Private Health Insurance in Australia For: Australia & New Zealand Study Tour Canadian College of Health Leaders Sydney, Australia 21 February 2012 By: Shaun Larkin Managing Director HCF
Outline Definition Health insurance sector: - snapshot - diagnosis Future directions Examples What does it all mean? Not for publication or distribution 2
Definition Industry Commission Report No. 57, Feb 97..a voluntary facility for private funding of hospital care and ancillaries, sitting alongside a compulsory tax-financed public system (Medicare) that is available to all. but..is constrained by regulation designed to pursue similar non-discriminatory access objectives to those in the public sector. Not for publication or distribution 3
Why Industry Commission Report No. 57, Feb 97? Not for publication or distribution 4
Health fund snapshot then (1997) 40 not for profit funds and 4 for profit funds Covers 2.8m memberships Covers 5.8m lives 31% of the population is covered Annual contribution income is $4.9b 87% of this was paid out in benefits Management fees average 12% Not for publication or distribution 5
Post Industry Commission changes 30% Rebate (1999) Lifetime Health Cover (2000) Solvency and Capital Adequacy (2001) Gap Cover (2000) Second Tier Default Benefit (2001) 35% / 40% Rebate (2005) Private Health Insurance Act (2007) Means-testing of 30% Rebate (2012) Not for publication or distribution 6
Private Health Insurer snapshot now 27 not for profit funds and 7 for profit funds Covers 4.8m hospital memberships (2.8m) Covers 11.9m lives (5.8m) 45% of the population is covered (31%) Annual contribution income is $15.4b ($4.9b) 85% of this was paid out in benefits (87%) Management fees average 9% (12%) Not for publication or distribution 7
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Private Health Insurance snapshot - now Major funds are: BUPA 2,778k hospital lives Medibank 2,678k HCF 1,249k NIB 752k HBF 671k Rest 2,127k Not for publication or distribution 9
Health fund sector diagnosis Industry Commission Report No. 57, Feb 97 It is generally agreed by most participants in the Industry Commission Inquiry that private health insurance is beset by a plethora of problems The most important cost drivers behind premium increases are thus not under the direct control of the funds. They reflect decisions by governments, doctors, patients and hospitals about what treatment occurs, where it takes place and at what price. Not for publication or distribution 10
Health fund sector diagnosis: then >>> now declining membership >>> growing since December, 1998 driven by 30% rebate and then in mid-2000 by Lifetime Health Cover (LHC) but relatively flat since end of 2001..as a percentage of population adverse selection is increasing: - young and healthy are not entering; and - high users, often the elderly, stay in >>> LHC as of 1 July 2000 Not for publication or distribution 11
Health fund sector diagnosis: then >>> now Industry is highly regulated with controls on pricing, rating system, product design, benefit design, prudential standards and reinsurance >>> ongoing incremental change occurring (e.g. reinsurance to risk equalisation) with industry consultation moral hazard continues to be evident >>> better understood and impact lessened by LHC onerous billing and claiming systems for members >>> - simplified billing systems in place - e-commerce developments continuing Not for publication or distribution 12
Health fund sector diagnosis: then >>> now unpredictable out of pocket for members >>> no gap developments in hospital now replicated in medical; dental; optical; and others with some success (varying by State; modality; geography) but market research says still a significant issue for many consumers traditional role is that of a passive buyer >>> tendering emerging with difficulty; focus still on buying, albeit smarter, i.e. not just price Not for publication or distribution 13
Then >>> now >>> future the right care at the right time at the right price * V = f (Q/C) Q = the right care - variation in practice Q = the right time - need for services C = the right price * Just like Ontario s Action Plan for Health Care Not for publication or distribution 14
the right care utilisation review peer review outlier review not draconian practice benchmarking and profiling quality indicators outcome studies EBM, CPGs, clinical pathways Not for publication or distribution 15
the right time continuity of care, i.e. the right place member education prevention Primary Secondary My Health Guardian: www.hcf.com.au/my_health_guardian.asp?member_id=guest focused disease/condition programs Not for publication or distribution 16
the right price agreed payments (provider networks) bundled services (per diem; per case) benefit design VBID ( aligning incentives to bridge the divide between quality improvement and cost containment - http://www.ajmc.com/vbid_related ) waiting periods limits copayments and deductibles exclusions risk sharing trade volume for discount rates Not for publication or distribution 17
Then >>> now >>> future Away from : individual; reactive; and sickness based approach reliance on interventions that offer the probability of treatment success segmented and fragmented cost control Not for publication or distribution 18
Then >>> now >>> future Towards : population based, health risk management approach using evidence based principles reliance on interventions that offer evidence of benefit system and/or episode cost control Not for publication or distribution 19
Then >>> now >>> future Through: collaboration clinician control of clinical matters information to members and providers incentives Not for publication or distribution 20
What does it all mean? Private health insurers have limited, but known, options to contain costs and will always look to where most expense is incurred At HCF we will continue to actively seek stronger alliances with our members and efficient, high quality providers by: finding ways to identify them finding ways to reward them Not for publication or distribution 21
http://www.finity.com.au/publication/us-health-reform-whats-happened-and-does-it-matter-to-australian-health-insurers Not for publication or distribution 22
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References Hospitals Contribution Fund of Australia (HCF) www.hcf.com.au slarkin@hcf.com.au or http://www.linkedin.com/in/drshaunlarkin Private Health Insurance Administration Council (PHIAC) www.phiac.gov.au Private Health Insurance Ombudsman (PHIO) www.phio.org.au Private Health Insurance Industry Commission, Report No. 57; February, 1997 http://www.pc.gov.au/ic/inquiry/57privatehealth/inquiry_documents/57privatehealth (+ http://www.pc.gov.au/projects/study/hospitals) Private Health Insurance in Australia: A Case Study (OECD Health Working Paper No.8; October, 2003) www.oecd.org/document/25/0,3746,en_2649_37407_2380441_1_1_1_37407,00.html European Observatory on Health Systems and Policies The Health Systems in Transition (HiT) profiles are produced by country http://www.euro.who.int/en/who-we-are/partners/observatory/publications/healthsystem-reviews-hits Not for publication or distribution 24