Cost comparative price report with AHA data addition international comparison

International Federation of Health Plans 2009 Comparative Price ReportMedical and Hospital Fees by Country 1

COMPARATIVE COST REPORTThe International Federation of Health Plans was founded in1968 by a group of health plan industry leaders from a dozencountries. It is now the leading global network of the industry,with one hundred member companies in 31 countries.Federation member plans meet regularly to share informationabout health care financing and health care delivery in theirhome countries.The attached comparative health care provider report wasdeveloped for the Federation council meeting, September 2-42009, in Preignac, France, as part of a discussion of total healthcare cost differences between major countries. 2

FOR ILLUSTRATIVE PURPOSES ONLY 3

FOR ILLUSTRATIVE PURPOSES ONLY Scans and Imaging Fees: CT Scan: Abdomen (US$) $1,800 $1,600 $1,600 USA Fee $1,400 Range $1,200 $1,000 $750 $800 $530 $600 $400 $400 $248 $319 $258 $161 $179 $200 $83 $- UK re A in da y s ce an nd US a i ca na an Sp la m ed Ca Fr er er M G th Ne A US USA Average USA High-end 5Note: Canadian scan prices include the government “reading” fee and thecharges used by private scanning facilities for patients who pay their own

FOR ILLUSTRATIVE PURPOSES ONLY Scans and Imaging Fees: CT Scan: Head (US$) $2,000 $1,800 $1,800 USA Fee $1,600 Range $1,400 $1,200 $950 $1,000 $800 $530 $600 $319 $300 $400 $212 $258 $161 $179 $200 $41 $- e s a y SA ce n K ar nd an ad ai U ic an U Sp rla m an ed Fr er he C M G et SA N U USA Average USA High-end 6Note: Canadian scan prices include the government “reading” fee and thecharges used by private scanning facilities for patients who pay their own

FOR ILLUSTRATIVE PURPOSES ONLY Scans and Imaging Fees: CT Scans: Pelvis (US$)$2,000 $1,700$1,800 USA Fee$1,600 Range$1,400$1,200 $950$1,000 $800 $530 $600 $300 $400 $248 $319 $258 $161 $179 $200 $83 $- e s y a n SA K ce ar nd an ad ai U ic an U Sp rl a m an ed Fr er he C M G et SA N U USA Average USA High-end 7Note: Canadian scan prices include the government “reading” fee and thecharges used by private scanning facilities for patients who pay their own

FOR ILLUSTRATIVE PURPOSES ONLY Scans and Imaging Fees: MRI Scan (US$) $1,800 $1,500 $1,600 USA Fee Range $1,400 $1,200 $1,200 $1,000 $824 $839 $800 $567 $600 $436 $500 $400 $235 $179 $200 $- Canada France Germany Netherlands Spain UK USA USA Medicare USA Average USA High-end 8Note: There are no Canadian government fees associated with MRIs because this equipment is typicallypurchased by local health authorities and is included with fees for facility-level use.

FOR ILLUSTRATIVE PURPOSES ONLY Physician Fees: Well-Baby Office Visit (US$)$160 $160 $148 $148 $140$140 USA Fee USA Fee Range Range$120$120$100 $88$100 $88 $80 $80 $60 $38 $40 $30 $60 $22 $20 $38 $15 $40 $30 $- $22 $20 $15 Canada France Germany Spain USA$- Canada France Germany Spain USA USA Low-end USA High-end 9

FOR ILLUSTRATIVE PURPOSES ONLY Physician Fees: Routine Office Visit (US$)$160 $151$140 USA Fee Range$120$100$80 $72 $59$60$40 $30 $31 $32 $22$20 $15$- Canada France Germany Netherlands Spain USA USA Medicare USA Low-end USA High-end 10

FOR ILLUSTRATIVE PURPOSES ONLY Physician Fees: Normal Delivery (US$)$6,000 $4,847$5,000 USA Fee$4,000 Range$3,000 $2,384$2,000 $1,601 $1,023 $1,041$1,000 $498 $622 $- Canada France Netherlands Spain USA USA Medicare USA Low-end USA High-end 11

FOR ILLUSTRATIVE PURPOSES ONLY Physician Fees: C-Section (US$)$7,000 $6,094$6,000 USA Fee Range$5,000 US Fee Range$4,000$3,000 $2,618 $1,812$2,000 $1,478 $915 $1,051 $1,139$1,000 $0 Canada France Netherlands Spain USA USA Medicare USA Low-end USA High-end 12

FOR ILLUSTRATIVE PURPOSES ONLY Physician Fees: Appendectomy (US$)$2,000 $1,803$1,800$1,600 USA Fee$1,400 Range$1,200$1,000 $800 $629 $600 $600 $494 $313 $376 $400 $285 $114 $200 $- Canada France Germany Netherlands Spain USA USA Medicare USA Low-end USA High-end 13

FOR ILLUSTRATIVE PURPOSES ONLY Physician Fees: Cataract Surgery (US$)$2,000 $1,731$1,800$1,600 USA Fee$1,400 Range$1,200$1,000 $800 $573 $653 $600 $530 $600 $496 $392 $400 $302 $200 $- Canada France Germany Netherlands Spain USA USA Medicare USA Low-end USA High-end 14

FOR ILLUSTRATIVE PURPOSES ONLY Physician Fees: Hip Replacement (US$)$4,500$4,000 $3,935$3,500 USA Fee$3,000 Range$2,500$2,000 $1,554 $1,269 $1,400$1,500$1,000 $727 $587 $500 $126 $- Canada France Germany Spain USA USA Medicare USA Low-end USA High-end 15

FOR ILLUSTRATIVE PURPOSES ONLY Hospital Charges: Average Cost Per Hospital Day (US$)$14,000 $12,708$12,000 USA Fee$10,000 Range $8,000 $6,000 $3,181 $4,000 $2,200 $2,000 $837 $1,050 $550 $502 $579 $- Canada France Germany Netherlands Spain USA USA Medicare USA Average USA High-end 16

FOR ILLUSTRATIVE PURPOSES ONLY Hospital Charges: Average Cost Per Hospital Stay (US$)$45,000 $40,680$40,000$35,000 USA Fee Range$30,000$25,000$20,000$15,000 $12,549 $9,840 $12,000 $9,043$10,000 $3,535 $3,388 $5,000 $2,261 $- SA K e n e da s nc U ai ar nd U a Sp ic a an la Fr ed r C he M et SA N U USA Average USA High-end 17

FOR ILLUSTRATIVE PURPOSES ONLY Total Hospital and Physician Costs: Appendectomy (US$)$30,000 $26,373$25,000 USA Fee Range$20,000$15,000 $11,997 $10,400$10,000 $5,000 $2,436 $2,700 $2,500 $2,700 $2,959 $2,634 $- re UK A in y da s ce an nd US a ic a na an Sp la m ed Ca Fr er er M G th Ne US USA Average USA High-end 18

FOR ILLUSTRATIVE PURPOSES ONLY Total Hospital and Physician Costs: Bypass Surgery (US$)$140,000 $116,798$120,000 USA Fee$100,000 USA Fee Range Range $80,000 $56,472 $60,000 $40,000 $22,092 $20,000 $14,111 $11,916 $15,761 $12,868 $- Canada France Spain UK USA USA Medicare USA Average USA High-end 19

FOR ILLUSTRATIVE PURPOSES ONLY Total Hospital and Physician Costs: Hip Replacement (US$)$100,000 $90,000 $80,000 $67,983 $70,000 $60,000 USA Fee Range $50,000 $40,000 $32,093 $30,000 $17,500 $20,000 $10,000 $8,438 $8,200 $8,500 $7,600 $9,152 $8,347 $- SA K e e n da y s nc U an ar ai nd U a Sp ic a m an la Fr ed er r C he M G et SA N U USA Average USA High-end 20

FOR ILLUSTRATIVE PURPOSES ONLY Total Hospital and Physician Costs: Normal Delivery (US$)$14,000 $12,226$12,000 USA Fee Range$10,000 $7,473 $8,000 $7,259 $6,000 $4,000 $2,800 $3,400 $2,555 $1,924 $1,957 $2,000 $1,000 $- SA K e e n y da s nc an ar U ai nd U a Sp ic a m an la ed Fr er r C he M G et SA N U USA Average USA High-end 21

FOR ILLUSTRATIVE PURPOSES ONLY Tests and Cultures: Pap Smear (US$)$70 $64$60 USA Fee Range$50$40$30 $27 $26 $24 $16 $20 $17$20 $14$10$- SA e e n y da s nc an ar ai nd U a Sp ic a m an la Fr ed er r C he M G et SA N U USA Low-end USA High-end 22

FOR ILLUSTRATIVE PURPOSES ONLY Tests and Cultures: Throat Culture (US$)$35 $32$30 USA Fee Range$25$20 $17 $17$15 $9 $10 $9$10 $5$- Canada Germany Spain USA USA Medicare USA Low-end USA High-end 23

FOR ILLUSTRATIVE PURPOSES ONLY Drug Prices: Lipitor (US$)$400$350 $334$300 USA Fee$250 Range$200$150 $125$100 $63 $53 $48 $40$50 $33 $32$- Canada France Germany Netherlands Spain UK USA USA Low-end USA High-end 24

FOR ILLUSTRATIVE PURPOSES ONLY Drug Prices: Nexium (US$)$450 $424$400 USA$350 Fee Range$300$250$200 $154$150 $102$100 $65 $67 $37 $36 $41$50$- Canada France Germany Netherlands Spain UK USA USA Low-end USA High-end 25

FOR ILLUSTRATIVE PURPOSES ONLY Drug Prices: Plavix (US$)$600 $540$500 USA Fee$400 Range$300$200 $133 $85 $77 $85 $77$100 $58 $59$- Canada France Germany Netherlands Spain UK USA USA Low-end USA High-end 26

Contact informationTom Sackville, Chief Executive, the International Federation of Health PlansTom was born in London in 1950. He gained a degree in Modern History andSpanish Literature from Oxford University, and began his working life infinancial services in New York specializing in European and Latin Americandebt.In 1983 he was elected to the British Parliament. He served as a GovernmentWhip in the Thatcher administration and later as a Minister in theDepartment of Health and the Home Office.Since 1998 he has been Chief Executive of the International Federation ofHealth Plans, a global network of leading health insurers with members in 30countries dedicated to the maintenance of high professional and ethicalstandards across the industry. 28

Contact information continuedTom SackvilleTom is an advisor to various healthcare enterprises, including a hospital ITservice provider. He is Chairman of Renal Services plc, a provider ofkidney dialysis in the UK and Italy, and of the board of trustees of TheFamily Survival Trust, a charitable foundation supporting victims of cultsand their families.email tom@ifhp.comUK cell +44 7710 787 673 29

List of Federation Member PlansArgentina FranceOmint Sa De Servicios Malakoff MedericAustralia GreeceAustralian Health Insurance Association Interamerican Life Insurance CompanyAustralian Unity Health Limited Hong KongBUPA Australia Limited BUPA (Asia) LimitedGMHBA Limited HSBC Medical Insurance LimitedHBF Health Funds Inc IrelandThe Hospitals Contribution Fund of VHI Healthcare LimitedAustralia Limited Spain ItalyHealth Partners Compañia de Seguros Adeslas SA UnisaluteMedibank Private Sanitas SA MauritiusNavy Health Limited Switzerland Administrators & Consultants LimitedNIB Health Funds Limited Helsana Versicherungen AG NetherlandsTeachers’ Federation Health Limited Tanzania Achmea HealthTeachers’ Union Health Strategis Insurance (Tanzania) Limited Zorgverzkeraars NederlandBelgium Thailand New ZealandAssociation Internationale de la Mutualite BUPA Health Insurance (Thailand) Limited Southern Cross HealthcareNationaal Verbond van Socialistiche Mutualiteiten Turkey Health Fund Association of New ZealandUnion Nationale des Mutualities Libres (MLOZ) Acibadem Saglik ve Hayat Sigorta S.A. UnimedBotswana United Kingdom NigeriaBotswana Public Medical Aid Scheme AXA PPP Healthcare Total Health Trust LimitedPULA Medical Aid Fund BUPA Peoples Republic of ChinaBrazil Europe Assistance Holdings BUPA China Representative OfficeAmil Participacoes LTDA Simplyhealth Group Saudi ArabiaCanada Western Provident Association BUPA Middle EastAlberta Blue Cross Plan Westfield Contributory Health Scheme South AfricaCanadian Life & Health Insurance Association USA Allcare Administration LimitedCanassurance Hospital Service Association Aetna Inc Bathobile Holdings LimitedGroup Medical Services Americas Health Insurance Plans Board of Healthcare Funders of Southern AfricaManitoba Blue Cross Blue Cross & Blue Shield Association Bonitas Medical FundMedavie Blue Cross Blue Cross & Blue Shield of Massachusetts Chartered Accountant (SA) Medical Aid FundPacific Blue Cross Blue Cross & Blue Shield of Wyoming Discovery HealthSaskatchewan Blue Cross HIP Health Plan of New York La-Health Medical SchemeChile Kaiser Foundation Health Plan Inc MedihelpBanmedica Venezuela Medscheme HoldingsColombia Sanitas Venezuela SA Metropolitan Health GroupAsociacion Colombiana de Empresas de Medicina Integral Zimbabwe Neil Harvey & AssociatesColsanitas SA CIMAS Medical Aid Society PolmedEPS Sanitas SA The Medical Aid Society of Central Africa Resolution HealthMedisanitas SA Sizwe Medical FundDenmark TransmedDanmark Sygeforsikring University of NatalDominican RepublicArs Humano 30

FOR ILLUSTRATIVE PURPOSES ONLYResources For Health Care Unit Price Comparisons 1. Pricelist for Dutch Hospitals: http://www.umcutrecht.nl/subsite/Prijslijsten_DBC-zorg/Prijslijsten_DBC-zorg/ (For a description of how Dutch DBCs compare to DRGs, please see: http://www.dbconderhoud.nl/Over-de-DBC-systematiek/Information-in-english) 2. The Canadian Institute for Health Information Health Spending Databases (hospital costs): http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=spend_e 3. Canada Diagnostic Centres: http://www.canadadiagnostic.com/fee-schedule.php 31

FOR ILLUSTRATIVE PURPOSES ONLY Resources For Health Care Unit Price Comparisons – cont.4. Selected Canadian Fee Schedules: Alberta: http://www.health.alberta.ca/professionals/SOMB.html British Columbia: http://www.health.gov.bc.ca/msp/infoprac/physbilling/payschedule/index.html Manitoba: www.manitoba.ca/health/documents/physmanual.pdf Newfoundland: http://www.health.gov.nl.ca/mcp/html/schedule/toc.htm Saskatchewan: http://www.health.gov.sk.ca/payment-schedules 32

FOR ILLUSTRATIVE PURPOSES ONLY Resources For Health Care Unit Price Comparisons – cont.5. French Diagnosis-Related Groups (DRGs): http://arimpl.free.fr/uploads/d96da9ec-081f-106f.pdf6. German Diagnosis-Related Groups (DRGs): http://www.g-drg.de/cms/7. USA Medicare Physician Fee Schedules: http://www.cms.hhs.gov/pfslookup/02_PFSsearch.asp?agree=yes&next=Accept8. Wiley InterScience Special Issue: Analysing the variation of health care treatment costs in Europe, Volume 17 Issue S1 , Pages S1 - S103 (January/February 2008): http://www3.interscience.wiley.com/journal/117882416/issue?CRETRY=1&SRETRY=09. New Choice Health (medical cost comparison resource): http://newchoicehealth.com/home 33

FOR ILLUSTRATIVE PURPOSES ONLY Resources For Health Care Unit Price Comparisons – cont.10. United States Prices and Fee Sources: – Scans and Imaging : USA charges include physician and facility fees. Non-Medicare US data reflect the average and maximum quotes provided by an online price comparison site – Physician Fees : Non-Medicare US low- and high-end charges reflect an estimate of the 25th and 95th percentile of charges – Hospital Charges / Total Hospital and Physician Costs : Non-Medicare US average to high-end range reflect an estimate of the average and 95th percentile of charges – Tests and Cultures : Non-Medicare US charges low- and high-end reflect an estimate of 25th and 95th percentile of charges. Medicare US charges reflect the nation wide average – Drug Prices : Non-Medicare charges, the low-end reflects the lowest prices based on a sample of several online US-based internet retail sites while the high-end reflects the maximum price across 61 counties based on a state-wide survey of New York retail pharmacies 34

FOR ILLUSTRATIVE PURPOSES ONLY Inpatient Utilization (American Hospitals)Sources: American Hospital Association, “AHA Trendwatch Chartbook 2008,” 2008. 35

FOR ILLUSTRATIVE PURPOSES ONLY Hospital Revenue and Expenses per Admission (American Hospitals)Sources: American Hospital Association, “AHA Trendwatch Chartbook 2008,” 2008. 36

Cost comparative price report with AHA data addition international comparison

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