Industry Statistics
Medical gap for insured in-hospital services - June 2002 quarter
Return to Medical Gap Information Contents Page
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 June 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 June 2002 quarter. This increase follows a relatively stable March 2002 quarter and a succession of increases every quarter from June 2000 to December 2001. 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 June quarter 2002, 3,269,137 in-hospital medical services (representing 78% of the total) were provided to patients with no out-of-pocket costs. This is an increase of 2 percentage points from the March quarter 2002 figure of 76%. The proportion of services with a known gap remained stable at 4% over the quarter.
Figure 1: Proportion of in-hospital medical services with no gap, Australia
The percent of services with no gap varies from 72% in New South Wales to 88% in South Australia.
The largest increase in the June 2002 quarter was in Tasmania with an 8 percentage point increase over the March quarter. In South Australia there was a 1 percentage point drop while all other states had increases ranging from 1 to 4 percentage points.
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.
Figure 2: In-hospital services with no gaps September 2000 to June 2002, 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% |
|
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% |
|
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% |
* 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 June 2002
Gap payments
The average gap payment for all insured in-hospital medical services was $16.23 in the June 2002 quarter, including services where there was no gap. This figure is an increase over the March 2002 figure of $15.97 but follows four quarters in succession in which there has been a decrease in the average gap payment.
The average payment by patients for services where there remained an out-of-pocket cost for the patient was $74.28 in the June 2002 quarter compared to $67.38 in the March 2002 quarter and $73.49 in the December 2001 quarter.
Previous 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 June quarter saw no change in the proportion of medical services with a known medical gap, stabilising at 4%.
Figure 4 summarises no gap services and average gap payments by state from September 2000 to June 2002.
Go to page 2
Topics in this section
Statistical Trends in Membership and Benefits
Annual Report - Operations of the Private Health Insurers