Risk equalisation and voluntary health insurance markets: The case of Australia

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1 Risk equalisation and voluntary health insurance markets: The case of Australia Luke B Connelly 1, Francesco Paolucci 2, James RG Butler 2 and Paul Collins 3 A presentation to the 31st Australian Conference of Health Economists, Hobart, 1-2 October Australian Centre for Economic Research on Health (ACERH); Centre for National Research on Disability and Rehabilitation Medicine (CONROD); and School of Economics; The University of Queensland 2 Australian Centre for Economic Research on Health (ACERH), The Australian National University 3 Private Health Insurance Administration Council (PHIAC) THE UNIVERSITY OF WESTERN AUSTRALIA

2 Overview of presentation Retrospective on regulation and reinsurance Risk equalisation the ex post scheme in Australia Numerical illustration Empirical results industry and firm level Conclusion

3 Retrospective on regulation and reinsurance Prior to 1953, the private health insurance industry was largely unregulated The National Health Act 1953 introduced Community rating and open enrolment regulations Commonwealth subsidies for medical and hospital services provided for people with private health insurance

4 Under open enrolment, funds could not refuse cover but could limit benefits: for chronic conditions for pre-existing illnesses, and via the imposition of an annual maximum benefit In , 12.2% of hospital benefit claims, and 1.73% of medical benefit claims were disallowed by insurers

5 A 1958 amendment to the National Health Act established Special Accounts for members with chronic conditions and pre-existing illnesses Funds deposited member premiums and public subsidies into the Special Accounts and paid claims from those Accounts Any deficit on the Special Accounts was funded by the Commonwealth (hence a vehicle for subsiding private health insurance) Special Accounts resulted in no inter-fund transfers

6 This system continued until: 1975 Medibank introduced 1976 Medibank Mark II allowed opt-out from Medibank into private health insurance As large numbers were expected to opt out, Commonwealth Government was concerned about growth in deficits on Special Accounts Special Accounts were replaced with a reinsurance arrangement Commonwealth committed $50 million per annum to the reinsurance pool

7 Cap on Commonwealth contributions introduced a redistributive requirement into the reinsurance pool Unfunded deficit had to be met by contributions from private health insurers Further developments: Commonwealth contribution increased to $100 million p.a State-based reinsurance pools introduced, Commonwealth contribution cut to $20 million 1989 Commonwealth contribution removed reinsurance scheme becomes a pure reinsurance scheme with no public subvention

8 Risk equalisation 1 April 2007: The Health Benefits Reinsurance Trust Fund established under section 73BC of the National Health Act 1953 is continued in existence as the Private Health Insurance Risk Equalisation Trust Fund (the Risk Equalisation Trust Fund) (Private Health Insurance Act 2007, p.285)

9 Australian risk equalisation scheme is ex-post (based on actual claims experience) Contrasts with arrangements in some European countries that have adopted an ex-ante scheme based on predicted expenditures

10 Services covered under the Australian scheme (figures in parentheses are the proportion of the total benefits being equalised): Hospital benefits (97.6%) Hospital substitute benefits (0.05%) Chronic Disease Management Program benefits (0.07%) High Cost Claimant benefits (2.28%)

11 Insurer A Insurer B Insurer C Insurer D Sum of payments into the RETF = Sum of payments out of the RTF (zero sum game) Individual insurers make or receive a net transfer, depending on claims experience Risk Equalisation Trust Fund (RETF) All insurers notionally deposit into AND withfraw from the RETF Insurer E Insurer F Insurer G Insurer H

12 RETF has two components 1. Age-Based Pool Eight age bands: one from age 0-54, seven covering remaining ages (55-59, 60-64,, 85+) Only age bands for 55+ have positive weights (i.e. generate a requirement to pay into the pool) Under previous reinsurance scheme, weights applied only to age bands for 65+

13 2. High Cost Claimants Pool Replaces pooling of claims for claimants with >35 days hospitalisation during a 12-month period Applies to benefits paid in excess of $50,000 for a claimant in any quarter allowing for amounts already contributed to the age-based claims pool

14 Numerical example ABP payment Fund 1 (1) (2) (3) (4) = (2) x (3) Member s age ABP weight Eligible benefits ABP contribution $13,818, $1,765,650 $264, $2,516,052 $1,069, $4,025,683 $2,415, $6,843,661 $4,790, $12,044,844 $9,154, $21,439,823 $16,723, $39,020,477 $31,996,791 Totals $101,474,325 $66,414,077

15 ABP payment Fund 2 (1) (2) (3) (4) = (2) x (3) Member s age ABP weight Eligible benefits ABP contribution $10,242, $1,308,721 $196, $1,864,927 $792, $2,983,884 $1,790, $5,072,603 $3,550, $8,927,781 $6,785, $15,891,449 $12,395, $28,922,438 $23,716,399 Totals $75,213,967 $49,226,898

16 HCCP payment Fund 2 (1) (2) (3) = (2) (4) = (2) (3) (5) (6) (7) = (0.82 (5) (6)) (7) q-1 s.t. (7)>0 Quarter (q) Gross benefits paid ABP payment Residual Cumulative residual (R) Threshold (T) HCCP q = 0.82(R T) HCCP q-1 1 Nil Nil Nil Nil Nil Nil 2 $75,292 $31,999 $43,293 $43,293 $50,000 Nil 3 $85,021 $36,134 $48,887 $92,180 $50,000 $34,588 4 $60,000 $25,500 $34,500 $126,680 $50,000 $28,290 Annual totals $220,313 $93,663 $62,878

17 RETF transfers (1) (2) (3) (4) = (2) T (3) T (5) = (4) T (3) RETF contributions (= ABP + HCCP) SEUs Total RETF contributions Total SEUs Expected benefits (6) = (2) (5) RE transfers (net transfers) Fund 1 $66,414, ,024 $66,450,671 $36,594 Fund 2 $49,289, ,193 $49,253,182 $36,594 Totals (T) $115,703, ,217 $

18 Note that: The value of the net transfers in this example ($36K) is a small fraction of the RETF churn ($115m) The RE scheme is a pure redistribution (zero sum game) scheme for the industry

19 Empirical results industry and firm level At the industry level: In , RETF churn was $2,908m Net transfers amounted to only $254m (8.7% of the churn) Note that the latter amount is the only amount that is actually transferred via the RE scheme

20 How does RE affect individual funds?

21 Net transfers by fund 8 largest Fund Market share (%) Net RE transfers Net RE as % of redistributed funds Net RE transfers as % of benefits paid Medibank $34,878, MBF $102,581, BUPAAH $37,039, HCF 9.04 $21,492, NIB 7.25 $73,348, HBF 6.65 $26,416, AUHL 3.46 $32,024, AHM 3.13 $21,195,

22 Net transfers by fund 8 smallest Fund Market share (%) Net RE transfers Net RE as % of redistributed funds Net RE transfers as % of benefits paid Phoenix 0.13 $5,549, DHF 0.11 $5,470, ACA 0.09 $3,935, HCI 0.06 $1,585, Transport 0.07 $76, CDH 0.05 $624, NHBA 0.04 $772, RBHS 0.04 $1,720,

23 Relationship between net transfer as % of benefits paid and number of individuals covered 0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 Number of individuals covered

24 Differences in net transfers as a proportion of each fund s benefits paid by size group Size group Lower half (n = 19) Upper half (n = 19) Mean no. of individuals insured Net transfers as a proportion of each fund s benefits paid Mean Variance t-statistic (p value) for difference in means 21, % , % (0.016) Statistical tests of differences in means and variances F-statistic (p value) for difference in variance 3.19 (0.010)

25 Conclusion Net transfers are small by comparison with the RETF churn Large funds: net transfers are a small proportion of benefits paid Small funds: net transfers tend to constitute a larger proportion of benefits paid there is greater variance than in large funds

26 This paper has not examined incentive effects, e.g. Are the insurers risk profiles purely exogenous? o If not, how weak/strong are the related selection incentives? Does the RE scheme lessen the incentives for funds to monitor and economise on benefit payments, or negotiate on supplier prices? How might the incentive effects of ex ante RE compare with the current ex post scheme in the Australian market?

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