system while in the hospital also count. Additional costs and mortality make these events especially troublesome, CMS says.

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Not everyone is pleased by this decision. The American Medical Association (AMA) submitted a letter to CMS in March expressing concerns about the decision. AMA said it has “grave concerns” about states extending the non-payment policy beyond the condition considered by Medicare. “Simply not to pay for complications or conditions that, while extremely regrettable, are not entirely preventable, is a blunt approach that is not effective or wise for patients or the Medicare or Medicaid program,” AMA Chief Executive Officer Michael Maves, MD, said.  The American Hospital Association (AHA) expressed similar reservations.

“It’s a welcome first step into the national debate on quality,” Matt Salo, executive director of the National Association of Medicaid Directors, told Kaiser Health News. “Clearly many states have already moved ahead, although that should never be taken as rationale for forcing the rest of them to do … well, anything. But improving quality in a coordinated fashion between Medicare and Medicaid is important.”

Read the final rule for complete details.


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