Who Pays ?

A curious situation has arisen where Medibank health insurer has negotiated a new contract with the Catholic hospital system.  The old contract is due to expire and the insurer is refusing to cover what it terms " preventable " incidents in hospital care.   Specific events that would fall outside the guidelines are " death in pregnancy ", " suicide in hospital " and " broken bones from a hospital fall ".

Childbirth mortality is certainly rare in this country, but it can not be entirely excluded.  It would seem very unfair to have an exclusion in the private system for something that is covered in the public system and exactly what this means needs to be clearly spelt out to fund members.

Suicide in hospital also covers a wide gambit.  A disturbed person with mobility might leave their bed and deliberately jump from a high window and it could be inferred that they should have been more closely watched, but that would involve a financially impossible level of staff required.

The edict on hospital falls resulting in broken bones suggests lack of care in ensuring bed guard rails are raised by nursing staff, but bone degeneration in the elderly is rampant and this would require even those with mobility to be escorted by a nurse at all times, and that would impose an impossible level of care cost.

What many find disturbing is that a new agreement has been negotiated, but the details have not be revealed to the public.   It is unacceptable that a person needing to go into hospital for a procedure and faced with making a choice between a Catholic hospital, other private hospitals or the public system could face a very different cost structure and be seriously out of pocket because of vagaries about exactly what is covered by private insurance.

This seems to be an attempt to impose a penalty for incidents that can be attributed to lack of professional care back onto the hospital concerned, rather than become an added cost to the provider of health insurance.   Should a patient suffer broken bones from a fall that should not have happened,
then recovery time remaining in hospital to recover would be at hospital expense, not a cost incurred by the insurer.

Anything that contributes to hospital safety is commendable, but this does tend to put the patient in the position of being the meat in the sandwich.  An accident that breaches the guidelines leaves a substantial bill hanging in the balance, rejected by the insurer but claimed by the hospital - and legally recoverable by court action.

It also raises an interesting legal can of worms.  The validity of contracts can be challenged and usually this results in a test case in court, and every court finding is likely to be subjected to appeal in a higher court.  Should an unfortunate patient be chosen as the example on which a finding is sought, he or she could find themselves embroiled in legal costs that run into millions.

This is a tactical manoeuvre between hospitals and an insurer to set new payment guidelines.  The outcome is of more than passing interest to those covered by this form of insurance and it is totally unacceptable that an outcome has been reached - and that outcome is not being revealed to those who will be affected by it's implementation.