Op-Ed: The Unintended Consequences of “No Pay for Errors”

Hospital_bedsMedicare’s policy to withhold payment for “never events” – the first effort to use the payment system to promote patient safety – remains intriguing and controversial. To date, most of the discussion has focused on the policy itself at a macro level (including two articles by yours truly, here and here).

In the past month, experts on two of the adverse events on the “no pay” list – hospital falls and catheter-associated urinary tract infections – have chimed in. Interestingly, while agreeing that the overall policy has upsides and risks, they came to strikingly different conclusions about the wisdom of including their pet peril on the list.

Let’s begin with UTIs. Last month’s Annals of Internal Medicine article by Michigan’s Sanjay Saint and colleagues begins, quite cleverly, with a quote from Ben Franklin: “By failing to prepare, you are preparing to fail.” Turns out that among Franklin’s many inventions was the flexible urinary catheter (so who the hell was Foley?). The piece nicely reviews the “no pay” policy and describes the epidemiology of catheter-associated UTI (CAUTI).

The central assumption of the “no pay” policy is that the adverse events in question can be prevented through assiduous application of evidence-base strategies. In the case of CAUTI, such strategies include: restricting which clinical units are allowed to place catheters, implementing systems to remind docs of the presence of catheters (Sanjay once studied housestaff and attendings and found that nearly 30% of residents and 40% of attendings were unaware that their patient had a Foley catheter, a phenomenon he dubbed “immaculate catheterization”), requiring automatic stop orders for catheters after 3-5 days, and providing feedback to providers about their organization’s or unit’s catheter-associated infection rates. When such “multimodal strategies” are implemented, 25-75% of CAUTIs can be prevented.

The authors warn of unanticipated consequences, many of which relate to the “present on admission” designation. You remember the deal – if a UTI was present on admission (POA), the hospital still gets paid its extra fee for the “complicating condition.” But if the infection’s first documented appearance is on day 2 of the hospitalization, Medicare assumes that the hospital caused it and cuts the payment. Because of the zeal to prove that the UTI was POA, write the authors,

“hospitals may encourage urinalysis and urine cultures at the time of hospital admissions… [thereby increasing] the likelihood of more positive urine culture results, which in turn leads to an increased use of antibiotics for treating patients with asymptomatic bacteriuria.”

These antibiotics, by the way, are unnecessary and do these patients absolutely no good. Despite this risk, the authors conclude…

“that [the new policy] may end up doing more good than harm, because hospitals are likely to redouble their efforts to prevent CAUTIs…”

My colleagues and I have raised concerns about the fairness of a policy that dings hospitals for infections that are, on average, preventable only half the time, but Saint and colleagues apparently feel that the overall benefit will counterbalance any potential injustice. Perhaps so.

In this month’s New England Journal of Medicine, Harvard’s Sharon Inouye (like Sanjay Saint, a former UCSF resident and good buddy of mine) and colleagues are less charitable in discussing the new policy as it relates to falls occurring in hospitalized patients. Noting that falls are common in both hospitals and community settings, the authors write that

“there is no evidence that hospital falls ‘can be consistently and effectively prevented through the application of evidence-based guidelines.’” [this is CMS’s standard for preventability]

They cite one systematic review that found that, at best, approximately one-in-five hospital falls are preventable. More concerning, there is no evidence that any intervention (including hip protectors, lowering the bed, or padding the floor surface) can prevent serious injury from falls.

But, while they are concerned about the justice of withholding payment for injuries that we don’t know how to prevent, they are even more lathered about the patient safety implications of not paying for in-hospital falls. They write,

“Unintended consequences are likely to include a decrease in mobility and a resurgence in the use of physical restraints in a misguided effort to prevent fall-related injuries… As a first step, the CMS should recognize that the goal is ensuring safe mobility, not merely preventing falls, and thus explicitly acknowledge the inherent tradeoff between safety and mobility.”

Sharon is a polite, sweet, and soft-spoken geriatrician, but she doesn’t shirk in her criticism of the CMS policy on falls:

“The inclusion of hospital falls in the new Medicare initiative appears to be premature, at best; at worst, it may be harmful to the very patients it is intended to protect and may ultimately increase the costs of Medicare beneficiaries because of its unintended consequences.”

Medicare is presently thinking about adding several new adverse events to the list, including ventilator-associated pneumonia, Clostridium dificile-associated disease, and hospital-onset delirium. Before they add any more conditions, CMS should rapidly commission studies of unintended consequences of the existing ones. It would be easy enough to study the frequency of antibiotic use for “UTIs” picked up at the time of hospital admission (an uptick over the last year would probably represent clinically inappropriate treatment for asymptomatic bacteriuria discovered during the POA inventory). Ditto a bump in the frequency of use of hospital restraints (applied in a misguided effort to prevent falls). If studies show that these unintended consequences are occurring and CMS can’t figure out a strategy to mitigate the harm, these adverse events should be removed from the list. Personally, after reading the Inouye article, I’d remove falls today, and only add it back if studies demonstrate that it is doing more good than harm.

I remain enthusiastic about “no pay for preventable adverse events” as a clever way to use payment policy to goose the system into focusing on patient safety prevention practices. But for “no pay…” to make a difference, there must be evidence-based prevention strategies to implement. If there aren’t – and, while there are some strategies for CAUTIs, there really aren’t for falls – then “no pay for errors” is just cost-reduction cloaked in the garb of patient safety.

Even scarier, when one factors in the impact of these unintended consequences on targets like falls, the policy might well hurt more patients than it helps.

Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World,” where this post first appeared.

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3 replies »

  1. Thanks, Michael. I agree with you to a degree – it is sad that we docs sometimes seem to need incentives to get us to do the right thing. (Parenthetically, I have been amazed that in the national discussions about physician incentives in healthcare reform debate [including the McAllen and Dartmouth Atlas riffs], how little discussion there has been about physician professionalism. It seems to be accepted that many physicians respond to their economic fee-for-service incentives by providing inappropriate care. There appears to be no outrage that so many physicians have lost their moral compass — indicative, I think, of our society’s abiding and well-earned skepticism about authorities in all walks of life, starting with our political leaders but sadly including physicians.)
    Anyway, returning to your point regarding “no pay for errors,” our increasing appreciation of the role of “systems” in the provision of high quality and safe care causes me to partly disagree with your point. Getting busy doctors to remember to remove Foley catheters just doesn’t work very well — even when the docs want to do the right thing. Here, like so many other parts of medicine, we need to organize systems of care that ensure that fallible human beings do the right thing every time. As you know better than anyone, creating such systems takes time, resources, and institutional will, and policies like “no pay…” help create the business case to make changes like these happen and stick.

  2. Bob:
    I greatly enjoyed your post. But let me push you for a moment. What struck me about the Saint article, and yours, is its moral blind spot. Call it “amoral medicine.” What should have accompanied the Saint article — and what I suspect you believe, as well — is an editorial taking physicians to task for needing a payment policy to force them to do something they should have been doing on their own.
    Put bluntly: all the adverse consequences of this new policy were completely avoidable. Who will tell doctors that their failure to act voluntarily was unethical and therefore led to this “blunt instrument” that, though designed to protect patients, has adverse consequences?
    By not confronting what caused the payment policy, doctors act no differently than bankers complaining about the impact of new Federal Reserve policies while completely ignoring their own professional abuses that led to more regulation.

  3. Bob,
    It is interesting to note that the two issues of falls and Foley catheters are related. Many patients get Foleys after surgery so that they won’t need to get up to use the bathroom and risk falling. Someone should study that relationship.