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AIS's Health Business Daily
Featured Story November 3, 2008 Blue Cross Plans, Providers Work to Develop 'Never-Events' Policies Reprinted from The AIS Report on Blue Cross and Blue Shield Plans, a hard-hitting independent monthly newsletter on business strategies, products and markets, mergers and alliances, and financing of BC/BS plans. By Jill Brown, Managing Editor, (jbrown@aispub.com) As Blue Cross and Blue Shield plans formalize their policies on "never events," they are following the lead of CMS or state health agencies, and are working with providers. So-called never events — medical care errors that are clearly identifiable and preventable, and have serious consequences for patients — have come under increasing scrutiny over the last five years. Examples include operating on the wrong body part or the wrong patient, leaving a foreign object in a patient, and patient death or disability resulting from medication errors or mismatched blood. Policies being developed and implemented hold hospitals and doctors financially responsible for never events - the incremental costs related to an avoidable complication or error, and in some cases all of the costs related to the patient's hospitalization. The Blues plans say their policies apply to all commercial and government products. Six Blues plans so far have developed policies to address payment for serious adverse events. A seventh — Health Care Service Corp. (HCSC) subsidiary Blue Cross and Blue Shield of Illinois — has a policy in development, but has not yet identified specific events. The National Quality Forum (NQF) in 2002 identified a list of 27 serious adverse events and advocated public reporting of these events. In 2006 it updated the list, expanding it to the present 28 events. CMS in August 2007 said it would not pay hospital claims at a higher rate for eight conditions, including some on the NQF list. In July 2008 it added three more conditions to that list. The agency also said it opened the process to develop three National Coverage Determinations that would address Medicare coverage of three other events on the NQF list: surgery on the wrong body part, surgery on the wrong patient, and wrong surgery performed on a patient. Some Blues Base Policies on CMS List WellPoint, Inc. subsidiary Anthem Blue Cross and Blue Shield says its policy builds on the CMS never-events program. "The events chosen are widely regarded as being events that could reasonably have been prevented through the application of evidence-based guidelines set by organizations such as the CDC and NQF," says spokesperson Jill Becher. She adds that Anthem now is evaluating how to implement the three events recently added by CMS. Blue Cross Blue Shield of Michigan and its Blue Care Network subsidiary used the same approach as did Anthem. "We believe this was pretty commonplace among health plans," says Kim Sorget, vice president of provider contracting and network administration at the Michigan Blues plan. "However, we vetted it out through a dialogue with the hospital," he adds. Blue Cross Blue Shield of Massachusetts followed the lead of four state agencies — the Office of Medicaid (MassHealth), the Group Insurance Commission, the Commonwealth Health Insurance Connector Authority and the Department of Correction - in adopting its never-events policy. The agencies, which collectively insure or purchase care for more than 1.6 million residents, said June 18 that they no longer would pay for costs associated with the 28 serious adverse events identified by NQF. The same day, the Massachusetts Blues plan unveiled its own policy applying to the same 28 events. "Our announcement was absolutely linked with the state's decision," explains Massachusetts Blues spokesperson Jay McQuaide. "However, we actually had been working on our policy for a number of months and chose the 28 never events because there is no disagreement about the fact that they are egregious and should never happen. We also believe the 28 events are clearly defined." Kansas Blues Has Longstanding Process Blue Cross and Blue Shield of Kansas has long had an "operating process" of not paying for "adverse or hospital-acquired conditions," says spokesperson Mary Beth Chambers. But the insurer now has developed a written policy that will become part of its annual contract with all providers, effective Jan. 1, 2009. The formal policy covers only the eight conditions identified by CMS. Blue Cross and Blue Shield of Kansas City also adopted CMS's eight conditions, and automatically added the three additional events identified by CMS in July 2008, according to spokesperson Susan Johnson. "As CMS evolves its program and includes more conditions not covered, we will most likely revise our program to follow suit." HCSC subsidiary Blue Cross and Blue Shield of Texas adopted the full list of CMS events, as well as several NQF conditions, according to spokesperson Margaret Jarvis. The insurer worked with the Texas Hospital Association to identify the events. And Illinois Blues
spokesperson Mary Ann Schultz says her company is "working with
the Illinois Hospital Association on how to implement such a plan and
also to decide on which events would qualify as never events."
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