Non-reimbursement for preventable health care-acquired conditions

The response from Swan to my article is appreciated. I find concerning the insights on how third-party managed care might have an adverse impact on patient rights and good medical practice. For example, Swan infers that subtotal compliance with antibiotic guidelines for caesarean deliveries is a quality concern. In scheduled caesarean deliveries, 100 patients must receive prophylactic antibiotics to avoid one infection-related complication.1 Material risks, such as anaphylaxis, plus uncertain consequences for the infant, must be disclosed. Accordingly, respect for informed decision making by mothers-to-be might better explain and justify a ceiling to guide uptake.

Regarding falls, Medibank references health care organisation datasets that aim to control for casemix but are not case-matched. These self-reported trend indicators are thus screening tools.2 Likely confounding variables limit extrapolation to clinical policy and practice. Falls reflect synergistic frailty of multiple biological systems. Diagnosis-related group payments exclude frailty,3 leaving only the non-reimbursable costs of associated complications. Patient access is thus biased toward lower risk instead of clinical merit. Resourcing of falls prevention and research, not penalties, would demonstrate genuine concern and commitment.

Patient safety continues to improve in line with the proactive professional and regulatory factors identified in my article. The support that Medibank proffers for its non-reimbursement penalties is limited to an internet publication by a United States government agency (http://www.ihi.org/engage/initiatives/tripleaim/Pages/default.aspx), which only speculates on the possible contribution of a related US government policy, has no named authors and does not appear to be peer reviewed. Thus, there seems to be no ethical justification for continuing with a non-reimbursement policy that detrimentally and unfairly discriminates against patients most prone to insurer-determined non-reimbursable complications. And while health care affordability is necessary, actions that may disingenuously shift costs from insurers to taxpayers are no solution.

Shareholder profit expectations encourage novel strategies, including those that limit disbursements while not overtly restricting client benefits. Among these strategies, interventions claiming to improve quality and affordability may enhance profitability by indirectly limiting lifetime access to anticipated health insurance benefits. Tax-advantaged medical savings accounts (MSAs) could reduce this risk and should be an option for Australians, along with self-managed superannuation. MSAs can deliver “affordable excellence”4 and so their potential benefits in addressing the market failures in the health sector should be diligently assessed.5