Price is not the only cost

One of Australia’s largest medical health insurers apparently has taken a significant step towards declining payment for the management of hospital-acquired complications [1].

Such action is meant to incentivise good clinical practice, thus minimising the incidence of those unwanted clinical outcomes. It also assumes that those negative outcomes can be eradicated by punishing those who are at fault for these complications to develop.

I accept that nursing, medical or administration staff might directly contribute to poor patients’ outcomes occasionally. By contrast, our original research shows that patient and disease factors significantly increase the risk of postoperative complications [2]. Generally, these factors are non-modifiable, which means that no one is at fault.

Factors that increase the risk of postoperative adverse events include the presence of a malignancy, medical co-morbidities (including elevated liver enzymes in asymptomatic patients, obesity, and an ASA score of higher than 2. These factors increased the risk of postoperative complications independently of each other [2].

Lets assume a hypothetical but rather typical patient from my clinical practice. Lets say my patient is scheduled for a modified radical hysterectomy for uterine cancer. Typically, she is overweight, has multiple comorbidities and an ASA score of 3. Her overall profile indicates that her risk of developing an adverse event after surgery is 58%.

In other words, six of ten patients with this common profile will predictably and unavoidably develop a surgical complication without anyone being at fault. This risk can be communicated with the patient even prior to surgery.

I predict that a punitive culture where health insurers do not reimburse for the management of postoperative complications will not result in a better quality of health care. Instead, it will result in poor quality of care because clinicians will take a more selective approach to accept or not-accept care for patients.

For the future I am worried that patients with an increased risk of adverse events (like our realistic but hypothetical patient above) will find it increasingly difficult to find a health care institution for treatment. In a culture that punishes adverse clinical outcomes high-risk patients will be turned down for care and left to die if there are negative consequences for health care organisations looking after the patient.

  2. Kondalsmay-Chennakesavan S, Bouman C, De Jong S, Sanday K, Nicklin J, Land R, Obermair A: Clinical audit in gynaecological cancer surgery: Development of a risk scoring system to predict adverse events. Gynecol Oncol 2009; 115: 329-33.