Some never events are non-reimbursible: Who should bear the cost of their treatment?

Never events are events, such as surgery performed on the wrong patient or wrong site surgery, which should never happen in a healthcare setting. They are defined as adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability.

Ken Kizer, MD, former CEO of the National Quality Forum (NQF) first coined the term never event in 2001. The list of never events has been revised over the years and there are now 29 “serious reportable events” that have been grouped into 7 categories:

1.      Surgical or procedural events

2.      Product or device events

3.      Patient protection events

4.      Care management events

5.      Environmental events

6.      Radiologic events

7.      Criminal events

Never events illustrate the quality of patient care. They adversely affect patient morbidity and mortality. They increase the cost of treatment due to prolonged hospitalization not only for the patient and also cause loss of revenue to the hospital.

Catheter-associated urinary tract infection (CAUTI), a nosocomial or hospital-acquired infection (HAI) is one such never event. They are often drug-resistant infections and so difficult to treat.

Who bears the cost of treatment of never events?

Some never events may be categorized as non-reimbursible events.

Mediclaim may not pay, CGHS may not pay.

The CGHS has issued a clarification in 2013 regarding admissible and non-admissible items under it.

“...However, if the beneficiary has to stay in the hospital for his/her recovery for a period more than the period covered in package rate, in exceptional cases, supported by relevant medical records and certified as such by hospital, the additional reimbursement shall be limited to accommodation charges as per entitlement, investigations charges at approved rates and doctor visit charges (not more than 2 visits per day per visit by specialists/consultants) and cost of medicines for additional stay.

No additional charge on account of extended period of stay shall be allowed if that extension is due to infection on the consequences of surgical procedure or due to improper proceed ...”

Medicare in US has adopted the non-reimbursement policy for certain never events - defined as "non-reimbursable serious hospital-acquired conditions" - in order to motivate hospitals to accelerate improvement of patient safety by implementation of standardized protocols (Patient Saf Surg. 2009 Dec 31;3:26). These include:

·         Catheter-associated urinary tract infection (CAUTI)

·         Vascular catheter-associated infection

·         Surgical site infection following coronary artery bypass graft (CABG) - mediastinitis

·         Surgical site infection following bariatric surgery (laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery)

·         Surgical site infection following orthopedic procedures (spine, neck, shoulder, elbow)

·         Deep vein thrombosis (DVT)/pulmonary embolism (PE) in total knee replacement and hip replacement

CAUTI rates are indicative of the infection control policy as well as antibiotic policy of the particular hospital.

The patient may not pay for the cost of the treatment of these events as these are largely preventable events.

Hence, the onus of treating this HAI lies on the hospital. And, they are also required to bear the cost of such preventable events.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA