Industry Statistics

Medical Services Statistics - March 2008 Quarter

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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.

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.

Definitions used in this report

Agreement means an agreement entered into between a medical practitioner, within the meaning of that term in subsection 3 (1) of the Health Insurance Act 1973, and an insurer, under which the practitioner agrees to accept payment by the insurer in satisfaction of the amount that would, apart from the agreement, be owed to the practitioner in relation to the treatment provided to the insured person
No gap agreement means an agreement where the medical practitioner agrees to accept a payment by the insurer in full satisfaction of the amount owed so that there is no gap, or no out of pocket expenses to be paid by the insured person.
Known gap agreement means an agreement where the medical practitioner agrees to accept a payment by the insurer in part satisfaction of the amount owed and the patient has provided informed financial consent so that the gap or out of pocket expense to be paid by the insured person is known in advance.
No agreement is where there is no agreement in place.
Amount charged is the invoiced amount or the amount accepted in full payment (if known).
Medicare benefit is the amount calculated by reference to the fees for medical services set out in the table of schedule fees.
Fund benefit is the amount the fund pays in full or part satisfaction of the amount owed to the provider in excess of the Medicare benefit.
Gap is the amount paid by the insured person, or their out of pocket expense, and is calculated as: (Amount charged) – (Medicare benefit) – (Fund benefit) = Gap. Negative gap is due to adjustments from the previous quarters. Gap shown where there should be no gap is due to rounding of components

No gap services

The proportion of in-hospital medical services for which there was no gap decreased in the March 2008 quarter by 0.6 percentage points to 84.0%.

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 March 2008 quarter, 4,457,594 in-hospital medical services (representing 84.0% of the total) were provided to patients with no out-of-pocket costs. This is a decrease of 0.6 percentage points from the December 2007 quarter figure of 84.6%. There was an increase in the proportion of services with a known gap, from 4.3% in December 2007 to 4.9% in March 2008.

Figure 1: Proportion of in-hospital medical services with no gap, Australia

Changes over the quarter in each state should be reviewed with caution following the changes in reporting in the June 2007 quarter. From the June 2007 quarter for the first time all insurers are required to report in every state. Previously, insurers with small coverage in a state reported that state’s data in their major state.

The percent of services with no gap in the March 2008 quarter varies from 74.3% in Western Australia to 89.1% in Tasmania.

There were decreases in the percent of services with no gap in all states except for Western Australia and Tasmania.

The proportion of in-hospital services with no gap and the changes over the quarters are shown in Figure 2, and graphed in Figure 3.

Figure 2: In hospital services with no gaps March 2005 to March 2008 and percentage point changes

Proportion of services with no medical gap	NSW/ACT	Vic	Qld	SA	WA	Tas	NT	Australia
March 2005	77.8%	82.8%	79.8%	88.1%	78.1%	81.8%	75.6%	80.6%
June 2005	78.1%	83.0%	80.0%	88.4%	78.3%	88.4%	75.8%	80.9%
September 2005	79.2%	84.4%	82.1%	89.1%	75.8%	87.4%	74.3%	82.0%
December 2005	80.1%	85.1%	82.8%	89.0%	76.5%	88.1%	76.8%	82.7%
March 2006	80.6%	84.9%	82.3%	89.5%	76.0%	88.6%	77.6%	82.6%
June 2006	80.5%	85.7%	83.1%	88.9%	75.8%	87.4%	76.7%	83.0%
September 2006	80.9%	86.5%	81.7%	89.7%	76.1%	88.6%	75.3%	83.1%
December 2006	80.3%	86.7%	81.4%	89.9%	76.1%	86.3%	75.5%	82.9%
March 2007	80.8%	86.4%	82.6%	88.0%	72.6%	87.6%	72.3%	82.7%
June 2007	79.9%	87.0%	81.9%	84.4%	73.3%	87.7%	75.5%	82.2%
September 2007	81.3%	88.0%	84.5%	84.8%	74.2%	86.3%	74.9%	83.6%
December 2007	82.6%	88.3%	84.7%	90.7%	73.0%	88.8%	78.0%	84.6%
March 2008	82.2%	87.4%	84.6%	87.9%	74.3%	89.1%	77.7%	84.0%
Percentage point change	NSW/ACT	Vic	Qld	SA	WA	Tas	NT	Australia
From March 2006 to June 2006	-0.2%	0.7%	0.7%	-0.6%	-0.2%	-1.2%	-0.9%	0.3%
From June 2006 to September 2006	0.4%	0.8%	-1.4%	0.8%	0.3%	1.3%	-1.4%	0.2%
From September 2006 to December 2006	-0.6%	0.2%	-0.3%	0.2%	0.0%	-2.3%	0.2%	-0.2%
From December 2006 to March 2007	0.6%	-0.3%	1.2%	-1.9%	-3.5%	1.3%	-3.3%	-0.2%
From March 2007 to June 2007	-0.9%	0.6%	-0.7%	-3.6%	0.7%	0.1%	3.3%	-0.6%
From June 2007 to September 2007	1.4%	1.1%	2.6%	0.4%	0.9%	-1.5%	-0.6%	1.5%
From September 2007 to December 2007	1.3%	0.2%	0.2%	5.9%	-1.2%	2.5%	3.1%	1.0%
From December 2007 to March 2008	-0.5%	-0.9%	-0.2%	-2.7%	1.3%	0.3%	-0.2%	-0.6%

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 $22.01 in the March 2008 quarter, including services where there was no gap. This was an increase from the December 2007 quarter gap which was $21.78.

• The average payment by patients for services where there remained an out-of-pocket cost for the patient was $137.60 in the March 2008 quarter compared to $141.55 in the December 2007 quarter .

• The March 2008 quarter saw an increase in the proportion of medical services with a known medical gap. The proportion of medical services with a known medical gap was 4.9% in the March 2008 quarter compared to 4.3% in the December 2007 quarter .

• Figure 4 summarises no gap services and average gap payments by state from March 2007 to March 2008.