In this section...
September 2001
The National Health Act 1953 and Health Insurance Act 1973 allow health funds to pay a benefit in excess of the Medicare Benefits Schedule (MBS) fee for medical services where conditions are met through contracts or other agreements. This allows health funds to provide 'no gap' or 'known gap' in-hospital medical services to insured patients.
The Private Health Insurance Administration Council (PHIAC) commenced collection of additional data from private health insurers designed specifically to measure the medical gap starting from the September 2000 quarter.
The September 2001 quarter figures in this report are from this new PHIAC collection and are the most accurate available. They are not directly comparable with statistics prior to the September 2000 report. Historical trend figures given in this report, prior to September 2000 are derived indicative estimates only.
In addition to summary tables and charts this report provides for the first time detailed medical service statistics by state. The detailed statistics provide information on medical services and gap payments for a range of charges in relation to the MBS fee. The information is further detailed by the type of agreement between health funds and medical service providers.
No gap services
The proportion of in-hospital medical services for which there was no gap has continued to increase. Note that each private episode of care may include a number of medical services provided by a number of doctors. The statistics in this report do not show gap by hospital episode. 'Gap' is defined as the amount payable by the patient (or out of pocket costs) after the Medicare Benefits and Fund Benefits have been paid. There is no gap payable where there is a "No gap agreement' between the fund and the provider, or where there is no agreement but the provider charges no more than the MBS fee.
In the September quarter 2001, 2,728,528 in-hospital medical services (representing 74% of the total) were provided to patients with no out-of-pocket costs. This is an increase of 3 percentage points from the June quarter 2001 figure of 71%.
Figure 1: Proportion of in-hospital medical services with no gap, Australia
The percent of services with no gap varies from 69% in the Northern Territory to 88% in South Australia.
The largest increase in the September 2001 quarter was in the Northern Territory with a 14 percentage point increase over the June figure, followed by Queensland with a 4 percentage point increase. Other States had increases of between 1 to 3 percentage points.
The proportion of in-hospital services with no gap and the changes since the September quarter is shown in Figure 2.
Figure 2: In-hospital services with no gaps September 2000 to June 2001, and changes* since September 2000
NSW/ACT |
Vic |
Qld |
SA |
WA |
Tas |
NT |
Australia |
|
|
Proportion of services with no medical gap - September 2000 |
50% |
69% |
58% |
69% |
71% |
51% |
23% |
60% |
|
Proportion of services with no medical gap - December 2000 |
55% |
71% |
62% |
75% |
77% |
64% |
60% |
65% |
|
Proportion of services with no medical gap - March 2001 |
64% |
70% |
63% |
83% |
77% |
66% |
58% |
69% |
|
Proportion of services with no medical gap - June 2001 |
66% |
74% |
66% |
85% |
79% |
71% |
56% |
71% |
|
Proportion of services with no medical gap - September 2001 |
69% |
77% |
70% |
88% |
80% |
72% |
70% |
74% |
|
Percentage point change |
||||||||
|
Percentage point change from |
5% |
3% |
5% |
7% |
6% |
4% |
37% |
5% |
|
Percentage point change from |
9% |
-1% |
1% |
8% |
0% |
2% |
-2% |
4% |
|
Percentage point change from |
2% |
4% |
3% |
2% |
2% |
5% |
-2% |
2% |
|
Percentage point change from |
3% |
3% |
4% |
3% |
1% |
2% |
14% |
3% |
* Changes should be viewed with caution as the reporting of these statistics is relatively new. Health funds have made changes to reporting systems to provide better information on medical services and in some cases the method of compilation provided data that is not consistent with data collected in previous quarters.
Figure 3: Proportion of in-hospital medical services with no gap, by State June 2000 to September 2001
Gap payments
The average gap payment for all insured in-hospital medical services was $18.55 in the September 2001 quarter, including services where there was no gap. This figure is a decrease over the June 2001 figure of $19.48. This decrease should be viewed with caution as it could be influenced by seasonal factors or by the data collection method, which is relatively new.
The average payment by patients for services, where there remained an out of pocket cost for the patient was $72.15 in the September 2001 quarter compared to $67.31 in the June 2001 quarter. This increase should also be viewed with caution as it could be influenced by seasonal factors or by the data collection method. It was also expected that the average gap, over services where a gap was paid, would increase. Doctors who charge smaller amounts above the schedule fee are likely to be among the first to sign up to no gap schemes or arrangements.
Figure 4 summarises no gap services and average gap payments by state from September 2000 to September 2001.
Figure 4: Summary of in-hospital medical services with no gaps September 2000 to September 2001
Quarter |
NSW/ACT |
Vic |
Qld |
SA |
WA |
Tas |
NT |
All States |
|
|
Sep-00 |
Proportion of services with no medical gap |
50% |
69% |
58% |
69% |
71% |
51% |
23% |
60% |
|
Average gap payment across all services* |
$26.13 |
$15.19 |
$28.91 |
$8.30 |
$18.41 |
$41.30 |
$9.99 |
$21.49 |
|
|
Average gap payment for services where gap was paid** |
$52.77 |
$49.72 |
$68.86 |
$26.84 |
$63.34 |
$84.59 |
$12.98 |
$54.20 |
|
|
Dec-00 |
Proportion of services with no medical gap |
55% |
71% |
62% |
75% |
77% |
64% |
60% |
65% |
|
Average gap payment across all services* |
$23.01 |
$15.52 |
$19.44 |
$7.41 |
$15.52 |
$24.71 |
$27.19 |
$18.18 |
|
|
Average gap payment for services where gap was paid** |
$51.41 |
$53.15 |
$51.65 |
$29.70 |
$66.13 |
$68.23 |
$68.24 |
$51.56 |
|
|
Mar-01 |
Proportion of services with no medical gap |
64% |
70% |
63% |
83% |
77% |
66% |
58% |
69% |
|
Proportion of services with known medical gap |
1% |
7% |
2% |
4% |
2% |
1% |
10% |
3% |
|
|
Average gap payment across all services* |
$29.27 |
$14.50 |
$22.08 |
$7.49 |
$13.10 |
$24.39 |
$31.30 |
$20.29 |
|
|
Average gap payment for services where gap was paid** |
$82.36 |
$48.18 |
$60.48 |
$45.24 |
$57.98 |
$71.22 |
$74.47 |
$64.73 |
|
|
Jun-01 |
Proportion of services with no medical gap |
66% |
74% |
66% |
85% |
79% |
71% |
56% |
71% |
|
Proportion of services with no gap or known medical gap |
2% |
6% |
2% |
4% |
3% |
1% |
8% |
3% |
|
|
Average gap payment across all services* |
$28.70 |
$14.39 |
$20.40 |
$4.32 |
$12.59 |
$22.08 |
$33.67 |
$19.48 |
|
|
Average gap payment for services where gap was paid** |
$85.02 |
$54.59 |
$60.58 |
$29.60 |
$58.83 |
$75.42 |
$76.96 |
$67.31 |
|
|
Sep-01 |
Proportion of services with no medical gap |
69% |
77% |
70% |
88% |
80% |
72% |
70% |
74% |
|
Proportion of services with no gap or known medical gap |
2% |
4% |
2% |
2% |
4% |
1% |
3% |
2% |
|
|
Average gap payment across all services* |
$28.39 |
$12.97 |
$19.20 |
$2.86 |
$13.46 |
$22.51 |
$30.00 |
$18.55 |
|
|
Average gap payment for services where gap was paid** |
$91.98 |
$55.92 |
$64.76 |
$24.82 |
$67.54 |
$81.25 |
$99.46 |
$72.15 |
*The average out of pocket payment by patients over all services including services where there was no gap
**The average out of pocket payment by patients for services where there was a gap.