Industry Statistics
Medical gap for insured in-hospital services – December 2003 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 2003 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 fell slightly in the December quarter 2003; following a general trend to increase every quarter since the data has been collected.
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 2003, 3,408,849 in-hospital medical services (representing 81.5% of the total) were provided to patients with no out-of-pocket costs. This is a decrease of 0.3 percentage points from the September quarter 2003 figure of 81.8%. The proportion of services with a known gap decreased by 0.1 percentage points, from 5.0% to 4.9%.
Figure 1: Proportion of in-hospital medical services with no gap, Australia
The percent of services with no gap varies from 75.9% in Western Australia to 93.2% in South Australia.
There were increases the percent of services with no gap in Queensland and South Australia, and decreases in all other states.
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 September 2000 to December 2003, and changes since December 2000
NSW/ACT |
Vic |
Qld |
SA |
WA |
Tas |
NT |
Australia |
|
|
Proportion of services with no medical gap - September 2000 |
50.4% |
69.0% |
57.7% |
69.0% |
70.9% |
51.0% |
23.1% |
60.1% |
|
Proportion of services with no medical gap - December 2000 |
55.2% |
70.8% |
62.4% |
75.1% |
76.5% |
63.8% |
60.2% |
64.7% |
|
Proportion of services with no medical gap - March 2001 |
64.5% |
69.9% |
63.5% |
83.4% |
77.4% |
65.8% |
58.0% |
68.7% |
|
Proportion of services with no medical gap - June 2001 |
66.2% |
73.6% |
66.3% |
85.4% |
78.6% |
70.7% |
56.3% |
71.1% |
|
Proportion of services with no medical gap - September 2001 |
69.1% |
76.8% |
70.4% |
88.5% |
80.1% |
72.3% |
69.8% |
74.3% |
|
Proportion of services with no medical gap - December 2001 |
71.8% |
79.7% |
74.6% |
89.9% |
80.0% |
75.4% |
73.0% |
77.0% |
|
Proportion of services with no medical gap - March 2002 |
70.6% |
80.1% |
73.3% |
89.1% |
78.7% |
75.1% |
76.1% |
76.3% |
|
Proportion of services with no medical gap - June 2002 |
72.1% |
81.6% |
76.8% |
87.8% |
79.8% |
82.9% |
78.5% |
78.2% |
|
Proportion of services with no medical gap - September 2002 |
72.9% |
83.7% |
77.1% |
90.7% |
80.6% |
83.2% |
79.0% |
79.4% |
|
Proportion of services with no medical gap - December 2002 |
73.9% |
84.0% |
78.5% |
93.0% |
80.9% |
84.6% |
79.6% |
80.3% |
|
Proportion of services with no medical gap - March 2003 |
75.3% |
84.6% |
78.8% |
93.0% |
83.4% |
84.2% |
81.0% |
81.0% |
|
Proportion of services with no medical gap - June 2003 |
76.2% |
84.6% |
80.8% |
93.3% |
75.2% |
85.8% |
81.1% |
81.1% |
|
Proportion of services with no medical gap - September 2003 |
77.0% |
85.4% |
81.5% |
93.1% |
75.9% |
86.0% |
82.6% |
81.8% |
|
Proportion of services with no medical gap - December 2003 |
76.6% |
84.7% |
81.6% |
93.2% |
75.9% |
85.7% |
82.5% |
81.5% |
|
Percentage point change |
||||||||
|
Percentage point change from |
4.8% |
1.8% |
4.7% |
6.1% |
5.7% |
12.8% |
37.1% |
4.6% |
|
Percentage point change from |
9.2% |
-0.9% |
1.1% |
8.4% |
0.9% |
2.0% |
-2.2% |
3.9% |
|
Percentage point change from |
1.8% |
3.7% |
2.8% |
2.0% |
1.2% |
5.0% |
-1.7% |
2.4% |
|
Percentage point change from |
2.9% |
3.2% |
4.0% |
3.1% |
1.5% |
1.6% |
13.6% |
3.2% |
|
Percentage point change from |
2.7% |
2.3% |
4.2% |
1.4% |
-0.1% |
3.1% |
3.2% |
2.7% |
|
Percentage point change from |
-1.2% |
0.5% |
-1.3% |
-0.8% |
-1.2% |
-0.3% |
3.1% |
-0.7% |
|
Percentage point change from |
1.5% |
1.5% |
3.6% |
-1.2% |
1.0% |
7.7% |
2.5% |
1.9% |
|
Percentage point change from |
0.8% |
2.1% |
0.3% |
2.9% |
0.8% |
0.4% |
0.5% |
1.2% |
|
Percentage point change from |
0.9% |
0.3% |
1.4% |
2.3% |
0.3% |
1.4% |
0.6% |
0.9% |
|
Percentage point change from |
1.4% |
0.6% |
0.3% |
0.0% |
2.5% |
-0.4% |
1.4% |
0.7% |
|
Percentage point change from |
0.9% |
0.0% |
2.1% |
0.3% |
-8.2% |
1.6% |
0.1% |
0.1% |
|
Percentage point change from |
0.8% |
0.8% |
0.7% |
-0.2% |
0.7% |
0.2% |
1.5% |
0.7% |
|
Percentage point change from September 2003 to December 2003 |
-0.4% |
-0.6% |
0.1% |
0.1% |
-0.1% |
-0.3% |
-0.1% |
-0.3% |
Note: The percentage point change will always reflect the actual un-rounded change in the proportion of medical services with no gap. There may be a slight discrepancy when calculating the change from the published (rounded) figures.
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 $18.09 in the December quarter 2003, including services where there was no gap. This was an increase compared to the September quarter 2003 gap which was $17.39.
The average payment by patients for services where there remained an out-of-pocket cost for the patient was $97.61 in the December 2003 quarter compared to $95.54 in the September 2003 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 2003 saw a decrease of 0.1 percentage points in the proportion of medical services with a known medical gap, from 5.0% to 4.9%.
Figure 4 summarises no gap services and average gap payments by state from December 2000 to December 2003.
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Topics in this section
Statistical Trends in Membership and Benefits
Annual Report - Operations of the Private Health Insurers