CMS No Longer Reimburses Health Care Providers For Services

4 Cms No Longer Reimburses Health Care Providers For Services That Are

Centers for Medicare & Medicaid Services (CMS) no longer reimburses healthcare providers for services that are required to treat certain complications of care, known as “never events.” These events are deemed preventable and should not occur if evidence-based guidelines are properly followed. Examples include stage III and IV pressure ulcers, pulmonary embolisms (PE) or deep vein thromboses (DVT) after specific surgeries, in-hospital fall injuries, retention of foreign objects post-surgery, wrong-site surgery, surgical site infections following specific procedures, transfusion of incompatible blood types, and urinary tract infections (UTIs) caused by catheterization. While some of these events are genuinely preventable, certain complications like DVTs and PEs may still occur despite adherence to preventive measures such as anticoagulants like heparin or Lovenox.

This change by CMS aims to incentivize healthcare providers to enhance patient safety and adhere rigorously to prevention protocols, thereby reducing the incidence of preventable complications. Hospitals are increasingly focusing on evidence-based guidelines to minimize these events, exemplified by protocols such as routine catheter care and early removal procedures to prevent catheter-associated urinary tract infections (CAUTIs). For instance, in many hospitals, strict protocols require documenting each step of urinary catheter management to prevent CAUTIs, highlighting the importance of prevention strategies as part of a broader patient safety initiative.

The concept of “never events” was introduced by CMS with the goal of reducing serious, preventable, and costly medical errors that have significant implications for patient health outcomes. According to the “Eliminating Serious, Preventable, and Costly Medical Errors” report (2006), CMS is actively exploring ways to diminish the occurrence of such events. These errors, including wrong-site surgery or mismatched blood transfusions, can lead to severe injuries or death, emphasizing the critical need for rigorous prevention measures.

The implementation of reimbursement rules reflecting the seriousness of these events has driven a substantial shift in inpatient care delivery models. The Deficit Reduction Act empowered CMS to adjust payments for hospital-acquired infections, which has prompted hospitals to invest more heavily in quality improvement initiatives. For example, some facilities have adopted “4-eyes” policies upon patient admission—a process requiring two registered nurses to thoroughly assess a patient to identify pre-existing conditions, thereby preventing hospital-acquired injuries that would otherwise impact hospital reimbursement. This shift underscores a broader move from volume-based to quality-based care, where facilities are held accountable for preventing avoidable complications.

In response to CMS policies, hospitals have developed specific protocols to prevent conditions categorized as “never events,” including blood incompatibility issues, pressure ulcers, surgical-site infections, and falls. These protocols often involve multidisciplinary approaches, staff training, and stringent monitoring procedures designed to ensure adherence to prevention guidelines. For example, preventive strategies for pressure ulcers involve regular position changes, skin assessments, and moisture management, while surgical site infection prevention includes perioperative antibiotic protocols and operating room sterilization standards.

Moreover, hospitals have adopted comprehensive safety checklists and team-based approaches—such as the World Health Organization’s surgical safety checklist—to foster communication, teamwork, and adherence to safety standards. These strategies contribute not only to reducing patient morbidity and mortality but also to aligning hospital financial incentives with safety and quality outcomes.

Despite these measures, some complications may still occur due to intrinsic patient factors or unforeseen circumstances. However, the focus remains on minimizing preventable events through diligent application of evidence-based practices. CMS’s policy not only encourages hospitals to improve safety protocols but also promotes transparency and accountability in healthcare delivery. This systemic shift ultimately benefits patients by aiming to reduce harm, enhance care quality, and lower healthcare costs associated with preventable errors.

Paper For Above instruction

The initiative by CMS to no longer reimburse hospitals for care related to preventable “never events” marks a significant evolution in healthcare quality and safety. These events, characterized by their preventability and serious consequences, have historically contributed to increased morbidity, mortality, and healthcare costs. The policy shift is rooted in the recognition that many of these adverse events can be eradicated through strict adherence to evidence-based clinical guidelines and improved clinical practices.

Fundamentally, “never events” are defined as serious, clearly identifiable, and preventable medical errors, including wrong-site surgery, surgical-object retention, pressure ulcers, and healthcare-associated infections such as CLABSIs and CAUTIs. According to the American College of Surgeons, these errors are often considered failures in systems or processes, highlighting the importance of systemic interventions to prevent them (American College of Surgeons, 2017). CMS's decision to withhold reimbursement for such events underscores the shift towards value-based healthcare—where payment is increasingly linked to quality outcomes rather than services provided.

One of the most illustrative examples is the implementation of protocols to prevent CAUTIs. Hospitals now routinely enforce catheter care guidelines, including aseptic insertion techniques, maintenance protocols, and early removal of unnecessary catheters. Such strategies are supported by research indicating that proper catheter management significantly reduces infection rates (Saint et al., 2016). These quality improvement initiatives exemplify how policy changes can propel healthcare facilities toward safer practices.

The impact of these policies extends beyond infection prevention. CMS’s efforts include addressing other “never events” such as surgical site infections (SSIs), falls, and retained surgical instruments. Addressing SSIs involves perioperative antibiotic administration, sterile surgical techniques, and postoperative wound care, all supported by clinical guidelines (Gesten et al., 2017). For falls, hospitals have implemented comprehensive fall prevention programs, including environmental modifications, patient assessment tools, and staff training—substantially reducing injury rates (Oliver et al., 2010).

Financial incentives aligned with patient safety have driven hospitals to adopt systematic quality improvement frameworks such as Plan-Do-Study-Act (PDSA) cycles, enhanced team communication, and safety checklists. The WHO Surgical Safety Checklist has been instrumental in reducing surgical complications and preventing wrong-site surgeries, emphasizing the importance of teamwork and communication in safer surgical practices (Haynes et al., 2009).

Despite these advances, some complications still occur due to factors like patient comorbidities or unpreventable circumstances. Nonetheless, the focus remains on reducing preventable “never events” through continuous process improvements and safety culture enhancement. The shift not only encourages hospitals to implement best practices but also fosters transparency and accountability, promoting trust and safety in healthcare delivery.

In conclusion, CMS’s policy to deny reimbursement for preventable adverse events exemplifies a strategic move toward higher quality, safer patient care. It incentivizes healthcare providers to rigorously adhere to clinical guidelines, utilize systematic safety protocols, and foster a culture of safety. As hospitals continue to innovate and improve practices, patients stand to benefit from reduced harm, better outcomes, and overall enhanced trust in the healthcare system.

References

• American College of Surgeons. (2017). National Surgical Quality Improvement Program (NSQIP). Retrieved from https://www.facs.org/quality-programs/nsqip/
• Gesten, C., et al. (2017). Impact of Surgical Site Infection Prevention Strategies. Journal of Hospital Infection, 96, 1-8.
• Haynes, A. B., et al. (2009). A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine, 360(5), 491–499.
• Oliver, D., et al. (2010). Strategies to Prevent Falls and Falls-Related Fractures in Hospital Inpatients. Cochrane Database of Systematic Reviews.
• Saint, S., et al. (2016). Preventing Catheter-Associated Urinary Tract Infection in Hospitals. The New England Journal of Medicine, 374(22), 2111–2119.
• Eliminating Serious, Preventable, and Costly Medical Errors—Never Events. (2006). CMS.gov. Retrieved from https://www.cms.gov
• Centers for Medicare & Medicaid Services. (2019). Hospital-Acquired Condition Reduction Program (HACRP). CMS.gov.
• O’Rourke, P. T., & Hershey, K. M. (2018). Never-Event Implications. Journal of Healthcare Quality, 40(4), 239-246.
• World Health Organization. (2009). Surgical Safety Checklist. WHO Publications.
• CDC. (2016). Guidelines for the Prevention of Intravascular Catheter-Related Infections. MMWR, 65(RR-10), 1–33.