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Non-reimbursement for preventable health care-acquired conditions

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Managing health care risk must be evidence based and not harm patients or the common good

The decision by Australia’s largest private health insurer Medibank to not reimburse hospitals for 165 hospital-acquired complications that it deems preventable has the stated objective of improving patient care and thereby containing costs.1 As with all health care claims, this requires assessment of potential efficacy as well as possible perverse or harmful outcomes.

Medibank’s policy appears to be an expansion of the 2008 decision of Medicare and Medicaid in the United States to improve hospitalised patient safety by refusing to pay for selected potentially preventable hospital-acquired conditions. These included care-related infections, pressure ulcers, retained surgical objects, and deep vein thrombosis or pulmonary embolism associated with total knee and hip replacement procedures.

It assumed that most of the adverse events might be prevented by widespread adoption of achievable practices; that the events could be measured accurately; that the events resulted in clinically significant patient harm; and that present-on-admission determination was feasible.2 Although the policy was seen as potentially effective, there was also recognition of the potential for unfairness, gaming and unforeseen consequences. Accordingly, the initial implementation…