Health insurer says it won't pay for adverse events.

WellPoint Inc., parent company of Anthem Blue Cross Blue Shield in New Hampshire, has unveiled anew policy regarding what it calls "reimbursement modifications" for providers aimed at eliminating preventable adverse events.

WellPoint officials said the primary focus of the policy "is to

Three of the most serious 11 events--termed "never" events--targeted by the nation's largest insurer are designated by the Centers for Medicare and Medicaid Services and the National Quality Forum and include: surgery performed on the wrong body part; surgery performed on the wrong patient; and wrong surgery performed on a patient.

WellPoint told its network hospitals that no one will be charged if any of the three events occurred.

According to CMS, "never" events add an average of an additional $700 per case to treat decubitus deers to $9,000 per case to treat post-operative sepsis, and medical errors may account for 2.4 million extra hospital days, $9.3 billion in excess charges (for all payers) and 32,600 deaths.

The federal Agency for Healthcare Research and Quality said in its 2007 report (covering data from 2000 through 2005) that despite hospitals' vigilance against serious medical errors, patient safety showed an average annual improvement of just 1.5 percent.

Among the other events that will be monitored under WellPoint's policy are: an object left in the body during surgery; air embolism or blockage; blood incompatibility; catheter-associated urinary tract infection; hospital-acquired injuries such as fractures, dislocations, intracranial injuries, crushing injuries and burns.

WellPoint said that only appropriate payment will be made and no additional charges are incurred if any of these events occur.

Richard Lafleur, M.D., Anthem's medical director in New Hampshire, said the policy is meant to align the insurer even closer to published standards from NQF, a nonprofit membership organization created to develop and implement a national strategy for health-care quality measurement and reporting, and standardizing largely volunteer policies of its provider members.

"Our approach is not much different than CMS," said Lafleur. "The alignment is an incentive. Many hospitals have voluntarily not charged for adverse events and have not even billed the patient. This is a collaborative effort."

Elliot Hospital in Manchester participates closely with a number of quality organizations, including CMS and is a member of the New Hampshire Quality Commission, a group comprised of all 26 acute-care hospitals in the state. It also participates in Anthem's Quality Hospital Incentive Program, or Q-HIP.

"We are really delighted to see WellPoint in alignment with CMS," said Maryann McEntee, vice president of quality and performance improvement. "Most of the industry has policies and procedures for any adverse event. If one were to occur, a full investigation is launched into the individual circumstances" said McEntee.

One issue that will require closer scrutiny on a case-by-case basis in regards to WellPoint's policy is what services will be reimbursed--if any--if a "never" event occurs but a particular service was not directly applicable to the event.

For example, would hospitals still get paid for patient room and board? Would the anesthesiologist get reimbursed if he or she performed appropriately under the standards?

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"We don't want to penalize outstanding performance" said Lafleur. "We're treating this as a system approach. How can we all work together? It's a bit like a three-legged stool; we need all three or it won't stand. We're all in this together to figure out the right approach."

Before this policy, Lafleur said such adverse events were dealt with on a case-by-case basis, but it was difficult to figure out what exactly happened from a claims standpoint. The new policy is a more "formalized approach" to practices the insurer followed before.

Lafleur said it's hoped that hospitals and providers will place an even greater emphasis on the work they are already doing to stem adverse events.

Many of these standards also are reviewed by CMS, such as infections resulting from urinary catheters, and are commonly tracked by most hospitals as well.

McEntee said that some patients enter the hospital with urinary tract infections from long-dwelling catheters--and not acquired at the hospital--and the facility follows strict "evidence-based guidelines" for catheters that are placed in the inpatient setting.

Another commonly studied adverse event is nosocomial, or hospital-acquired, infections, such as pneumonia, but this metric is not currently included in the WellPoint policy.

NQF has reported an estimated 2 million such infections occur each year, accounting for an estimated 90,000 deaths and adding $4.5 to $5.7 billion in health-care costs.

First and foremost, the outcome of the new policy is increased patient safety, WellPoint said, but the insurer hopes that providers will collaborate on best practices.

"We're already doing this through our HIP program, but we hope those in the program will share information on many of these identifiers" said Lafleur.

But the first year's goal of the policy is relatively modest--getting a "unified voice" among WellPoint's providers, said Lafleur.

Lafleur added: "Our hope is to work with everybody."