Industry Statistics
Medical gap for insured in-hospital services – September quarter 2004
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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 September 2004 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 September quarter 2004 by 0.6 percentage points.
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 September quarter 2004, 3,917,630 in-hospital medical services (representing 81.8% of the total) were provided to patients with no out-of-pocket costs. This is an increase of 0.6 percentage points from the June quarter 2004 figure of 81.2%. There was a deccrease in the proportion of services with a known gap, from 5.0% in June 2004 to 4.8% in September 2004.
Figure 1: Proportion of in-hospital medical services with no gap, Australia
The percent of services with no gap varies from 76.1% in Western Australia to 93.8% in South Australia.
There were increases in the percent of services with no gap New South Wales, Queensland, South Australia and Tasmania. There were decreases in Victoria, Western Australia and the Northern Territory.
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 September 2001 to September 2004, and changes since September 2002
NSW/ACT |
Vic |
Qld |
SA |
WA |
Tas |
NT |
Australia |
|
|
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% |
|
Proportion of services with no medical gap - March 2004 |
77.4% |
85.4% |
81.3% |
93.3% |
77.3% |
85.3% |
80.3% |
82.0% |
|
Proportion of services with no medical gap - June 2004 |
77.0% |
85.3% |
80.1% |
92.7% |
76.4% |
86.8% |
78.3% |
81.2% |
|
Proportion of services with no medical gap - Sep 2004 |
78.1% |
83.9% |
81.3% |
93.8% |
76.1% |
87.6% |
76.8% |
81.8% |
|
Percentage point change |
||||||||
|
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% |
|
Percentage point change from December 2003 to March 2004 |
0.8% |
0.7% |
-0.3% |
0.1% |
1.4% |
-0.4% |
-2.1% |
0.5% |
|
Percentage point change from March 2004 to June 2004 |
-0.4% |
-1.1% |
-1.2% |
-0.6% |
-0.9% |
1.5% |
-2.0% |
-0.7% |
|
Percentage point change from June 2004 to September 2004 |
1.2% |
-0.4% |
1.3% |
1.0% |
-0.2% |
0.8% |
-1.5% |
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 $18.93 in the September quarter 2004, including services where there was no gap. This was a decrease from the June quarter 2004 gap which was $19.14.
The average payment by patients for services where there remained an out-of-pocket cost for the patient was $104.01 in the September quarter 2004 compared to $102.02 in the June quarter 2004.
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 September quarter 2004 saw a small decrease in the proportion of medical services with a known medical gap. The proportion of medical services with a known medical gap was 4.8% in the September quarter 2004 compared to 5.0% in the June quarter 2004.
Figure 4 summarises no gap services and average gap payments by state from September 2002 to September 2004.
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Topics in this section
Statistical Trends in Membership and Benefits
Annual Report - Operations of the Private Health Insurers