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Risk Equalisation in Australia: An Overview. Francesco Paolucci Research Fellow (ACERH, ANU) [email protected] Friday, March 7, 2008, 10am 9th RAN Meeting in Dublin / Ireland . Agenda. Health care financing in Australia; Risk-equalisation in Australia;

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Risk Equalisation in Australia: An Overview

Francesco Paolucci

Research Fellow (ACERH, ANU)

[email protected]

Friday, March 7, 2008, 10am

9th RAN Meeting in Dublin / Ireland

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  • Health care financing in Australia;

  • Risk-equalisation in Australia;

  • Limitations & potential developments .

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Part 1.

Health Care Financing in Australia

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Health care financing in Australia

Mix of public-private financing of health services:

Private Health Insurance (PHI) (National Health Act, 1953);

Public Health Insurance (Medicare, 1984).

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Public Health Insurance: Medicare (1984)

Universal compulsory coverage;

Tax-financed single-insurer;

It provides coverage free of charge:

for (some of) the costs of private medical services (Medicare Benefits Schedule) and pharmaceuticals (Pharmaceutical Benefits Scheme);

for the full cost of being treated as a public patient in a public hospital.

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Private Health Insurance (PHI)

Voluntary coverage;

46% of the population has PHI (PHIAC, 2007);

PHI share of total health expenditures 7% (PHIAC, 2007);

Fairly competitive market:

38 funds (32 not-for-profit);

75% market share for the 6 largest insurers.

Heavily regulated (e.g. mandatory subsidies).

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PHI Act 2007

  • Separated from National Health Act 1953;

  • Appointed Actuary;

  • Re-registration of health funds;

  • Broader Health Cover;

  • Changes in Subsidies (e.g. Risk-Equalisation).

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Appointed Actuary

Health funds must advise actuary of:

proposed changes to premiums or benefits;

development of new products or major changes to products;

any other event expected to have a significant financial impact.

Appointed Actuary must provide advice to the Ministry of Health and Ageing which is responsible for approving/disapproving the changes (previously disallowance).

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Re-registration (by July 2008):

Restricted access or open;

Change of status: not-for-profit or for-profit;

Merger and acquisition of health funds allowed.

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NIB (6th insurer with 6.4% of market share):

March 2007: announced plans to demutualise;

19 July 2007: members vote in favour of demutualisation;

December 2007: listed ASX.

MBF (2nd insurer with 18.3% of market share):

17 August 2007: Council endorse demutualisation proposal;

31 August 2007: BUPA announces interest in buying MBF;

22 October 2007: Government prohibits the takeover;

2008: MBF expects to demutualise and list on ASX.

Medibank Private (1st insurer with 27.7% of market share):

December 2006: Medibank Private Sale Act passed;

2008: ASX listing expected if coalition government re-elected uncertain after Labour’s election.

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Broad Health Cover

Before (2007):

Primary coverage for (parts of) the costs of services uncovered by Medicare:

Hospital charges levied by private hospitals;

Home nursing;

Ancillary services.

Duplicate coverage for the costs of services covered by Medicare (no opt-out):

Hospital services delivered in public hospitals to private patients (with more choice, shorter waiting times and better (perceived) quality of care).

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Broad Health Cover

After (2007):

Primary coverage also for:

Allied health services, and non-traditional therapies.

Duplicate coverage also for:

Out-patient care;

Home dialysis and chemotherapy;

Specificallyexcludes GP services.

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Changes in Subsidies

Complex mix of explicit and implicit subsidies in PHI.

Before (2007):

Implicit subsidies:

Lifetime community-rating per product per insurer (with open enrolment) (1953, 2000 “Lifetime Health Cover”).

Explicit subsidies:

Reinsurance scheme (1976);

A tax penalty of 1% of income (> $50,000 p.a. for singles and $100,000 p.a. for couples) if individuals do not hold PHI (the PHIIS-scheme “Medicare levy surcharge” (1997));

30% ad valorem premium-rebate for PHI-buyers (1999), 35% for those aged 65-69 and 40% for 70+ (2005).

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Changes in Subsidies

After (2007):

Implicit subsidies:

Reduction of LHC community-rating age penalty from 35 to 10 years (2007).

Explicit subsidies:

Unchanged the Medicare levy surcharge and 30-40% ad valorem premium subsidy;

Risk-equalization scheme (Private Health Insurance Act, 2007).

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Part 2.

Risk-equalisation in Australia

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Risk-equalization (RE)

  • Origins of RE;

  • RE policy objectives;

  • Modality of RE;

  • Benefits/costs equalised;

  • Risk-factors;

  • Components of RE model.

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Origins of RE

  • “Special Accounts” – January 1959:

    • > 35 days in hospital in a year: claims paid by Govt;

    • Initially included over 65s.

  • “Reinsurance” – October 1976:

    • Two age-bands (+/- 65 years old):

      • 100% of claims for in-hospital care for 65+;

      • 100% of claims for 65 - if > 35 days in hospital in a year;

  • Claims only shared by health funds;

  • Reduced to 79% pooling in 1995;

  • Initially national, changed to state based in January 1984.

  • “Risk-equalisation” – April 2007:

    • Change of name but no change in basic principles;

    • Increasing pooling by age category;

    • High cost claims pool (replaces +/- 35 days).

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    RE policy objectives

    • RE policy objectives:

      • “… allows a more equitable treatment of health funds with different coverage of high risk groups to support Community Rating”;

      • To increase “the industry stability in the context of Community Rating”;

      • To constrain product differentiation;

        (PHIAC 2006-7; DoHA 2000; Industry Commission PHI, 1997).

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    RE policy objectives

    • Principle of Community Rating:

      • no improper discrimination against:

        • Health status;

        • Gender, race, sexual orientation or religious;

        • Age of a person, except for LHC;

        • Where a person lives, except to the extent where people live in different risk equalisation jurisdictions;

    • no risk rating of different groups for the same product.

      Private Health Insurance Act 2007 Part 3‑2 Division 55

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    RE modality

    Modality C:






    RETF=Risk Equalisation Trust Fund

    C=Contribution; S=Subsidy; P=Premium

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    RE per State


    State A

    State B

    State C




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    Benefits/costs equalised

    Hospital benefits;

    Hospital substitute benefits, i.e. treatment that:

    Substitutes for an episode of hospital treatment;

    Is any of, or any combination of, nursing, medical, surgical, diagnostic, therapeutic, pharmacological (…) or other services or goods intended to manage a disease, injury or condition;

    Chronic Disease Management Program benefits, i.e. treatment that:

    Reduces complications in a person with chronic disease(s);

    Requires a written plan specifying the allied health service or other goods/services to be provided;

    Is coordinated by a person responsible for ensuring the services are provided according to the plan and monitoring the patient's compliance;

    High Cost Claimants benefits.

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    RE definition:

    “A system for sharing the hospital costs of high risk groups between private health insurers (PHIAC 2006-7).”

    System is ex-post (retrospective) and based on actual costs;

    Current risk-factors:

    Age – seven age bands;

    No gender;

    No health status.

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    Components of RE model

    Age Based Pool (ABP):

    Benefits for persons aged 55 and over at an increasing rate, from 15% for 55 to 59 year old up to 82% for persons aged 85 +;

    High Cost Claimants Pool (HCCP):

    Benefits paid for high cost claims (> $ 50,000) after the age based benefits are taken into account.

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    The amount to be notionally allocated to the HCCP for a claim is calculated in accordance with the formula:

    m ( R – T ) - H

    m is 82%;

    R is total gross benefit for the current and the preceding 3 quarters less the amount allocated to the ABP in the current and preceding 3 quarters;

    T is the designated threshold ($50,000);

    H is the sum of the amounts allocated to the HCCP in the preceding 3 quarters;

    Subject to a maximum of 82% of gross benefits being included in Risk Equalisation when summing the ABP and HCCP components.

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    Part 3.

    Limitations & potential developments

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    Highly imperfect mechanism

    • Policy objective of equitable treatment of funds with different coverage of risk groups?

    • Age only risk-adjuster;

    • 7 age-bands:

      • 2 between 55 and 64;

      • 4 between 65 and 85+;

  • Funds will be disadvantage if they have more:

    • Females vs. males;

    • Females of child bearing age vs. other females;

    • People aged in the early 50s compared to younger aged people;

    • High-risk groups than funds in other states

    • ………………………

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    Policy objectives in the context of Community Rating:

    To increase the industry stability?

    To prevent improper discrimination and constrain product differentiation?

    Adverse selection: a constant threat to the stability of the PHI market.

    Medicare (1984):

    % of PHI-enrolees declined from 50% (1983) to 30% (1997);

    PHI coverage increased from 31 to 37 per cent among the 70+ years old and decreased from 46 to 22 per cent among people between 25 and 34 years old (Butler, 2007; Connelly and Brown, 2006; Butler, 1998);

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    1997-2000, subsidies (PHIIS, 30% rebate, LHC etc.):

    43% PHI-enrolees;

    Re-commencement of adverse selection in the post-LHC period (Connelly and Brown, 2006);

    Premium differentiation via product differentiation (“Swiss cheese policies”, premium of high-risk policies estimated 15 times higher than for low-risk policies);

    Further changes (2005-2007):

    Increased rebate for 65+;

    PHI covers more long-term services;

    Reduction of LHC age penalty from 35 to 10 years:

    More incentives for worse risks to join → increased incentives for adverse & risk selection;

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    Australia’s risk-equalisation system is de facto a claims-equalisation scheme;

    Claims-Equalisation refers to a system of ex-post (retrospective) claims-based subsidies that equalises the financial differences between insurers that arise from differences in actual claims.

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    Claims-equalisation schemes result in a reduction of the insurers’ financial risk that:

    Reduces the premiums, in particular for the high risks (i.e. it increases affordability);

    Limits price-competition (i.e. it decreases efficiency);

     tradeoff affordability - efficiency

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    Potential developments

    Allow insurers to risk rate & replace community rating by a premium rate band;

    Remove the 30-40% subsidies;

    From ex-post to ex-ante risk-equalisation:

    Risk-Based Capitation proposal (2003):

    Irish model’s age-bands;


    Product type;

    Evaluation of the current RE system within the next 3 years.