The Wisdom and Justice of Not Paying for “Preventable Complications”

Abstract

FAR TOO MANY PATIENTS EXPERIENCE PREVENTABLE HARM from medical care in US hospitals. To promote quality and safety, many employers and insurers are linking financial incentives to clinical performance. These programs, often called pay for performance, use a carrot (pay more for better quality) or a stick (pay less for lower quality). To date, most pay-for-performance programs have encouraged physicians to use evidence-based interventions or improve patient satisfaction. The Centers for Medicare & Medicaid Services (CMS) has taken the lead, with many insurers following, in linking pay for performance to reducing harm. In October 2008, hospitals will no longer derive additional payments they sometimes receive when Medicare patients develop 1 of the following 8 preventable complications: objects (such as surgical instruments or sponges) left in patients after surgery, hospital-acquired urinary tract infections, central line–associated bloodstream infections, administration of incompatible blood products, air embolism, patient falls, mediastinitis after cardiac surgery, and pressure ulcers. In addition, CMS has published that conditions being considered for 2009 expansion of the list include ventilator-associated pneumonia, Staphylococcus aureus septicemia, and deep venous thrombosis or pulmonary embolism. The tacit assumption to the “not paid for preventable complications” approach is that an error occurred in a patient’s care that, if avoided, would have prevented the harm and ensuing costs. For one complication on the CMS list, foreign objects inadvertently left in patients after surgery, this is undeniably true. Linking errors to harm for the remaining complications is more complex. For strategies built around the “not paid for preventable complications” concept to be clinically and morally acceptable and to achieve the policy goal of improving quality of care, it must be certain that preventable complications are important and measurable and truly are preventable. In this Commentary, we discuss the CMS initiative in the context of these metrics. Complications Should Be Important and Measurable