Insurer-led rehab care threatens patient choice, says AMA

3 minute read

It also costs millions more than out-of-hospital care and uses valuable hospital beds that could be better used elsewhere.

A “private health system authority” would deliver independent oversight and coordinated reform across the private health sector, saving the healthcare system millions and freeing up thousands of hospital beds, according to a new report from the AMA.

The Out-of-hospital care models in the private system report, released today, found that the insurer-led approach to out-of-hospital care led to inequity for patients, a lack of clinical autonomy and increased cost both financially and in terms of hospital resources.

Professor Steve Robson, the federal AMA president, said there were many procedures where clinically suitable patients should be able to access out-of-hospital care, such as rehabilitation following hip and knee replacements — some of the most common procedures performed, and a significant cost to the healthcare system.

“The cost difference between rehabilitation at home and hospital per patient is around $6200,” he said.

“Looking at knee replacements alone, our report found expanding access to out-of-hospital rehabilitation to patients who would prefer this and were assessed as clinically appropriate by their surgeon, could save up to $62.7 million and free up to 94,000 beds per annum.

“That’s a lot of extra beds for a health system in crisis — a system that’s struggling with ballooning elective planned surgery waiting lists.

“These are conservative estimates of potential savings, as research shows that out-of-hospital care can also be beneficial for patients recovering from other surgeries, strokes, or even patients who require mental health treatment or palliative care.

“For some patients, out-of-hospital care can deliver the same outcomes as in-hospital care, while also providing patients with other benefits such as the ability to recover in the comfort of home,” said Professor Robson.

The AMA called for the sector to design models of out-of-hospital care that were patient-centred and clinician-led.

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“At the moment, many out-of-hospital care models in the private system are insurer-led and delivered — often referred to as vertical control,” said Professor Robson.

“This is an equity issue for patients, as not all insurers fund or provide these models of care and there are no safeguards in place to protect patients.

“This current insurer-led approach has also created a situation that puts patient choice and clinical autonomy at risk, with some insurers only providing out-of-hospital care with select providers and not necessarily involving the patient’s doctor.

“This situation can, in part, be attributed to a lack of independent oversight and coordinated reform across the private health sector.

“We need nationally consistent guidelines for out-of-hospital programs to ensure private health policies remain easily comparable.

“This is why we are calling for a private health system authority to lead reform, including the development of these guidelines.”

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