Who Pays for Complications

Refusing to Pay for Complications

By TARA PARKER-POPE

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A number of insurers, including Medicare and Medicaid, no longer pay doctors to treat complications “that could reasonably have been prevented.” These are often called “never events,” because they should never have happened.

The goal is to force hospitals and doctors to improve safety practices and cover the costs associated with their own errors. The idea is good in theory, writes Dr. Pauline Chen in today’s Doctor and Patient column, but when it comes to complications, all patients aren’t created equal.

Data from almost 900,000 cases in over 1,000 hospitals…found that patient characteristics could have a marked impact on the rate of several of these payer-specific “never event” complications. Preexisting conditions like diabetes, chronic lung disease or malnutrition rendered patients more susceptible to certain complications no matter how much the physician intervened. In fact, the researchers were even able to predict the degree of susceptibility with the use of mathematical modeling.

“There are many things we can be doing to improve quality,” said Dr. Donald E. Fry, lead author of the study and executive vice president for Michael Pine and Associates. “But there has to be the understanding that high-risk patients can affect the rate of certain complications.”

To learn more, read the full column, “Who Pays for Medical Complications?”