The specific objectives the ADA feels obligated and competent to comment upon are:

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1 14-16 Chandos Street St Leonards NSW 2034 All Correspondence to: PO Box 520 St Leonards NSW January, 2014 Mr John Edge First Assistant Secretary Medibank Sale Taskforce Department of Finance John Gorton Building King Edward Terrace PARKES ACT Dear Sir, Re: Scoping study into the proposed sale of Medibank Private Limited Thank you for your letter of 8 January 2014 inviting the Australian Dental Association Inc. (ADA) to provide comment on the Government s objectives for the proposed sale of Medibank Private Limited (MPL). The specific objectives the ADA feels obligated and competent to comment upon are: 1. To contribute to an efficient, competitive and viable private health insurance industry; 2. To maintain service and quality levels for Medibank policy holders, including in regional and rural Australia; 3. Having regard to the above objectives, to maximise the net proceeds from the sale. The ADA would take it as given that the sale process will treat Medibank employees in a fair manner, through the preservation of accrued entitlements and will do what it can to ensure those employees are placed into effective engagements with other private health insurance companies (PHIs) or other enterprises. Introduction: The proposed sale of MPL provides the Government with the opportunity to impose requirements on PHI to ensure they deliver to the consumer what they are designed to provide equitable rebates that offset the costs of health care to ensure improved health care to their customers. Significantly, over the last 10 years the traditional emphasis in private health insurance was through not-for-profit operations and a strong mutual ethos that went with this arrangement. There has been a change with the number of for-profit insurers increasing from four to nine 66.7% of hospital treatment policy holders are now covered by a for-profit insurer. All too often the focus and activities of the insurers are directed to maximising their bottom line profitability. Telephone (612) Facsimile: Administration (612) Executive (612) Publications (612) Website:

2 The Government s ownership of MPL has allowed it to influence PHI behaviour. However, with the Government s removal from the PHI market, a freer market will arise potentially allowing PHIs an improved ability to exploit their customers to further maximise the bottom line. Measures must be taken to ensure the removal of a significant PHI, such as MPL, the competitiveness between PHIs is not lost. At the same time the opportunity exists for a comprehensive review of the PHI market so as to ensure the focus of PHIs is not solely on profitability (as would seem to be the case now) but on the introduction of measures requiring PHIs to respond to their customers health needs. PHIs are insurers not health providers. This differential must be maintained otherwise the blurring of this role will result in PHIs seeking to provide cheaper, less effective health measures, which will compromise health care delivery all with the objective of profit maximisation. This has to cease. Health insurers have now ventured into being a health care provider. The conflict between the company s corporate responsibility to maximise returns to shareholders is totally incompatible with a PHI delivering and funding actual health care. In this scenario the obligation to maximise profit makes it impossible for the insurer to provide anything other than cheap, often second rate care. In this letter, the ADA will outline its concerns. The ADA sees the sale of the Government owned MPL as an opportunity for government to review the PHI market and practices. The sale of such a large insurer will have a marked effect on PHI in Australia and this opportunity must be taken by government to exert influence on PHI practices for better health care delivery to PHI policy holders. The ADA would be happy to provide further information if required. Many of the recommendations made in this letter reflect recommendations made by the ADA in the submission to the ACCC in relation to its report to the Senate on PHI conduct. This submission can be viewed at: (30 August 2013) 2 1. To contribute to an efficient, competitive and viable private health insurance industry Initially, responses provided will focus primarily upon the issues of competitiveness and viability of PHI from the perspective of the consumer the PHI member or policy holder. The recommendations call on the Government, in leaving the PHI market, to require PHIs to modify their behaviour to the benefit of their customers and health providers. Many aspects of PHI conduct are anti-competitive and fail to provide the consumer with the level of information and knowledge required to enable them to make informed decisions as to the nature and type of policy consumers need. Information provided is often very complex and poorly expressed in legal jargon and should be made simpler and clearer for consumers. Inducements and the like offered (offer payments towards gym memberships, sporting equipment and shopping vouchers) only further confuse and complicate the customer s evaluation of competing products. Comparisons between PHIs are difficult to make due to the complexity of cover and exclusions offered. Business rules and other restrictions make it very difficult for the consumer to compare policies and decide which cover best suits their situation. The existence of the Medicare

3 Surcharge levy is often confusingly/incorrectly marketed and exploited by PHIs to encourage customers to obtain PHI. These are of great concern to the ADA as nearly all services covered under general treatment products have maximum benefit amounts and the proportion of the treatment costs covered varies between insurers and policies and there are restricted services not all dental treatment receives a rebate from all funds. Dental represents over 50% of the general treatment payout by PHI. Recommendation 1 A compulsory advertising code making it mandatory for PHIs to: a. Recommend that consumers consider whether the Medicare levy surcharge (or other relevant provisions of taxation law) specifically has an impact on them. Depending on the consumer s circumstances, there may not be any taxation implications that would be remedied by having a private health insurance policy. This recommendation must include providing consumers with unbiased information regarding the Medicare levy surcharge, etc. so as to make an informed decision; and b. Advise consumers on the importance of evaluating their situation to ensure they take out the insurance they require, and the precise insurance product selected actually meets their requirements. c. Legislation should be introduced to repeal those sections of health fund legislation that permit non-disclosure of health fund business rules. Instead, legislation should introduce a requirement that health funds publish clear, simple, easy to understand, and publicly available business rules and information to make comparative analysis of policies to be carried out. The Government should seize upon the opportunity of the sale on MPL to enforce the above aspects upon the new operator and owner of MPL and on the PHI market. Portability rules to enable consumers to switch PHI to ensure their policy matches their needs should be simplified. Recommendation 2 Change the current portability rules relating to issuing transfer certificates under the Private Health Insurance Act 2007 (and corresponding Private Health Insurance Code of Conduct) to require that both old insurers and new insurers give/request the transfer certificate in a faster time than the current 14 day period from ceasing insurance/receiving the request. 3

4 4 Recommendation 3 The ADA calls for health funds to be brought to account to provide justification for the effective decline in rebated benefits compared to premium increases and if suitable explanation is not provided then remedial action be imposed through legislation to rectify this decline. See attached ADA National Dental Update January Recommendation 4 As a consequence of Recommendation 3, the ADA calls for health funds to increase dental and other ancillary service rebates for all services on an annual basis and the review be in line with CPI and/or premium adjustments, whichever is the higher. The Government should use the impending sale of MPL to enforce as a condition of sale that regular and annual review and increase of dental rebates per item of service to at least match CPI. Recommendation 5 There be no annual or lifetime limits on dental rebates in health fund policies. Recommendation 6 Health funds should be banned from actively and directly attempting to influence their members to receive treatment from the health funds contracted providers as it interferes with the patient/dentist relationship and substantially lessens competition. Recommendation 7 Health funds should cease to promote their contracted providers by the use of terminology that contravenes the Dental Board of Australia (DBA) Guidelines and the Health Practitioner Regulation National Law Act (National Law). Recently, the ADA has observed attempts made by government that enable MBP related entities to engage in health care delivery. For example, some cynics may have seen the introduction of Medibank Health Solutions (MHS) as an attempt by MPL and government to increase the participation of MPL in the delivery of health services to defence personnel and to possibly Department of Veterans Affairs benefit recipients. MHS sought to contract with health providers to provide services to eligible persons at prices significantly below market rates. The pursuit of this was no doubt profit driven as it seemed little attention was given to health outcomes. To overcome this, ADA suggests the following recommendations be adopted: Recommendation 8 Health fund rebate and general structure for service delivery must be designed with the health interests of the member/patient/customer uppermost and should not be constructed to generate unjustified or super profits for the health fund or related entity.

5 5 Recommendation 9 Health experts be engaged to assess the manner in which health fund rules governing utilisation and rebate levels for services are implemented to ensure the health interests of health fund members are being correctly prioritised. Recommendation 10 If there are to be annual limits imposed by health funds (which are opposed by the ADA) then health funds be required to provide to all contributors current and complete details of such limits. Recommendation 11 Health funds be required to provide all general treatment/ancillary policy holders with an itemised copy of current rebate levels for all general treatments. Recommendation 12 There be greater uniformity in business rules and qualifying periods between PHIs policies in order that for consumers to make valid comparison between health fund policies. Recommendation 13 When there is evidence of PHIs: Providing erroneous interpretation of dental item numbers; or Refusing to rebate for dental services carried out over multiple appointments until all the services in a treatment have been completed; Sanctions be imposed to curtail such activities designed purely to delay payments or avoid paying rebates for legitimate services (such as financial penalties, or in the case of repeated infringements, loss of licence to operate as a health fund). Recommendation 14 If the Government wishes to assist consumers with provision of information about the financial impact of receiving health care where services are rebated by health funds, the Government must demand the buyer of MPL and health funds generally to publish clear, easy to comprehend rebate tables and make them easily accessible to contributors. The following responses will focus primarily upon the issues of competitiveness and viability of PHI from the perspective of the consumer the PHI member or policy holder and the health provider. The provision of incentives by the Australian Government to consumers to take up private health insurance provides an economic basis and justification for PHIs to deliver to consumers a product that responds to the Australian Government s objectives delivering a product that provides better health care to policy holders. The ADA sees these incentives provided to PHIs being used by

6 them as an opportunity to maximise their profit. In dealing with the sale of MPL the Australian Government must ensure that in the sale process it ensures that PHIs operate in a manner that delivers the best possible product for consumers and respects the autonomy of healthcare providers. ADA therefore recommends: Recommendation 15 Where health funds attempt to unilaterally de-recognise a practitioner, the following protocols must apply: 6 There be full and accurate disclosure of the health fund s reasons for such action to both the health practitioner and the patient; Any communication between a patient and health fund regarding de-recognition of the dentist be on agreed terms between the fund and dentist; Rights of review of such decisions must be put in place natural justice must apply; and There be procedural fairness in the de-recognition process. Recommendation 16 Discriminatory conduct relating to the payment of rebates based on the provider of the services affiliation with a PHI not be permitted as it is against the health interest of the patient and undermines open competition. Where the same contribution (premium) rate is paid, the contributor must be entitled to the same rebate for the same itemised procedure regardless of which health provider provided the service. Economic fairness and equality must be maintained. One significant concern for the ADA is the impact the sale of MPL may have on the competiveness of the market. In recent years, the number of mutual PHIs has significantly reduced. Most PHIs are now full for profit enterprises. At the same time, the market has also seen a significant number of mergers so that the number of PHIs in the market is decreasing with the larger PHIs picking up market share. Government must be careful in selling MPL that it does so to ensure continued competitiveness between PHIs. There are major market holders in the PHI market and a sale to one of these enterprises will reduce effective competition. A sale to a major PHI or a stakeholder in PHI (such as the National Australia Bank through its HICAPS service) may only serve to create an effective duopoly; such action would not result in sufficient competition and would serve to create a greater ability for major players remaining in the PHI market to maximise profit. The Government itself may lose any effective ability to monitor PHI conduct. In conjunction with the sale, the ADA would strongly suggest it invests greater resources into bodies such as the Australian Prudential Regulation Authority, the Private Health Insurance Administrative Council and the Private Health Insurance Ombudsman office. Government must also ensure, notwithstanding it being the vendor of MPL, the scrutiny attached to the sale of MPL

7 is the same for this transaction as would exist for other such transactions. Full, complete and independent appraisals of the impact of the sale by the Australian Competition and Consumer Commission (ACCC) and Foreign Investment Review Board (FIRB) must be undertaken. Recommendation 17 With the removal of the government owned MPL from the PHI market, increased investment be directed to enhance the operation of PHI regulatory bodies To maintain service and quality levels for Medibank policy holders, including in regional and rural Australia Many of the comments made above under Heading 1 are relevant to addressing this issue. In relation to the delivery of care by providers of ancillary health care, it is recognised that delivery of health care in remote and very remote areas carries challenges. Steps could be introduced by PHIs to fund or partially underwrite private practitioners to deliver care in these regions. Delivery of care, particularly dental care, requires the practitioner to invest substantially in capital for equipment. A conservative estimate of cost to set up a dental practice would involve expenditure of anywhere between $350, ,000. To support this expenditure it is necessary to have a viable market of dental patients; something which is difficult in low population remote areas. If PHIs were required to fund/subsidise travel expenses to access care it would provide viable patient numbers and thus overcome a significant hurdle for providers and PHI customers. Recommendation 18 An appropriate segment of the proceeds of sale of MPL be directed to dental health programmes that will assist disadvantaged Australians to receive quality dental care. 3. Having regard to the above objectives, to maximise the net proceeds from the sale The ADA recognises the budget/financial difficulties faced by government. Notwithstanding the ADA sees an opportunity for the proceeds of sale to not only enhance the Government s balance sheet but to also provide the financial resources to enable it to invest in health delivery programmes that can provide long-term sustainable outcomes. The significant profits generated by MPL reported at being $233 million in 2013 and especially from ancillary care policies will be reflected in the sale price and at least that proportion of the sale price reflected by this must be siloed into health delivery programmes that aid in the delivery of such ancillary care to Australians. The proceeds must be used to maximise (the impact) of the net proceeds on the health of Australians. The ADA provides an annual Federal Budget Submission to Treasury/Department of Finance. This document must be reviewed and the proposals outlined adopted by use of the proceeds of sale. See Recommendation 17.

8 Thank you for the opportunity to comment. As indicated if further information is required please contact Robert Boyd-Boland or Phone: ). Yours faithfully, 8 Dr Karin Alexander Federal President

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