Anthem is a strong advocate for patient safety. We work collaboratively with the doctors and hospitals in our network to improve the quality of patient care by identifying measurable and preventable medical errors (known as “adverse events”).
Adverse events are unexpected, unintended or unwanted outcomes or injuries. Unfortunately, not all adverse events can be prevented. But we’re working with doctors and hospitals to reduce your risks, both medically and financially.
There are certain adverse events that should never occur in a health care setting. Our policy is that neither members nor their health plan should pay fees associated with the following types of events (also known as “never events”):
- Surgery performed on the wrong body part.
- Surgery performed on the wrong patient.
- Wrong surgical procedure performed on a patient.
Other adverse events include hospital-acquired conditions (HACs) that have been identified by the Centers for Medicare and Medicaid Services (CMS). These are considered HACs only if the conditions were determined NOT to be present on admission. This determination is made by using what is called the present on admission (POA) indicator, which hospitals submit with their claims:
Our program is based on the CMS approach. Our policy support non-payment for the following hospital-acquired conditions:
- Object left in the body during surgery.
- Air embolism or blockage.
- Blood incompatibility.
- Catheter-associated urinary tract infection.
- Vascular catheter-associated infection.
- Pressure ulcers (stages 3 & 4).
- Hospital-acquired injuries (falls and trauma): fractures, dislocations, intracranial injury, crushing injury, burn, and other unspecified effects of external causes.
- Surgical site infection following:
a. Coronary artery bypass graft – CABG (mediastinitis).
b. Certain orthopedic procedures.
c. Bariatric surgery for obesity.
- Deep vein thrombosis (DVT) and pulmonary embolism (PE) following hip or knee replacement.
- Manifestations of poor glycemic control (CMS) and patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility (NQF).
We are committed to working collaboratively with physicians and hospitals in its network to identify preventable adverse events that are measurable and can be prevented as a means of improving the quality of patient care.
What is the score on hospital quality?
Find out with the Quality-In-Sights® Hospital Incentive Program (Q-HIP®).
Q-HIP is an award-winning program that ties hospital payments to the quality of patient care. Currently, payments are tied to the number of services instead of the quality of care. The goal of the program is to help all patients get the best health care.
Hospitals are reviewed in three areas:
- Patient safety – This area looks at how the hospital's patient care processes align with nationally accepted best practices.
- Health outcomes – This area looks at how the results of a patient's care compares to other hospitals across the country.
- Patient satisfaction – This area looks at public patient survey results
Q-HIP measures are based on standards supported by nationally recognized quality groups. These include the Centers for Medicare & Medicaid Services (CMS), American College of Cardiology (ACC), the Institute for Healthcare Improvement (IHI), the Joint Commission (JC), the National Quality Forum (NQF), and the Society of Thoracic Surgeons (STS).
Q-HIP has grown from 16 hospitals in 2003 to more than 600 by the end of 2011. Q-HIP has won many awards but the program's growth is the best reflection of its success.
Legal Disclaimer: Quality-In-Sights® and Q-HIP® are registered service marks of Anthem Southeast, Inc. and are used with permission.