Non-reimbursement for preventable health care-acquired conditions

Medibank supports the statement made by Davis that “current best practice is to proactively produce a health care environment in which controllable factors, such as inevitable errors and systematic failures, do not reach patients”.1 Contrary to Davis’s other claims, however, the efforts made by Medibank to enhance the quality of care for our members align with this practice.

There is considerable room for improvement in the provision of care in hospitals. For example, 7.5% of women who have a caesarean delivery do not receive appropriate antibiotics to prevent infection, and while all falls are not preventable, if every hospital had the same falls rate as the best performing ones, there would be 17 710 fewer such events in Australian hospitals.2

Our efforts to address these issues are based on the Triple Aim Initiative for improving our members’ health outcomes, enhancing their experience and increasing the affordability of private health insurance.3

In line with this aim, we are working to ensure that hospitals are more accountable for the complications that occur during admission, which not only significantly affect patient outcomes but also add 17.3% to inpatient costs.4 Our approach ensures that hospitals treat complications seriously and, where guidelines exist, that they follow those guidelines in the delivery of care.

These changes will not “disadvantage policy holders most at risk of non-reimbursable events, such as elderly, obese or seriously ill patients”.1 To pay contracted hospitals, Medibank uses a system based on diagnosis-related groups. This ensures that hospitals are appropriately compensated for patients at high risk of complications and for those with significant comorbidities.

Davis also claims that there is no evidence that the financial disincentives introduced into the US Medicare and Medicaid system in 2012 have improved outcomes. However, a December 2015 review identified a 17% decline in the rate of complications from 2012 to 2013. It was further estimated that about 50 000 fewer patients died in hospitals as a result of the reduction in complications and approximately US$12 billion in health care costs were saved from 2010 to 2013.5