Industry Statistics
Medical gap for insured in-hospital services - December 2002 quarter
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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 December 2002 quarter figures in this report are from this 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 detailed medical service statistics by state in both excel format and pdf format. The detailed statistics provide information on medical services and gap payments for a range of charges in relation to the MBS fee. The information contains further detail 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 increased in the December 2002 quarter. This increase follows a general trend to increase every quarter since the data has been collected, except for a relatively stable March 2002 quarter.
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 show gap by medical service; they 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 December quarter 2002, 3,321,266 in-hospital medical services (representing 80.3% of the total) were provided to patients with no out-of-pocket costs. This is an increase of 0.9 percentage points from the September quarter 2002 figure of 79.4%. The proportion of services with a known gap increased marginally, by 0.6 percentage points, to 4.0%.
Figure 1: Proportion of in-hospital medical services with no gap, Australia
The percent of services with no gap varies from 74% in New South Wales to 93% in South Australia
The largest increase in the percent of no gap services for the December 2002 quarter was in South Australia with a 2.3 percentage point increase over the September quarter. There were increases in all other states, ranging from 0.3% in Victoria and Western Australia to 1.4% in Queensland and Tasmania.
The proportion of in-hospital services with no gap and the changes over each quarter since the collection began in September 2000 is shown in Figure 2, and graphed in Figure 3.
Figure 2: In-hospital services with no gaps December 2000 to December 2002, and changes* since December 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% |
|
Proportion of services with no medical gap - December 2001 |
72% |
80% |
75% |
90% |
80% |
75% |
73% |
77% |
|
Proportion of services with no medical gap - March 2002 |
71% |
80% |
73% |
89% |
79% |
75% |
76% |
76% |
|
Proportion of services with no medical gap - June 2002 |
72% |
82% |
77% |
88% |
80% |
83% |
79% |
78% |
|
Proportion of services with no medical gap - September 2002 |
73% |
84% |
77% |
91% |
81% |
83% |
79% |
79% |
|
Proportion of services with no medical gap - December 2002 |
74% |
84% |
79% |
93% |
81% |
85% |
80% |
80% |
|
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% |
|
Percentage point change from |
3% |
3% |
4% |
1% |
0% |
3% |
3% |
3% |
|
Percentage point change from |
-1% |
0% |
-1% |
-1% |
-1% |
0% |
3% |
-1% |
|
Percentage point change from |
2% |
1% |
4% |
-1% |
1% |
8% |
2% |
2% |
|
Percentage point change from |
1% |
2% |
0% |
3% |
1% |
0% |
0% |
1% |
|
Percentage point change from |
1% |
0% |
1% |
2% |
0% |
1% |
1% |
1% |
* 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
Gap payments
The average gap payment for all insured in-hospital medical services was $16.64 in the December 2002 quarter, including services where there was no gap. This was an increase compared to the September 2002 quarter of $16.23.
The average payment by patients for services where there remained an out-of-pocket cost for the patient was $84.26 in the December 2002 quarter compared to $78.80 in the September 2002 quarter.
Increases in the average payment by patients for services where there remained an out-of-pocket cost should be viewed with caution. 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.
The December quarter saw an increase of 0.6 percentage points in the proportion of medical services with a known medical gap, from 3.4% to 4.0%.
Figure 4 summarises no gap services and average gap payments by state from September 2000 to December 2002.
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Topics in this section
Statistical Trends in Membership and Benefits
Annual Report - Operations of the Private Health Insurers