Health Insurance Summit
22-23 July 2013
Sydney Harbour Marriott Hotel
• We’re spending more and more on our
• Government cannot sustain its relative funding of
our healthcare – it’s an enormous opportunity.
• We need a clear long term vision about how we
in PHI would like the healthcare system to look.
• Nearer term reform has to cognisant of and
influenced by the long term vision and context.
• Reform won’t happen on its own and requires
Where’s it all end?
• Expenditure on health in Australia was estimated to be
$130.3 billion in 2010-11, up from $77.5 billion in 2000-01.
• This expenditure was 9.3% of gross domestic product in
2010-11 up from 8.2% in 2000-01. The estimated recurrent
expenditure on health was $5,796 per person.
• 69.1% was funded by governments, up from 67.7% in
2000-01. The two largest components of the increase in
health expenditure were public hospital services, which grew
by $2.2 billion in real terms, followed by medications
Source: Health expenditure Australia 2010-11 Australian Institute of Health and Welfare
Commonwealth outlays – it’s just not sustainable….
10 point long term vision for PHI
1. 100% of Australians enjoy the protection of PHI i.e. its compulsory. Multiple licensed PHI insurers compete via
price and service for enrolees.
2. Minimum comprehensive hospital and dental benefits are prescribed by regulation. Insurers cover the full
spectrum of healthcare.
3. Premiums are risk rated but kept affordable through a combination of active health risk and utilisation
management, hospital and provider cost control/quality assurance, a focus on clinical outcomes, risk equalisation
and the broad positive risk selection made possible by compulsion.
4. Government subsidies for premium follow the enrolee and are based upon income, inherent medical risk factors
(including age) and other disability factors (including geographical).
5. Risk is equalised across insurers through a system of prospective cost reimbursement providing insurers with
commercial incentives to invest in risk management.
6. Insurers set premiums independent of Government control with competition delivering the necessary pressure on
premiums. Government (PHIAC) continues to regulate prudential and professional standards.
7. Doctor, hospitals and other clinical providers are remunerated on the basis of negotiated prices and outcomes.
There are no regulated minimum prices. Insurers contract with both private and public providers.
8. Price signals (i.e. out of pocket gaps) create price signals to help manage demand and facilitate provider price
competition. The extent of the gap increases with the level of discretion implicit in the treatment. So for example,
nil gap for an emergency procedure and maybe 20% for non-emergency caesarean section.
9. Medical savings accounts assist enrolees in meeting the cost of gaps. Savings income within the account isn’t
taxed as an incentive to save. Medical savings accounts especially help in later years of life as utilisation becomes
10. Consumers enjoy a high degree of choice and empowerment via various mechanisms and technologies which
make transparent provider prices, accessibility and quality. Electronic personal health records aid and abet the
coordination, continuity, efficacy and safety of care.
Short term (doable) goals
• Expanded cover for GP services associated with risk
and utilisation management.
• Denticare means 100% of population has some PHI.
• Premium setting independence – capping of the
• Prospective risk equalisation.
• No provider price fixing.
• Risk rating behaviour and reducing moral hazard.
• Personalised electronic health record.
• Medical savings accounts.