risk sharing in the australian private health insurance...

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Risk sharing in the Australian private health insurance market

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Research Paper 4June 2015

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About PHIAC

The Private Health Insurance Administration Council (PHIAC) is an independent statutory authority that regulates the private health insurance industry. Private health insurance policy is set down by the Australian Government via the Department of Health (DoH).

PHIAC’s statutory objectives are described in the Private Health Insurance Act 2007 (PHI Act). Section 264-5 of the PHI Act instructs PHIAC in performing its role, to “take all reasonable steps” to strike an “appropriate balance” between the three objectives of:a. fostering an efficient and competitive health

insurance industry;b. protecting the interests of consumers; andc. ensuring the prudential safety of individual

private health insurers.In order to promote these objectives, PHIAC has undertaken research on competition and other issues within the Australian private health insurance industry. The aim of this research is to support an improved understanding of the Australian private health insurance industry.

It is important to stress that PHIAC is not a policy body. As noted above, policy responsibility for private health insurance is reposed within the DoH as principal adviser to the Minister for Health and the Government. Accordingly, PHIAC does not seek to propose, nor to advance, any particular policy prescription or solution to the matters it examines. It does, however, aspire to provide the factual and contextual basis for a much improved discussion about the important issues that affect private health insurance in Australia. It should not be implied that any view expressed in this research paper is necessarily that of the Minister for Health or the Government.The Government announced in the 2014–15 Budget that PHIAC will be closed with effect from 1 July 2015. PHIAC’s operations will be merged into, predominantly, the Australian Prudential Regulation Authority, with the remainder of its functions reverting to other agencies.

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Preface

Private health insurance is a vital product for many Australians. Around 47 per cent of Australians — or 11.3 million people — hold a health insurance policy which covers them for hospital treatment, while around 56 per cent of the population — or 13.2 million people — are covered for general treatment. In addition, around 12 per cent of the value of all health services provided in this country is paid for by the private health insurance industry.

Risk sharing between the consumer and the insurer is an important element in any insurance market. Consumers seek to maximise the transfer of risk to the insurer at minimal cost, while insurers seek to ensure the risk they are taking on is appropriately priced. The process of striking a balance between risk transfer and pricing is central to a competitive insurance market. The private health insurance market has this characteristic but is different to other insurance markets in one fundamental respect – private health insurers are required to community rate their products. This means that the premium charged for cover cannot vary by specific risk characteristics, such as the health status or age (except to the extent allowed under Lifetime Healthcare Cover), of an individual policyholder. Notwithstanding community rating, there is a wide range of hospital products on the market. The more expensive products are likely to provide more comprehensive coverage, with the health insurer bearing more of the risk relating to the financial costs of treatment. The premiums become cheaper as the consumer accepts a higher level of risk by including one or more features such as an excess, co-payments, exclusions and restrictions, which results in the consumer facing higher out-of-pocket costs for their care. These additional costs may provide consumers with an incentive to constrain their utilisation of services.This paper explores the regulatory approach, recent industry trends and policy issues relating to the various features embedded in health insurance policies which spread the risk of the financial costs of treatment between the insurer and the consumer in respect of hospital cover. The paper focuses on hospital products because this is where policy makers have imposed

greater regulatory constraints, and because hospital products represent about three-quarters of the industry by benefits paid. While the issue of risk sharing also arises in the general treatment products, policy makers have chosen to have less intervention in this market in terms of how general treatment products are designed.The paper also focuses on features involving cost sharing (such as an excess and co-payments) and coverage (such as exclusions and restrictions). However, this paper does not address the risk that consumers may be required to pay an additional cost (out-of-pocket or gap payment) arising from the difference in the fees charged by the hospital and medical provider and the benefit paid by the insurer for a particular treatment. While the extent to which these gap payments are covered in a health insurance policy represents another form of risk sharing between the insurer and the policyholder, this issue is not related to product design which is the focus of this paper.There is very little published material examining the spreading of risk between insurers and consumers in the private health insurance industry. However, the paper draws on submissions received by PHIAC in response to its Discussion Paper No. 1, Competition in the Australian Private Health Insurance Market, released by PHIAC in November 2012.1 PHIAC also acknowledges helpful discussions with the Private Health Insurance Ombudsman.2

1 See www.phiac.gov.au. Not all submissions received by PHIAC were publicly release. PHIAC has preserved confidentiality where it was sought both in this report and on its website.

2 The functions of the Private Health Insurance Ombudsman have transferred to the Commonwealth Ombudsman with effect from 1 July 2015.

http://www.phiac.gov.au

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Use of this Paper

While PHIAC endeavours to ensure the quality of this publication, it does not accept any responsibility for the accuracy, completeness or currency of the material included in this publication and will not be liable for any loss or damage arising out of any use of, or reliance on, this publication.

This publication is available for your use under a Creative Commons Attribution 3.0 Australia licence, with the exception of the Commonwealth Coat of Arms, photographs, images, signatures and where otherwise stated. The full licence terms are available from http://creativecommons.org/licenses/by/3.0/au/legalcode. Use of PHIAC material under a Creative Commons Attribution 3.0 Australia licence requires you to attribute the work (but not in a way that suggests that PHIAC endorses you or your use of the work).

PHIAC material used ‘as supplied’

Provided you have not modified or transformed PHIAC material in any way including, for example, by changing the text; calculating percentage changes; graphing or charting data; or deriving new statistics from published PHIAC statistics — then the PHIAC prefers the following attribution: Source: Private Health Insurance Administration Council

Derivative work

If you have modified or transformed PHIAC material, or derived new material from those of PHIAC in any way, then PHIAC prefers the following attribution: Based on Private Health Insurance Administration Council data

Use of the Coat of Arms

The terms under which the Coat of Arms can be used are set out on the It’s an Honour website (see www.itsanhonour.gov.au)

Disclaimer

The purpose of this paper is to stimulate discussion. It is not a position paper and the information canvassed in it does not constitute recommendations or legal advice. While PHIAC endeavours to ensure the quality of this paper, it does not accept any responsibility for the accuracy, completeness or currency of the material included in this paper, and will not be liable for any loss arising out of any use of, or reliance on, this paper. PHIAC encourages readers to seek independent advice and to exercise care in relation to any material contained in this paper.

http://creativecommons.org/licenses/by/3.0/au/deed.en

http://creativecommons.org/licenses/by/3.0/au/legalcode

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http://www.itsanhonour.gov.au

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About PHIAC 1

Preface 2

1. Risk transfer through cost sharing 51.1 Introduction 51.2 Regulatory approach 5

Excesses 5Co-payments 6Fixed percentage amount 7

1.3 Trends in excesses 71.4 T rends in excess, co-payments and fixed percentage amounts 81.5 Matters for discussion 8

Excesses 8Co-payments and fixed percentage amounts 9

2. Risk sharing through coverage adjustment 102.1 Introduction 102.2 Regulatory approach 112.3 T rends in exclusions and restrictions 112.4 P roducts containing exclusions, benefit limitation periods, restrictions, and caps on hospital treatment 12

Exclusions 12Benefit limitation periods 13Restricted products 13Caps on hospital treatment 13

2.5 Trends in full cover policies 132.6 D ifference between the top and bottom of the market 142.7 Matters for discussion 14

Competition 14Other consumer issues 15Community rating 16Regulation of premium changes 16Government incentives 16Other issues 17

References 18

Table of Contents

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1. Risk transfer through cost sharing

1.1 IntroductionHealth insurers share the risks relating to the financial costs of treatment between themselves and policyholders by including various features in insurance policies. This chapter examines the regulatory approach, recent trends and policy issues relating to the use of an excess and a co-payment (including a fixed percentage of cost) as a means of sharing the financial risk of treatment between the insurer and the consumer.

1.2 Regulatory approach

Excesses

An excess is the fixed amount a policyholder agrees to pay for hospital treatment before a private health insurance benefit is payable. For example, if a policy has an excess of $200 per hospital admission, the insured person is required to pay the first $200 of the hospital costs if they go to hospital as a private patient. The excess may be capped per hospital admission and on an annual basis, or on an annual basis only. In April 2015, 31 of the 343 insurers offered for purchase at least one hospital product4 for purchase with an excess.5 The 3 insurers who do not currently offer for purchase a hospital product with an excess are small

restricted insurers. Relative to April 2013, there has been an increasing use of an excess in hospital products. In particular, 69 per cent of hospital products available for purchase in the NSW market in April 2015 include an excess compared with 59 cent April 2013.Private health insurers can set any level of excess they wish on hospital products. However, the level of excess for hospital treatment is regulated for Medicare Levy Surcharge (MLS) purposes.6 Policyholders who are above the income thresholds7 are exempt from the MLS provided that:• they hold a complying health insurance product8

that covers hospital treatment; and• any excess payable in respect of benefits under the

policy is no more than:− $500 in any 12 month period in relation to a

policy under which only one person is insured; and

− $1,000 in any 12 month period in relation to any other policy.9

3 There is one small health insurer (Queensland Teachers’ Union Health Fund) that does not offer health insurance products in NSW.

4 The presentation of statistical information relating hospital products throughout this paper refers to non-corporate hospital products.

5 This statistic, and other comparable statistics in this paper, is based on non-corporate hospital products currently on the market for purchase in NSW as reported on www.privatehealth.gov.au. The results would be very similar in other jurisdictions as health insures tend to offer the same product nationally.

6 The level of the excess for hospital treatment is not regulated for the purposes of the Private Health Insurance Rebate. A person is eligible for this rebate provided they hold a complying health insurance product and earn less than the income test thresholds.

7 For the 2014–15 income tax year, the income thresholds for MLS purposes start at $90,000 for a single person with no dependents, and $180,000 for a family with one dependent child, with the threshold rising $1,500 per dependent child.

8 The term ‘complying health insurance product’ is defined in Division 63 of the Private Health Insurance Act 2007.

9 Sub-sections 3(5) and 3(7) of the Medicare Levy Act 1986.

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http://www.privatehealth.gov.au


This policy approach means that those wishing to avoid the MLS must purchase a hospital cover product where the excess is no greater than the above limits. It also means that effectively the market for policies with an excess greater than the above limits is confined to consumers with incomes below the MLS income thresholds.10

Another implication of this policy approach is in the setting of the size of the excess. The most common excess is $250 (half the maximum) or $500 per annum (the maximum amount) for a product covering a single person, and $500 (half the maximum) or $1,000 per annum (the maximum amount) for a product covering more than one person. Some insurers offer a wider range of excess choices, with the excess set side of the $250 amount (say, $200 or $300) or below the $500 amount (say, $400) for a product covering a single person, and a similar approach for policies covering more than one person. One health insurer offers a family product where each adult would pay an excess on hospital admission set at a maximum of $500 per adult per year while dependent children would not pay an excess.11 This may be a sign that the market is operating in a competitive way with insurers seeking to differentiate themselves in the market place and providing consumers with choice.

Co-payments

A co-payment is where the policyholder agrees to pay an agreed amount each time a service is provided. For example, a policy may have a co-payment clause that requires payment of the first $50 for each day’s hospital accommodation. In this case, if the insured person is in hospital for three days, they would be required to pay the first $150 of hospital accommodation costs. It is noted that a policy may have no excess or co-payment requirement, either an excess or co-payment requirement, or both an excess and co-payment requirement.

The co-payment is typically set as an amount per day of a hospital stay, and is usually capped per hospital stay or per annum, or both per hospital stay and per annum. • An example of a potentially low co-payment

product on the market in NSW is one which requires the consumer to pay $40 per day for a private or shared room capped at $280 per hospital stay and $30 per day for day surgery, but with no cap on the annual amount of co-payments.

• An example of a high co-payment product on the market in NSW is one which requires the consumer to pay $100 per day for a private or shared room capped at $500 per hospital stay and $150 per day for day surgery. The total co-payment is capped at $1,000 per year.

Co-payments are not subject to any regulation. Consequently, a policy can require any level of co-payment without affecting the MLS, the Private Health Insurance Rebate or the Lifetime Health Cover (LHC)12 status of the consumer. This has resulted in a wide range of co-payment options available in the market providing consumers with considerable choice, again perhaps signalling that the market is operating in a competitive way.Health insurers offer more hospital products with an excess than with a co-payment. In April 2015:• 8 out of the 34 insurers offered for purchase at

least one hospital product with a co-payment in the NSW market13 compared with 31 insurers which offered at least one hospital product with an excess;

• 8 per cent of hospital products providing family cover on the market in NSW have a co-payment compared with around 69 per cent with an excess;14 and

10 In April 2015, only two small health insurers offered a hospital product with an excess greater than the MLS limits, with the excess on each product set at $750 or $1,000 for a single person policy and $1,500 or $2,000 for other policies. Further, there are only 3 of these products available for purchase in the NSW market out of a total of 251 products.

11 This means that the maximum excess per year is $1,000 (that is, two times $500), and hence the product is exempt for MLS purposes.

12 The LHC means that if the consumer does not have hospital cover on the 1st of July following their 31st birthday and then decides to take out hospital cover later on, the consumer pays a 2 per cent loading on top of their premium for every year the consumer is aged over 30. For example, if the consumer takes out hospital cover at age 40, they pay 20 per cent more than someone who first took out hospital cover at age 30. The maximum loading is 70 per cent. Once the consumer has paid a LHC loading on their private hospital insurance for 10 continuous years, the loading is removed as long as the consumer retains their hospital cover.

13 A further two insurers offered co-payment products in the past and who no longer offer such products for purchase.

14 Family (two adults with dependants) hospital products currently offered in NSW have been used in this paper are as representative for the products available for purchase in the Australian market. In fact, insurers generally offer the same product in each jurisdiction with only the price varying between jurisdictions.


• 38 per cent of hospital products available on the market in NSW providing family cover with a co-payment also include an excess.15 These comprised only 3 per cent of the total number of hospital products providing family cover in that market.16

Relative to April 2013, there has been a movement away from including a co-payment in hospital products. In particular, in April 2015 only 8 insurers offered one or more hospital products including a co-payment for purchase in the NSW market compared with 10 insurers in April 2013.17 The low usage of co-payments in hospital products may reflect concerns around the consumer facing uncertain out-of-pocket expenses whereas an excess provides certainty to the consumer on they much they have to pay.

Fixed percentage amount

Some hospital cover policies set the benefit at a fixed percentage of the hospital accommodation costs of a private hospital episode, perhaps combined with a cap on the amount to be paid by the policyholder. In effect, the fixed percentage has the same impact as an excess or a co-payment. There is no regulation of the fixed percentage amount or the magnitude of the cap. In April 2015 (as was the case in April 2013), only one small insurer offered three hospital products of this kind.18

15 That is, 8 products with an excess and a co-payment compared with 21 products with a co-payment on the market.

16 That is, 8 products with an excess and a co-payment compared with 251 hospital products on the market.

17 There are only 17 products of this kind available for purchase in April 2015 compared with 52 in April 2013. This large drop is due to one insurer who had a large number of hospital products with a co-payment available for purchase in NSW in April 2013 whereas this insurer offered no such products in April 2015.

18 Hospital products with a fixed percentage of hospital accommodation costs on the market at April 2015 are 65 per cent, 75 per cent and 90 per cent. An example of the cap on out-of-pocket costs in the case of the 90 per cent fixed percentage product is $500 per adult for each calendar year for hospital admission (not payable by dependent children).

1.3 Trends in excessesThere has been a moderate increase in the proportion of policies with an excess and/or a co-payment19 over the past decade. This is summarised in Figure 1.The key observations are as follows:• The most notable change is the decline in hospital

cover policies with an excess greater than the $500 (single)/$1,000 (more than one person) maximum amounts for MLS purposes and/or a co-payment, from 23.2 per cent of total policyholders with hospital cover in March 2003 to 0.7 per cent in March 2015.20 This decline could represent a delayed response to the policy change in July 2000 when the maximum amounts for MLS purposes were set. It may also indicate the low level of interest consumers with incomes below the MLS thresholds have in taking out health insurance with an excess greater than the maximum allowable for MLS purposes.21

• More than offsetting this decline has been the growth in policyholders with an excess equal to or less than the $500/$1,000 maximum limits and/or a co-payment. The small upward movement between March 2013 and March 2015 (76.8 per cent to 79.4 per cent) is consistent with the upward movement in the number of product with an excess on the market (see above).

• Overall, the proportion of policyholders with an excess and/or co-payment has been steadily increasing, from 69.6 per cent in March 2007 to 80.1 per cent in March 2014.

Over the period 1989 to 2003, the percentage of hospital cover policies with a ‘front-end deductible’ (currently known as an excess) has been continuously increasing, from around 6 per cent in June 1989 to 20 per cent in June 1995, 50 per cent in June 2000 and 59 per cent in June 2003. The average annual growth rate in policies with an excess was 19 per cent over the period June 1989 to June 2003. While this data is not strictly comparable to the data in Figure 1,22 the large shift towards policies including an excess since 1989 represents a significant structural change.

19 This means that the PHIAC data captures policies with an excess and no co-payment, no excess and a co-payment, and both an excess and a co-payment.

20 March 2015 is the lowest point in this series.

21 In support of this, see footnote 10.

22 The methodology used to collect the statistics was changed in September 2002. As an illustration, as at June 2003, data on front-end deductibles (old data series) is 59 per cent of hospital cover policies compared with 73 per cent of hospital cover policies with an excess (new data series). That is, there is a 14 percentage point gap between the new and the old series.


1.4 Trends in excess, co-payments and fixed percentage amounts

PHIAC currently does not collect quarterly data on hospital cover policies which include an excess or a co-payment and insured persons subject to an excess or a co-payment (ie, separately), nor on the number of policies which pay a fixed percentage amount of hospital accommodation costs and insured persons subject to a fixed percentage amount.

1.5 Matters for discussion

Excesses

The maximum excess of $500 for policies covering a single person and $1,000 for any other policy for MLS purposes commenced on 1 July 2000. Prior to this, the maximum excess was $1,000 for a single person and $2,000 for any other policy. It was considered at the time that an excess of this magnitude was designed to make health insurance products “so inexpensive and tokentistic” to appeal to high income earners seeking

to avoid the MLS with “no intention of using the private health care system”.23 Over time, the real value of the maximum excess has been eroded by inflation, as illustrated in Table 2. Another way to look at this issue is to compare the excess with average yearly earnings. Over the period since 2000, the excess as a proportion of average yearly earnings has approximately halved, from 1.2 per cent and 2.4 per cent based on the $500 and $1,000 excess respectively in 2000 to 0.6 per cent and 1.2 per cent respectively in 2015. This erosion in the value of the excess means that it is acting as less of a constraint on consumers utilising hospital services.

23 Supplementary Explanatory Memorandum, Taxation Laws Amendment Bill (no 6) 2000, page 8 and 9, available at www.comlaw.gov.au.

1. Hospital cover policies with an excess and/or co-payment

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Policies with an excess and/or a co-payment

Policies with an excess < $500/$1,000 and/or a co-payment

Policies with an excess > $500/$1,000 and/or a co-payment

Note: Data on the percentage of persons insured with hospital cover and subject to an excess relative to the total number of insured persons and the percentage of hospital cover policies with an excess relative to the total number of hospital cover policies is very similar. Data on the split of insured persons with an excess less than, or greater than, $500/$1,000 is not available.

Source: PHIAC


2. Real value of maximum excess

Amount set in July

2000

Real value in March 2015 based on movements in the Consumer Price Index

Real value in March 2015 based on movements in the health component of the Consumer Price Index

$500 $341 (or 32 per cent decline) $249 (or 50 per cent decline)

$1,000 $683 (or 32 per cent decline) $555 (or 50 per cent decline)

Source: PHIAC

Medibank Private submits24 that this erosion in the real value of the maximum excess has the following implications:

• It places upward pressure on premiums because the effect of maintaining the nominal value of the excess is to transfer risk to the insurer over time. If the real value of the maximum excess was maintained, it is estimated that premiums could be up to $300 per annum lower. Consequently, the budget cost of the Private Health Insurance Rebate is higher than otherwise.

• Apart from an excess, there are many other features available to health insurers which involve the policyholder carrying some of the risk of the cost of hospital care such as co-payments, exclusions and restrictions. Because these features are not regulated, health insurers may adjust them so that the risk borne by policyholders is not eroded over time and in effect compensate insurers for the declining real value of the maximum excess.

• The ability of consumers to select an optimal amount of risk is reduced as the real value of the maximum allowable excess declines. From the consumer’s point of view, this could be considered to be a sub-optimal outcome.25

Notwithstanding these arguments, there is clearly a limit to how much the maximum excess can be increased as there is a point where the size of the excess will lead to consumers buying the product to avoid the MLS with little likelihood of utilising the private hospital system. Furthermore, the attendant consequences for product design and associated impacts on community rating might need to be fully assessed before increasing the minimum excess amount.

Co-payments and fixed percentage amounts

As mentioned, co-payments and fixed percentage amounts are not regulated for MLS purposes. This opens the possibility that co-payments could be set at an amount so as to enable annual premiums to be below the cost of the MLS. Similarly, the fixed percentage amount could be set so low as to enable annual premiums to be set below the cost of the MLS.As with a high excess, products with a high co-payment or a low fixed percentage amount may be attractive to consumers wishing to avoid the MLS with little intention of utilising their cover when hospital treatment is required. This provides an argument to regulate the maximum amount of a co-payment and the minimum percentage amount. However, at present, there does not appear to be evidence of insurers offering products with co-payments and fixed percentage amounts designed to enable premium levels to be set to achieve this outcome.26 This is not to say such products may not emerge in the future.

24 Medibank Private’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, page 12.

25 In this respect, there is some evidence that consumers are increasingly choosing private hospital cover with the maximum excess. For example, Medibank Private indicates that the number of policyholders choosing the maximum excess has doubled over the last three years. Medibank Private’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, page 12.

26 The highest co-payment in the NSW market, where the co-payment is capped, is currently $1,000 per annum, and the lowest fixed percentage amount of hospital accommodation costs currently in the market is 65 per cent combined with a $1,000 cap per hospital admission (not payable by dependent children and no annual maximum).

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2. Risk sharing through coverage adjustment

2.1 IntroductionInsurers provide hospital products that exclude or restrict benefits for some treatments, impose benefit limitation periods and/or restrict the coverage to being treated as a private patient in a public hospital, in return for lower premiums. • Exclusionary products are those which do not

cover a particular treatment as a private patient in a public or private hospital. Common treatments excluded include expensive treatments such as cardiac services, assisted reproductive services (infertility services), hip and knee replacements and/or treatments typically not required by the age group the product is targeting.27

• Restrictions are where the policy covers certain treatments, but only to a limited extent. For example, a policy may cover the cost of a hip replacement, but only as a private patient in a public hospital. Consequently, the policyholder is not covered for this treatment at a private hospital. Another example is that the benefit for a particular treatment performed in a private hospital may be limited to the minimum default amount for hospital

accommodation costs set out in the Private Health Insurance (Benefit Requirements) Amendment Rules 2011. This is likely to result in the insured person incurring significant out-of-pocket expenses for hospital accommodation costs if treated in a private hospital, but there is likely to be no (or minimal) out-of-pocket expenses if treated as a private patient in a shared ward of a public hospital.

• Hospital treatment benefits, including accommodation as a private patient in a private or public hospital, may be capped to a particular number of days, say 100 days per year.

• Benefit limitation periods are where the policyholder only receives minimum default benefits for hospital accommodation costs for an initial period (usually two years) after purchasing the policy (provided the person is not switching from another insurer).28

This chapter outlines the regulatory approach, recent trends and policy issues relating to the use of exclusions, restrictions, caps on hospital treatment and benefit limitation periods as a means of sharing the financial risk of treatment between the insurer and the consumer.

27 A product which is effectively the same as an exclusionary product is an inclusionary product. The difference is that inclusionary products start from the assumption that all treatments (other than the minimum mandated rehabilitation, psychiatric and palliative care services) are excluded. Particular treatments are then included in the policy to make up the product the consumer buys.

28 Under Division 78 of the PHI Act, insurers are prohibited from imposing benefit limitation periods for persons transferring to a new policy, either within the one insurer or between insurers.


2.2 Regulatory approachRegulation of the content of health insurance products could be described as ‘light touch’. The only regulatory requirement is that hospital products must cover psychiatric, rehabilitative and palliative care, at least at the default rate.29 Beyond this minimum requirement, there is no limit on how many treatments can be excluded from a policy, or on the use of restrictions or benefit limitation periods. Furthermore, there are no additional regulatory requirements in respect of hospital products providing cover for being treated only as a private patient in a public hospital. There are also no limits on these features for MLS or private health insurance rebate purposes.

This ‘light touch’ approach to product regulation has been in place since 1995. Prior to 1995, insurers could only exclude treatments in a private hospital and the insurer still had to pay benefits for all treatments in a public hospital.

29 Sub-section 72(2), item 1 of the PHI Act. The default rate is the minimum benefit level set the Private Health Insurance (Benefit Requirements) Amendment Rules 2011.

2.3 Trends in exclusions and restrictions

Figure 3 shows the proportion of hospital cover policies with: (i) an exclusion, (ii) a restriction, and (iii) an exclusion and/or a restriction. It is important to note that the data on exclusionary products does not capture products which exclude items that are not covered by Medicare (such as ambulance and most cosmetic surgery). It is also noted that the data on restrictions captures products with at least one treatment subject to a benefit limitation period exceeding 12 months and products which only cover treatment in a public hospital.

3. Trends in exclusions and restrictions

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Exclusions and/or restrictions (a)

Restrictions (b)

Exclusions (c)

Note: The significant increase in exclusionary products in March 2011 relative to March 2010 is partly due to a re-classification of policies between exclusions and restrictions by some insurers. Furthermore, there is a break in the excess and co-payment data in June 2007 due to a change in the definition used. While the data on exclusionary products pre and post March 2011 and the data on excess and payments pre and post June 2007 is not strictly comparable, the data over the entire period can be taken as a proxy for the overall trend.(a) This includes hospital policies with exclusions and restrictions, with exclusions but no restrictions, and with restrictions but no exclusions.(b) This includes hospital policies with restrictions with or without exclusions. (c) This includes hospital policies with exclusions with or without restrictions.

Source: PHIAC


Over the period since 2003, the proportion of hospital cover policies with one or more exclusions has increased significantly (see Figure 3). However, this data needs to be interpreted with caution because a large part of the increase in March 2011 (from 16.2 per cent in March 2010 to 26.5 per cent in March 2011) can be attributed to a reclassification of policies by some insurers. Further, the fall in exclusions in March 2013 and the rise in restrictions is also largely due to reclassifications by some insurers. Given the deficiencies in the data, it is reasonable to conclude that the proportion of hospital cover policies with an exclusion has more likely doubled since June 2003 rather than quadrupling as shown in Figure 3. In contrast, the proportion of hospital cover policies containing a restriction has remained broadly flat over the period March 2003 to March 2012, but has since risen from 34.4 per cent in March 2012 to 44.8 per cent in March 2015. In aggregate, the proportion of hospital cover policies containing at least one exclusion and/or restriction has risen from 36.4 per cent in March 2003 to 53.0 per cent in March 2015.Observations made by industry stakeholders explaining the growth in exclusionary products include the following:• Products with exclusions provide the opportunity

for consumers to buy cheaper health insurance products as premiums increase at a faster rate than average incomes. In particular, they are attractive for low health risk (young) consumers.30 In this respect, some insurers are actively marketing products to attract younger age groups.31 Comparatively cheap health insurance products are also attractive for those consumers seeking to avoid the MLS. The concern is that consumers who are price sensitive are making their decision to select a low priced product when buying health insurance for the first time or to downgrade their coverage based on price considerations rather than on health risk considerations.

• Affordability of private health insurance products could be becoming a more important issue over time.32 As a guide, the cost of top hospital cover (before the Private Health Insurance Rebate) has risen from around 4.4 per cent of average weekly earnings in 2002 to around 6.3 per cent in 2015.33 This reflects that health inflation is about twice the rate of inflation in the broader economy. If affordability is an issue, the availability of exclusionary products provides the opportunity for existing consumers to downgrade their cover and pay a lower premium, and for new consumers to enter the health insurance market at a lower than otherwise pricing point.

• The growth in exclusionary products could, in part, be a response by health insurers to the constraining of premium increases by the Government.34 Consequently, health insurers may wish to add exclusions to products in order to maintain profitability.

2.4 Products containing exclusions, benefit limitation periods, restrictions, and caps on hospital treatment

Exclusions

The use of exclusions in hospital products has increased since April 2013. In particular, the number of insurers offering one or more products with one or more exclusions (excluding ambulance) has increased from 17 in April 2013 to 22 in April 2015. The number of hospital products available for purchase which include one or more exclusions has increased from 65 products (or 24 per cent of total products) to 85 products (or 34 per cent of total products). This upward trend is consistent with the upward trend in the last two years in the number of hospital policyholders holding a policy with an exclusion (see Figure 3).

30 KPMG’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, page 9.

31 An example is that many advertising campaigns by health insurers (such as nib) are targeting the young low health risk consumer.

32 KPMG’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, page 9.

33 PHIAC estimates.

34 Confidential submission to Discussion Paper No 1, Competition in the Private Health Insurance Market.


Benefit limitation periods

PHIAC does not specially collect data on the number of policies or insured persons with hospital cover products which contain a benefit limitation period.35 However, a review of hospital products open for new policyholders shows that benefit limitation periods are not commonly used. In fact, in April 2015 only 6 out of the 34 health insurers included benefit limitation periods in at least one of their hospital products currently on the market for purchase in NSW compared with 8 insurers in April 2013. Furthermore, 2 out of these 6 health insurers include a benefit limitation period for only one treatment (either psychiatric, palliative, reproductive or gastric banding treatments), while the other 4 insurers use benefit limitation periods more extensively.

Restricted products

Restricted products fall into two categories. The first is those which provide coverage in both private and public hospitals but limit the benefits payable on particular treatments. A common restriction is limiting the benefits payable on psychiatric, rehabilitative and palliative care to the default rate or limiting particular treatments to public hospitals. PHIAC does not specially collect any data on the number of policies or insured persons with a restriction of this type.36 However, in April 2015, 22 of 34 health insurers offered for purchased at least one hospital product limiting benefits payable for a particular treatment compared with 14 insurers in April 2013. The number of hospital products currently on the market for purchase in NSW covering two adults with dependants and with this type of restriction is 75 (or 30 per cent of the total number of hospital products). This compares with 52 products (or 19 per cent of the total) in April 2013. Consequently, there has been a shift towards products with restrictions between April 2015 and April 2013. This upward trend is consistent with the upward trend in the last two years in the number of hospital policyholders holding a policy with a restriction (see Figure 3).

The second category is those products which limit coverage to being treated as a private patient in a public hospital. This means that the policyholder is not covered for treatment in a private hospital. These products may or may not include an excess, restriction or exclusion. They are amongst the cheapest products on the market, comparable in price to products offering cover for treatment at a public or private hospital but with a significant number of treatments excluded. PHIAC does not specifically collect data on the number of policyholders with a public hospital cover product.37 In April 2015, 10 of the 34 health insurers offered for purchase in NSW at least one product providing public hospital cover only compared with 13 insurers in April 2013. While the number of insurers offering a public hospital only policy has fallen, the percentage these policies comprise of the total on the market has remained unchanged at around 7 per cent between April 2013 and April 2015.38

35 A policy with a benefit limitation period where the benefit is restricted for more than 12 months is considered to offer ‘reduced cover’ (and hence a restricted product) for the purposes of PHIAC’s statistics.

36 PHIAC’s statistics on restricted policies include both categories of restricted products.

37 PHIAC’s statistics on restricted policies include both categories of restricted products.

38 In April 2015, there were 17 non-corporate public hospital only products on the market in NSW compared with 20 in April 2013.

Caps on hospital treatment

Health insurers may offer a product where the costs of hospital treatment, including accommodation as a private patient in a private or public hospital, may be capped to a particular number of days. PHIAC does not specially collect data on the number of policies or insured persons with this product. However, in April 2015, only 1 of the 34 insurers offered for purchase a product of this kind. This product caps benefits for hospital treatment at 100 days per year. This product does not have exclusions, restrictions or benefit limitation periods.

2.5 Trends in full cover policiesFigure 4 shows the market share of hospital cover policies with full (or comprehensive) cover with or without an excess since March 2003. Policies with full cover have been declining slowly since March 2006. In March 2015, 47.0 per cent of policies provided full cover, and 72.9 per cent of these included an excess.


2.6 Difference between the top and bottom of the market

Hospital products at the top of the market are defined as those having no exclusions (with the possible exception of ambulance), no restrictions, no co-payments and no excess. Hospital products at the bottom of the market can be categorised into two groups. The first category contains products which provide very limited cover in private and public hospitals. These products have numerous exclusions or restrictions, and typically include an excess. An example of such a product is one providing cover only for injuries incurred in an accident. The second category contains products which provide cover for treatment as a private patient in a public hospital. This category of products may also contain exclusions, restrictions and an excess. These two product types at the bottom of the market are similarly priced (for example, in the $70 to $120 per month pre-rebate price range for a policy covering a single person and $140 to $240 for family cover). About 25 per cent of hospital products available for purchase on the NSW market in April 2015 fall into these two groups.

The difference in pricing between the top and bottom hospital products is shown in Table 5. In annual terms, this difference is $1,212 for a single adult policy and $2,796 for a two adults with dependents policy. This suggests that insurers have considerable scope to design products to achieve particular pricing points to target particular segments of the market.

2.7 Matters for discussionThere is a wide range of views on the impact of hospital products with less than comprehensive coverage on the private health insurance market.

Competition

On the positive side, many argue that products with less than comprehensive coverage enhance competition in the industry. Private health insurers are able to design products to meet the particular needs of consumers, and consumers are able to choose the product that best meets their perceived needs and financial circumstances. It has been noted that the capacity of health insurers to offer products at the cheaper end of the market spectrum

4. Proportion of policies with full cover

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Full cover policies with an excess

Full cover policies with no excess

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Note: Full cover means policies that have no restriction on benefits paid after 12 months and no exclusions (except an exclusion for ambulance and treatments which are not covered by Medicare). Policies which meet this test but have a co-payment and/or an excess and/or a fixed percentage amount are considered to be full cover policies.

Source: PHIAC


promotes competition in the low health risk, low claiming and price sensitive segment of the health insurance market.39 Furthermore, insurers appear to be strategically targeting either the whole market by having a range of products, or the top end of the market by only offering products with comprehensive coverage, the middle of the market in terms of pricing, or particular segments of the market (such as the young). This is a sign the health insurance market is behaving in a competitive way by seeking to meet the demands of the market. On the negative side, many argue that the wide range and complexity of hospital cover products currently available impedes competition in the market. This argument is based on the view that the wide variation in the inclusion of restrictions, exclusions, co-payments, excess, and benefit limitation periods makes it very difficult for consumers to compare products and to choose the best value product for their particular circumstances. This is one explanation for the low level of consumer movement between insurers despite the wide dispersion in prices of similar products. Both these points together (low movement and wide dispersion) suggest that the level of competition in the private health insurance industry may not be what it should be.40

39 Teachers Union Health Fund’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, page 3.

40 The Research Paper No. 2, Portability, Switching and Competition in the Australian Health Insurance Industry, June 2015, available at www.phiac.gov.au, discusses both these points in some detail.

Other consumer issues

A major concern with products with less than comprehensive coverage is that consumers may become dissatisfied with private health insurance when they seek to undergo a treatment which has been excluded, particularly in the circumstance where the consumer was not aware of the exclusion. Some argue that this undermines the long term value of private health insurance.41 Another concern is that many of the low cost products promoted to the younger segment of the market provide restricted benefits on psychiatric services even though the prevalence of mental health issues among young adults is reasonably high.42 These concerns highlight the importance of consumer information and awareness in ensuring that products with less than comprehensive coverage are fully understood at the time of purchase and beyond. Regulatory measures such as the requirement for health insurers to annually provide consumers with a Standard Information Statement (SIS) and the requirement to inform policyholders of any changes to their policy are directed at achieving this outcome. Consumers can also obtain information from their insurer’s website and www.privatehealth.gov.au.

41 Defence Health’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, pages 6 to 8.

42 Consumers Health Forum of Australia’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, page 2.

5. Price of top and bottom hospital products in NSW A

Bottom hospital products (per month and before the rebate)

Top hospital product (per month and before the rebate)

Per cent difference

Single adult $93 $194 109%

Two adults with dependants $192 $425 121%

A These prices are on the weighted average (by market share) across those insurers offering the particular hospital product.

Source: PHIAC

http://www.privatehealth.gov.au


Community rating

There are mixed views of the impact of products with less than comprehensive coverage on the principle of community rating and the sustainability of the private health insurance industry. • On the one hand, it is seen as a positive because

these products enable consumers to purchase a product suitable to their perceived health risks. This attracts low risk young consumers into the private health insurance market earlier than otherwise, and they will possibly retain and upgrade their cover over time as their health risks change. It is argued that having these low risk young consumers in the private health insurance system is better for everyone in the system as they subsidise high cost claimants on comprehensive policies, and for this reason allowing products with less than comprehensive coverage supports a community rated private health insurance industry. Furthermore, low risk young consumers purchasing products with exclusions and restrictions make the same contribution to the risk equalisation pool as consumers on comprehensive products.43

• On the other hand, many argue that products with less than comprehensive coverage undermine the principle of community rating.44 The policy objective of community rating is universal price and coverage so as to remove the ability of insurers to price on the basis of risk so low risk groups (the young and healthy) subsidise the high risk groups (the aged and unhealthy). However, products with less than comprehensive coverage effectively introduce risk-based pricing by enabling the low risk groups to pay lower premiums based on their perception of health risk.

43 The Australian Health Service Alliance’s and hirmaa’s joint submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, page 13.


Regulation of premium changes

The Minister for Health is required to approve requests for premium changes, unless the change is contrary to the public interest.45 This approval process occurs on an annual basis. An option available to insurers if they are unable to obtain their preferred increase in premiums is to increase the level of exclusions, restrictions and benefit limitation periods for existing policyholders to achieve a particular profit target. Some industry stakeholders consider that the ability of health insurers to do this arguably undermines moves to constrain premium increases.46

Government incentives

The policy objectives of the MLS and the Private Health Insurance Rebate are to encourage consumers to take out private health insurance in order to relieve pressure on the public hospital system. As mentioned above, private health insurance products as a minimum only need to provide cover for psychiatric, rehabilitative and palliative care at the default rate. This means that a health insurer can offer a minimalist health insurance product at a comparatively low price (see Table 5) while the consumer avoids the MLS and obtains the private health insurance rebate. As mentioned above, included in this category of products are those that either:• limit cover to being treated as a private patient in a

public hospital; or• provide for treatment as a private patient in a

private and public hospital but with a large number of exclusions or restrictions.

45 This requirement is set out in section 66-10 of the Private Health Insurance Act 2007.

46 Consumers Health Forum of Australian’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, page 2.


There are two opposing views on the merits on these low cost products. • One view is that these products do little to relieve

pressure on the public hospital system and should not then qualify for the Private Health Insurance Rebate and be exempt for MLS purposes.

• The alternative view is that these products either provide an additional revenue source for public hospitals (those that pay benefits for treatment as a private patient in a public hospital),47 or at least relieve some pressure on the public hospital system and in this way help achieve the Government’s policy objectives.48 Again, it is noted that, through the Risk Equalisation Transfer Fund, purchasers of these products do contribute to the treatment costs of higher risk groups. In this way, low cost products do assist in sustaining the private health system.

Other issues

Other observations about the current market environment made by industry stakeholders include the following:• Insurers which only offer comprehensive products

face the prospect of losing market share over time and attracting only consumers at the higher end of the health risk profile. Consequently, these insurers may face increasing market pressure to offer products with less than comprehensive coverage to remain competitive and to manage their risk profile.

• The question arises whether products with exclusions are actuarially priced with no cross subsidisation or risk adjustment. One insurer has suggested that current industry pricing practices take into account the age group and risk profile of the market being targeted in pricing products with exclusions.49 This argument suggests that there could be a case for some form of government invention to ensure insurers price such products actuarially only on the basis of the impact of the treatments excluded and not on the age group or risk profile of the consumer taking up this product. The alternative view is that products with exclusions are appropriately priced and there is no case for government intervention.

• Exclusionary and restricted benefit products result in an increased administrative burden for hospitals as they introduce added complexity to claiming, billing and payment collection process. Hospitals are also exposed to additional financial risk particularly if it cannot be foreseen and confirmed whether a patient’s policy will provide adequate cover.50

47 For example, in 2013–14 private health insurers paid $952 million in benefits to public hospitals, or 12.5 per cent of total benefit payments to public and private hospitals. In percentage terms, 2013–14 is the equal highest level (with 2011–12) since when this data was first collected in 1997–98 and the low point was 2002–03 at 8.3 per cent. It is important to note that these benefit payments relate to all hospital products (public only products and public and private products).

48 That is, consumers with a product with a lot of exclusions may still be covered for the particular treatment they need in a private hospital.


50 Submissions to Discussion Paper No 1, Competition in the Private Health Insurance Market, Australian Private Hospitals Association’s submission, page 2, and the Little Company of Mary Health Care’s submission, page 5.

18

References

Australian Health Service Alliance’s and hirmaa’s joint submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, PHIAC, available at www.phiac.gov.au Australian Private Hospitals Association’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, PHIAC, available at www.phiac.gov.auLittle Company of Mary Health Care’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, PHIAC, available at www.phiac.gov.auConsumers Health Forum of Australia’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, available at www.phiac.gov.auDefence Health’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, available at www.phiac.gov.au Discussion Paper No. 1, Competition in the Australian Private Health Insurance Market, PHIAC, November 2012, available at www.phiac.gov.auKPMG’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, , available at www.phiac.gov.au

Medibank Private’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, available at www.phiac.gov.au Research Paper No. 1, Competition in the Australian Private Health Insurance Market, PHIAC, June 2015, available at www.phiac.gov.auResearch Paper No. 2, Portability, Switching and Competition in the Australian Health Insurance Industry, June 2015, available at www.phiac.gov.auTeachers Union Health Fund’s submission to Discussion Paper No 1, Competition in the Private Health Insurance Market, available at www.phiac.gov.au

Legislation

Medicare Levy Act 1986, available at www.comlaw.gov.auPrivate Health Insurance Act 2007, available at www.comlaw.gov.auPrivate Health Insurance (Benefit Requirements) Amendment Rules 2011, available at www.comlaw.gov.auSupplementary Explanatory Memorandum, Taxation Laws Amendment Bill (no 6) 2000, page 8 and 9, available at www.comlaw.gov.au

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