The Centers for Medicare & Medicaid Services (CMS) is taking several actions to improve the quality of care in hospitals and reduce the number of "never events" -- preventable medical errors that result in serious consequences for the patient.

"Never events cause serious injury or death to beneficiaries and result in unnecessary costs to Medicare and Medicaid due to the need to treat the consequences of the errors," said CMS Acting Administrator Kerry Weems. "[These] steps reflect our strong conviction that these events, in fact, should be prevented, and our commitment to protecting Medicare and Medicaid patients from them."

A final acute care inpatient prospective payment (IPPS) rule that went on display at the Office of the Federal Register for publication August 19, 2008 updates Medicare payments to hospitals for fiscal year (FY) 2009 and provides additional incentives for hospitals to improve the quality of care provided to people with Medicare. As part of these quality of care incentives, the rule includes payment provisions to reduce never events that occur in hospitals.
In addition to the final rule, CMS sent a letter to state Medicaid directors providing information about how states can adopt the same never events practices. The letter specifically encourages states to adopt the same non-payment policies outlined in Medicare's final rule. Nearly 20 states already have or are considering methods to eliminate payment for some never events.

CMS also announced the opening of a process to develop three National Coverage Determinations (NCDs) that would address Medicare coverage of certain surgical procedures. Medicare NCDs set national policy on whether Medicare will cover an item or service and under what conditions. In the absence of an NCD, coverage decisions are made by the local contractors that process and pay Medicare claims. The three types of surgery under consideration are surgery on the wrong body part, surgery on the wrong patient, and wrong surgery performed on a patient.

Occurrences of the types of surgeries in the NCDs have been identified by the National Quality Forum (NQF) as "Serious Reportable Events," commonly referred to as "never events." Evaluating coverage of these procedures is yet another important step for Medicare in addressing concerns regarding never events.

CMS begins the NCD process by commencing a national coverage analysis (NCA) with a 30-day public comment period. During the comment period CMS accepts comments from the public regarding the issues under consideration. A proposed decision memorandum will be released on or before February 1, 2009, for another round of public comments and then finalized no later than April 30, 2009.

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