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Oswald Barrett
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6 Deloitte Access Economics Pty Ltd ACN Grosvenor Place Level 9, 225 George Street PO Box N250 Sydney, NSW 2000 Competition Policy Review Secretariat The Treasury Langton Crescent PARKES ACT 2600 Tel: Fax: / / Competition issues in the market for the supply of medical prostheses Deloitte Access Economics is pleased to provide this note as part of Applied Medical submission to the Competition Policy Review. The aim of this note is competition issues in the market for the supply of prostheses and the potential implications for competition between the public and private health systems. This note does not seek to provide a detailed examination of all the competition issues in the market for the supply of prostheses, or to provide detailed policy recommendations. However, we are undertaking more detailed analysis of this issue and understand that there will be opportunities to provide further material and discuss these issues in detail with the Review team at a later date. The market for medical prostheses would be a public benefit in encouraging greater competition and choice in sectors with substantial government participation such as health care. The market for medical devices constitutes a significant component of overall expenditure in the health system. Total expenditure by private health insurers on prostheses was estimated to be $1.6 billion in 2012, which is equivalent to just over 10% of the $15.3 billion in total benefits paid to members by private health insurers in 2012 (Private Health Insurance Administration Council 2013). Expenditure on prostheses is also significant in the public system; however, information on total expenditure is not readily available. Statutory framework Under the Private Health Insurance Act 2007, private health insurers must pay mandatory minimum benefits for a range of prostheses that are provided as part of an episode of hospital treatment where a Medicare benefit is payable for the associated professional service. The kinds of prostheses Deloitte refers to one or more of Deloitte Touche Tohmatsu Limited, a UK private company limited by guarantee, and its network of member firms, each of which is a legally separate and independent entity. Please see for a detailed description of the legal structure of Deloitte Touche Tohmatsu Limited and its member firms. Liability limited by a scheme approved under Professional Standards Legislation. Member of Deloitte Touche Tohmatsu Limited

au / / Competition issues in the market for the supply of medical prostheses Deloitte Access Economics is pleased to provide this note as part of Applied Medical submission to the Competition Policy

7 Page 2 6 June 2014 that need to be covered are set out in the Private Health Insurance (Prostheses) Rules The list of prostheses in these rules is known as the Prostheses List. Suppliers who wish to have their product placed on the list must apply to the Minister of Health. The Prostheses List Advisory Committee (PLAC) in turn advises the Minister on the listing of prostheses and their appropriate benefits. If a device is placed on the list, private health insurers must pay the minimum benefit for its benefit class where it is used in an episode of hospital treatment. Thus, the role of the PLAC is both to assess whether a particular prosthesis meets minimum quality standards to be placed in a particular benefit class and to determine an appropriate minimum benefit for items in that class. Policy purpose The policy purpose of establishing a minimum benefit was to provide a price cap so as to control growth in the cost of prostheses over time and thus the sustainability of the Australian private health insurance system. These changes occurred in response to rapid growth in expenditure on prostheses between 1999 and 2002 (Department of Health and Ageing 2009). Since 2005, expenditure on prostheses per treatment episode has grown below the rate of inflation (Medical Technology Association of Australia 2013). However, while the creation of a minimum benefit to be paid by insurers can help contain the growth of outlays on prostheses or at least create greater certainty about the expected rate of increase in benefits, it also has the potential to constrain innovation in the market. Minimum benefit levels may also in some benefit classes be more reflective of historical pricing than current supplier costs, particularly if suppliers achieve improved economies of scale over time. Getting this balance right is an important challenge for policy makers, with significant implications for competition in the broader health care system. Potential impacts on competition in the market for supply of prostheses While acknowledging the range of policy aims that the current regulatory process for the supply of prostheses seeks to address, there are a number of aspects of the current regulatory and market structure that have the potential to limit competition and innovation. First, those responsible for selecting the prosthesis to be used in any given procedure have reduced incentives to choose the most cost effective device. This occurs because insurers are required to pay the minimum benefit for whichever device is used. This effectively reduces incentives for decisionmakers to consider cost effectiveness in selecting prostheses with comparable health outcomes. Moreover, hospitals may receive prostheses from suppliers at a discounted price or pay a price equal to the minimum benefit but also receive a rebate from suppliers. Since insurers are required to pay the actual minimum benefit as stated in the Prostheses List, hospitals are able to retain any difference between the cost of the item and the minimum benefit. This, in turn, can complicate the incentives faced by market participants. Second, to support competition between products that seek to achieve the same clinical purpose but are placed in different benefit classes, it is important that the processes for listing prostheses in particular benefit categories and the determination of minimum benefit levels for those categories are as transparent as possible. Indeed, the process of classifying devices into different benefit classes combined with the reduced incentives for those who choose which prosthesis to use, has the potential to amplify potential issues of cost effectiveness. For example, if products which perform the same clinical purpose are placed in multiple benefit classes with different minimum benefit

The Prostheses List Advisory Committee (PLAC) in turn advises the Minister on the listing of prostheses and their appropriate benefits.

8 Page 3 6 June 2014 levels, decision makers will have reduced incentives to choose the most cost effective device since insurers are required to pay the minimum benefit regardless of which device is chosen. Broader implications for competition between the public and private health system To the extent that the current regulatory and market structure reduces the degree of price competition in the supply of medical devices in procedures performed on private patients, this can have significant implications for competition between public and private health providers. In particular, decision-makers in the private health system have reduced incentives to consider cost effectiveness in choice of prostheses which could ultimately lead to higher premiums for private health insurance and in turn impact the attractiveness of private health insurance for consumers. In this regard, increasing transparency of prostheses pricing through approaches such as benchmarking or price disclosure rules may offer effective mechanisms to enhance competition. Similarly, revisiting the process by which minimum benefit levels are set may help improve competition within and across benefit classes. In conclusion, competition issues in the supply of medical devices have the potential to significantly impact competition between the private and public health system. Deloitte Access Economics is in the process of investigating these issues further, including developing appropriate international comparisons and is keen to provide further advice to the Review on an ongoing basis. References Quarterly Statistics Jun General use restriction This advice is prepared solely for the purpose of a submission to the Competition Policy Review. The advice is not intended to and should not be used or relied upon by anyone else and we accept no duty of care to any other person or entity. The advice has been prepared for the purpose of providing a submission to the Competition Policy Review. You should not refer to or use our name or the advice for any other purpose.

Broader implications for competition between the public and private health system To the extent that the current regulatory and market structure reduces the degree of price competition in the supply

Australian health insurance: extrapolated savings from health and medical research Australian Society for Medical Research

Australian health insurance: extrapolated savings from health and medical research Australian Society for Medical Research 2 June 2012 Pty Ltd ACN: 149 633 116 Dr Paul Dawson, President Australian Society