Actuaries Institute submission to the Private Health Insurance Review

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1 7 December 2015 The Hon Sussan Ley MP Minister for Health Parliament House CANBERRA ACT Dear Minister Actuaries Institute submission to the Private Health Insurance Review This letter outlines a range of considerations that the Actuaries Institute wishes to raise in relation to the Federal government s review of the Australian Private Health Insurance (PHI) system. This letter reflects the views of the Institute and its members. The Actuaries Institute represents over 4,100 members including 2,200 Fellows. Our members have significant involvement in the development of health, general and life insurance and superannuation regulation, financial reporting, risk management and related practices in Australia and Asia. Background to Actuaries in Health Insurance Actuaries have played an active part in the Australian Private Health Insurance (PHI) industry over many years. This culminated in the creation, in 2004, of a formal Appointed Actuary role for Health Insurers as a key adviser to both the board and management. This role encompasses a range of activities including pricing, product design, outstanding claim liability appropriateness, capital management, and the annual Financial Condition Report. In 2014, the Actuaries Institute released a green paper titled Who will Fund Our Health? The paper can be found at The paper noted that governments around the world are facing the challenge of increased health care expenditure. In Australia this increase in expenditure is driven by a range of factors including: Ageing of the population with the resulting increase in the demand for healthcare, A reduction in the proportion of working Australians supporting the costs, An increase in the overall level of wealth, which has historically seen an increase in demand for healthcare, Increases in chronic diseases like cardiovascular diseases, cancers, obesity and diabetes, that are, in part, due to various behavioural trends. Institute of Actuaries of Australia ABN Level 2, 50 Carrington Street, Sydney NSW 2000, Australia T +61 (0) f +61 (0)

2 In Australia most health funding is based on a pay-as-you-go approach with a mix of sources including government (about 65-70%), Private Health Insurance (less than 10%), individuals (about 15%), and other providers such as WorkCover providers (less than 10%). Much of this funding is supported by people of working age (via taxes paid on income), although greater costs are born at older ages. Summary of Recommendations The Actuaries Institute supports the current community rated Private health Insurance (PHI) system. We recognise that the stability of the PHI system requires that there be a cross section of the community with PHI cover. The following sets out our suggestions for consideration by the review. 1. Change the risk equalisation system to provide incentives to participants in the PHI system to improve health outcomes 2. Allow health insurers access to broader health funding enabling incentives for the insurer to influence whole of person health 3. Focus the tax rebate on hospital cover rather than extras 4. Provide discounts to premiums for people under the age of Review the Medicare Levy Surcharge for lower incomes and those drawing on superannuation incomes. 6. Increase the allowable excess on policies which exempt the policyholder from the Medicare Levy Surcharge to reduce premium costs 7. Consider introducing loadings on premiums for smokers or other life style choices that impact health outcomes 8. Consider introducing Health Savings accounts or closer integration between health funding and superannuation systems. 9. Review short-term opportunities to reduce costs for example reducing costs of prostheses. 10. Remove some of the complexities in the PHI system namely the high cost and overly bureaucratic approach to price approvals. 11. Introduce rules regarding consistent communication of terms and conditions of products to enable effective product comparisons 12. Enable the effective sharing of health data. Page 2 of 10

3 The attachment to this letter sets out the Actuaries Institute s thoughts and reasons for the above recommendations with discussion of the following areas: Goals of the Private Health System Specific initiatives to reduce costs of health services Participation rates A more equitable and sustainable system through a rebalancing of hospital product mix Funding pricing and risk equalisation Health saving accounts Complexity within the system Data sharing Other areas of comment The Actuaries Institute thanks the review for their attention to the considerations raised above. We would be happy to actively engage with the PHI review to have more in depth conversations about any of the points raised above. Please contact our CEO, David Bell on (02) or via , Yours sincerely Estelle Pearson President Page 3 of 10

4 Attachment Goals of the Private Health System The Actuaries Institute considers that there are three, interrelated goals of the private Health system. 1. To assist in the sustainability of the overall health system by reducing demand on the public health system, 2. To provide a method for those who can afford to fund their personal health costs, and 3. To allow additional choice (e.g. choice of hospital or medical providers, choice of timing) within the overall health system to improve health outcomes. The Actuaries Institute recommends that the following principles should underpin PHI policy in Australia: The Private Health system exists to supplement the publicly funded health system with, PHI a key part of funding the Private Health system. The private health system should be cost effective and affordable to a wide cross section of the community. In Australia, a key driver of affordability is the community rating system for setting PHI premium rates. The private health system should be effectively integrated with the overall health system The private health system should be simple for consumers to understand. The private health system should provide incentives for preventative health measures. The private health system should be underpinned by regulatory frameworks that supports competition and encourages innovation. Specific initiatives to reduce costs of health services The cost of health services is increasing. In the short term there are a number of initiatives where reform may assist in reducing costs, we note that these are likely to be one-off improvements and not materially change the rate of growth in health costs. 1. Allowing funding for minor procedures undertaken outside of hospital. Current regulations focus most hospital benefits on in-patient services. While this is the most appropriate environment for many hospital procedures; many minor procedures could be undertaken at lower cost outside hospitals. For these currently, patients are often admitted to hospital for a short period to facilitate benefits to be paid. This is likely to increase overall costs within the system. We recommend that the government, working within clinical guidelines, develops a list of minor procedures that could be performed and funded by PHI outside of hospital. Page 4 of 10

5 2. Allowing insurers to choose to which hospitals and doctors they will pay benefits. Currently insurers have to pay a default level of benefits at all hospitals and for any doctor. There is increasing variation within both the cost and health outcomes of various doctors/hospitals. By allowing insurers to focus on providers with lower costs or better health outcomes, the costs associated with many procedures are likely to reduce as hospitals continue to drive efficiency. 3. Changing the way benefits for prostheses are funded within the private system. Prosthesis benefits are paid for at a scheduled rate set by the government. In many cases, the same devices can be purchased at a lower cost by public hospitals leading to some inefficiency within the private system. While it is important to continue investment into improved prostheses, it is also important to keep costs down. A 10% reduction in the cost of prostheses is expected to lead to a reduction of up to 2% in prices for hospital cover, with the highest reductions being seen on top hospital coverage. Longer term initiatives that could limit the costs of the PHI system 1. Ways of aligning the incentives to keep customers healthy. The current system supports greater usage by individuals since providers are paid based on volume. This has proven to be inefficient and, in consequence, health systems overseas are moving away from this model. While it is complex to align interests between governments, insurers and various providers, the Actuaries Institute believes solutions can be found if insurers are able to engage with the broader health system including primary care. We would support changes that would allow insurers to support the whole of person, person centred approach to health care funding. Participation rates The community rating model relies on cross subsidies whereby the, generally younger members of the population, fund the higher health costs of the aged. Community rating therefore requires there to be a cross section of the community holding private health insurance. The existing PHI system is under pressure, in particular: 1. The cost of health services continues to increase at levels well above inflation. 2. Participation rates are patchy across the various segments of the population. In particular: a. Participation of year olds is much lower than at other ages. b. There are continuing trends that, while not changing overall participation rates, lessen the level of cover individuals hold within the private system. Without changes to incentives and the design of the PHI system there is a risk that the more healthy people will drop out of the PHI system resulting in higher costs for the remaining members. The following recommendations are aimed at stabilising the PHI system. Page 5 of 10

6 The participation rate of PHI has increased slowly since the introduction of Lifetime Health Cover in Hospital coverage of the Australian population is approximately 47% (September 2015 APRA results), with coverage with extras higher at about 52%. Although hospital coverage is historically high at 47%, many people have switched to cheaper products with exclusions, restrictions or increased excesses. The switching of products has enabled people to remain in the PHI system albeit with lesser cover. Whilst this indicates that the market is innovating with new product designs, there is a risk that consumers may not be sufficiently aware of their reduced level of cover. Of particular concern though is that participation is below average in two key age groups year olds and 85+ year olds - as shown in the graph below. It is critical to engage with the younger group since these are likely to be healthy and generally increase the support for the overall private health insurance system. To increase the attractiveness of PHI to younger people we suggest that the Government consider increasing the discounts that apply to premiums for people under age 30. Other measures that may support overall participation include: 1. Having the rebate apply to Hospital cover only. Currently the rebate applies to hospital and extras cover. We suggest that the rebate only apply to hospital cover. This would mean that, for the same cost to Government, a higher rebate could apply to hospital cover which is expected to reduce the cost of the public hospital system. Page 6 of 10

7 2. Increasing the maximum excess level and indexing going forward The current maximum excess which exempts the policyholder from the Medicare Levy Surcharge ($500 for singles and $1000 for families/couples) was set in If this amount were increased with CPI, we would see a maximum excess of above $700, or even greater if the increase was based on health cost inflation. The maximum excess level should be reviewed and increased to more appropriate levels balancing the need to keep premiums down with the level of insurance. 3. Increasing the Medicare Levy surcharge at lower incomes One aspect driving the reduced participation at younger ages is the limited impact of Medicare Levy Surcharge. If the Medicare Levy Surcharge were increased at lower incomes, there would be a greater incentive to engage with the PHI system at a younger age. 4. Changing the income definition for the application of the Medicare Levy Surcharge The current basis for assessing both the rebate level and Medicare Levy Surcharge excludes superannuation withdrawals past the preservation age. Including these is likely to increase participation at these older ages. A more equitable and sustainable system through a rebalancing of hospital product mix Over recent years, the Actuaries Institute has noted the increase in customers with exclusionary products. While initially this may seem like a negative since the public system is now required to support these customers for some procedures, it is important to note that this may have been a driver to keep people within the PHI system and hence support the Risk Equalisation system. With this in mind, it is importance to balance: large proportion of people within PHI having coverage of the widest range of procedures which, in turn should reduce the price of products that cover a wide range of procedures, and The overall participation in the PHI system, which lessens the overall cost of the system but may increase the cost to individuals purchasing top cover. In addition to this aspect, exclusionary products are often more complex, which is covered below in further detail. We believe that the appropriate balance is currently not being achieved and make two recommendations to support customers purchasing, and remaining on, hospital products that cover a wide range of procedures. Page 7 of 10

8 1. Having a lower rebate apply to exclusionary Hospital products Many insurers provide a range of hospital covers with some offering limited cover at lower cost to the consumer. While having lower cost cover is in the interests of the consumer when choosing to purchase cover, these products can be more complex to understand and removes less burden from the public system. By reducing the rebate to being lower on exclusionary hospital products, the government would seek to change the customer-pricing curve to reduce the burden on the public hospital system. 2. Increasing the Medicare Levy Surcharge if you hold exclusionary levels of hospital cover Similar to the above, this would support individuals upgrading cover to remove additional costs from the public health system. We also support that consumer choice is important and hence support that a range of products should be available for purchase and still receive some form of government support. Given this, we believe that there should remain a lower rebate on exclusionary hospital products rather than remove the rebate completely. Another approach of achieving more customers holding a broader hospital coverage is redefining what constitutes a Complying Health Insurance Product (CHIP) to a more comprehensive level of cover. This would, in effect, remove the rebate from those products that no-longer meet the CHIP definition. While this may achieve a similar goal, we believe careful consideration is needed due to the potential for unintended consequences to occur using this approach. Funding pricing and risk equalisation Pricing within PHI is a core area of actuarial practice. The Actuaries Institute notes that the stability of the community rating system requires that there be an appropriate cross section of the community with PHI cover. We also note that adopting a risk rating system whereby an individual s premium is based on their own individual risk factors, would see a reduction in participation rates and an increase in pressure on the public health system. There may be improvements in the system that retains the core community rating principles while also allowing price signals to be sent for controllable health conditions (e.g. smoking and obesity). Based on previous research undertaken by actuaries, these loadings may be minor at younger ages even if the whole of life cost is large. A key aspect of community rating is the risk equalisation system. We believe that this risk equalisation system can be reviewed to enable proper incentives to manage health outcomes. The following provide a summary of potential changes: Move to a prospective system for assessing risks, rather than our current retrospective system. Develop ways to increase alignment between risk equalisation and cost saving measures. Under the current system, cost savings of older members are shared across all funds, limiting the attractiveness of investment in these areas. Page 8 of 10

9 Develop a different systems or weights for different levels of hospital cover, with top cover having a higher weighting. We also note that the current highly regulated system of pricing approvals is costly to the industry. We recommend that a more flexible approach to pricing be adopted with a formal price monitoring system implemented to enable pricing oversight. Health saving accounts Health saving accounts (HSA) exist in a number of countries around the world to enable pre-funding some, or all, future health costs. These can be compulsory or have tax incentives, similar to superannuation in Australia, or both. These funds are then used to pay either for future premiums or direct health costs. The Actuaries Institute supports the pre-funding of healthcare costs associated with ageing. The use of superannuation balances to pre-pay for future private health care costs via incentives should be investigated as part of this review. If this approach is taken further, it is important to ensure that any approach is equitable between generations as well as different wealth cohorts. Although the mechanism is available not everyone would have enough to pay for retirement income and PHI. Another approach to pre-funding of health care costs is long term insurance contracts with level (or agreed) premiums. Changing regulations to allow this may be easier to achieve than full health saving accounts, although there are risks that this will lessen long term participation in the system (e.g. customers may drop out at the end of a long term contract due to the affordability challenges). Complexity within the system Funding of healthcare is complex due to customers lacking detailed knowledge about a range of treatments and the risks they face with respect to their health. In 2007, the then PHI Ombudsman introduced a classification of both hospital and extras products. This classification was intended to provide customers a simple way to compare prices of similar products. There is now a wider range of products within the PHI market. Despite the growth in products and price points, the original classification system has not been reviewed. Furthermore, a number of aggregators have developed more simple methods of comparing appropriate health insurance products. These algorithms are closely guarded and are likely to be updated as new products are introduced. The Actuaries Institute recommends that one approach of improving the transparency and simplicity within the PHI system is: An update to the Ombudsman approach of classifying products. The current approach is likely to be out of date and an improved approach would provide greater delineation of products. Legislate that these rating be included in both the Standard Information statements, and be provided to customers during the sales conversation (regardless of the channel used to purchase PHI), and Increase the use of privatehealth.gov.au. This website is likely to require a refresh to improve usability and navigation. Page 9 of 10

10 Data sharing Health outcomes can be improved through the proper use of health data. We recognise that health data is sensitive for individuals. However, we believe that improvements in outcomes are worth the additional costs of appropriately storing and sharing health data. We would support the Australian Government developing a draft Health data sharing framework and working with all stakeholders to ensure that appropriate health data can be shared. Other areas of comment In addition to those items outlined above, we would like the review to investigate the following: 1. People can now buy health insurance through many distribution channels. The more distribution channels the better. We believe that there should be a review of the way that products are promoted and compared to ensure that customers are aware of what they are buying. 2. Australia has both a public and private health system. The interaction of these two systems can lead to friction and inefficiencies. We encourage the review to investigate ways to better integrate the two systems. These should be underpinned by the core principles of efficiency and simplicity for customers, insurers, and providers. Page 10 of 10

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