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Outcome 4 - Individual Health Benefits

Individual Health Benefits

Access to cost-effective medicines, medical, dental and hearing services, and improved choice in health services, including through the Pharmaceutical Benefits Scheme, Medicare, targeted assistance strategies and private health insurance

Highlights

 Continuous glucose monitoring (CGM) initiative expansion. The CGM initiative was expanded to include three additional patient cohorts with over $277 million being allocated over four years. As a result of the expanded eligibility criteria from 1 March 2019 to 30 June 2019, an additional 1,843 people have participated in the scheme. Program 4.8.
 Gold, Silver, Bronze and Basic tiers for hospital products were introduced to simplify private health insurance for consumers. Over 5,200 products on the PBS. 14,089 eligible breast prostheses reimbursement claims were processed. 13.6 million Australians have private health insurance.

Programs contributing to Outcome 4

Summary of results against

performance criteria

Program

Targets met

Targets substantially met

Targets not met

Data not available

Program 4.1: Medical Benefits

5

-

-

-

Program 4.2: Hearing Services

-

1

-

-

Program 4.3: Pharmaceutical Benefits

11

1

-

-

Program 4.4: Private Health Insurance

2

-

-

-

Program 4.5: Medical Indemnity

2

-

-

Program 4.6: Dental Services

-

-

-

1

Program 4.7: Health Benefit Compliance

1

-

-

-

Program 4.8: Targeted Assistance – Aids and Appliances

3

-

-

-

Total

24

2

-

1

Program 4.1: Medical Benefits

The Department met all performance targets related to this program.

The Department supported the Government to provide access to a modern, high-quality Medicare system based on current clinical evidence. This includes the continuation of the review of the Medicare Benefits Schedule (MBS) by the clinician-led MBS Review Taskforce. The review is delivering an MBS that aligns with evidence-based and contemporary clinical practice. The resulting modernised MBS delivers both net savings for Government that are being reinvested in Medicare and better health outcomes for patients by recognising new and often more effective and efficient health technology and high value care.

The Department continued to support the Government to operate targeted assistance programs for Australians who require life saving treatment not available in Australia, and allow Australian residents to receive help with the cost of essential medical treatment while travelling within an eligible Reciprocal Health Care Agreement (RHCA) country. Assistance was also provided to women who have undergone a mastectomy as a result of breast cancer through the Breast Prostheses Reimbursement Program.

The Disaster Health Care Assistance Scheme provided assistance with health costs for Australians who have been affected by natural disasters overseas including drought, bushfires and floods.

In 2018-19, the Department supported the National Pathology Accreditation Advisory Council to develop five revised pathology accreditation standards. These reflect current best practice and continue to ensure Australians have access to high quality pathology services through the National Pathology Accreditation Program.

Ensuring continued access to a Medicare system that provides modern, high quality and cost-effective professional health services that are in line with current clinical evidence

Continued review of Medicare Benefits Schedule (MBS) items to maintain a Medicare system that provides high value care to the Australian public based on contemporary evidence and practice.

Source: 2018-19 Health Portfolio Budget Statements, p.98 and Health Corporate Plan 2018-19, p.6

2018-19 Target

2018-19 Result

Clinical Committees will have considered 95% or more of the MBS items.

Implementation of all Government responses to Review recommendations agreed in 2018-19 will be either underway or complete.

The MBS Review Taskforce has completed its initial consideration of 100% of the more than 5,700 existing MBS items and has prepared more than 60 reports for consultation.

Implementation is underway of Government responses to review recommendations agreed in 2018-19.

Result: Met

While the MBS Review Taskforce has completed its initial consideration of the more than 5,700 existing items and prepared over 60 reports, a number of these reports will be the subject of stakeholder consultation throughout 2019-20, prior to being finalised for Government consideration.

Stakeholder engagement is critical to the success of the Review, ensuring risks associated with implementation of recommendations can be identified and mitigated.

The Australian Government has announced its response to a number of MBS Review recommendations that impact on rural and regional Australians. From 1 November 2018, a new MBS item was introduced to enable nurses, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers to provide dialysis in very remote areas. This directly benefits Aboriginal and Torres Strait Islander Australians who previously had to travel to receive treatment.

Providing targeted financial assistance, including to Australians who require life-saving medical treatment not available in Australia, and access to breast prostheses for women who have had breast cancer

Provide financial assistance to Australians for appropriate medical treatment not available in Australia or for out-of-pocket health care costs as a result of specific overseas disasters.

Source: 2018-19 Health Portfolio Budget Statements, p.99

2018-19 Target

2018-19 Result

Applications for financial assistance for medical treatment overseas are assessed in accordance with program guidelines.

Ensure that payments to affected individuals for out-of-pocket healthcare costs arising from specified international adverse events are provided in an effective manner.

All applications for financial assistance for medical treatment overseas were assessed in accordance with the established program guidelines, with financial assistance provided to eligible applicants.

Visitors from countries with RHCAs received necessary treatment and no significant issues were encountered when accessing public health care.

The Department continued to provide policy advice to the Department of Human Services, ensuring health care assistance was provided to eligible Australians.

Result: Met

The Medical Treatment Overseas Program (MTOP) and the Disaster Health Care Assistance Schemes are demand-driven programs. Eligible people receive reimbursement for out-of-pocket health care expenses related to any injury or illness that has resulted from one of the incidents covered by the Schemes.

The Australian Government has RHCAs with New Zealand, United Kingdom, Republic of Ireland, Sweden, the Netherlands, Finland, Italy, Belgium, Malta, Slovenia and Norway.

In 2018-19, the Department received 46 applications for financial assistance under the MTOP. A total of 32 individuals requiring care received MTOP funding to undergo treatment overseas. These applicants were supported by independent expert advice from relevant medical professionals and specialists.

In 2018-19, MBS services were provided in a timely manner to visitors to Australia under the RHCAs.

Improving the quality of life of women who have undergone a mastectomy as a result of breast cancer, through efficient processing of claims from eligible women under the National External Breast Prostheses Reimbursement Program.

a. Claims processed within ten days of lodgement.

Source: 2018-19 Health Portfolio Budget Statements, p.99

2018-19 Target

2018-19 Result

2017-18

2016-17

2015-16

2014-15

≥90%

92%1

97%

95%

98%

98%

Result: Met

Of the 14,089 eligible claims made under the Breast Prostheses Reimbursement Program, 92 per cent were processed within 10 business days of lodgement.

Timely processing of claims under this program benefits recipients through the provision of reimbursement for the cost of their prostheses.

Supporting safe and effective diagnostic imaging and pathology services

Mitigate potential risks to patient safety and improve quality pathology services through maintaining a consistent and contemporary accreditation framework that underpins all Medicare eligible pathology services.

Source: 2018-19 Health Portfolio Budget Statements, p.99

2018-19 Target

2018-19 Result

Ensure consumers have continued access to up-to-date, quality pathology services through reviewing and updating the Australian Pathology Accreditation Framework, as required.

The Department ensured consumers had continued access to safe and quality pathology services through contemporary quality standards.

Five revised pathology accreditation standards were endorsed.

Result: Met

The Department supported the National Pathology Accreditation Advisory Council (NPAAC) to deliver its work program focused on the development and maintenance of contemporary quality standards for pathology laboratories. These standards provide minimum best practice for pathology laboratories.

Five revised pathology accreditation standards were endorsed by the NPAAC and were referenced as legislated pathology accreditation standards for pathology laboratories.

Supporting the delivery of high quality radiation oncology services

Ensure Australians have access to high quality radiotherapy services through the Radiation Oncology Health Program Grant Scheme.

Source: 2018-19 Health Portfolio Budget Statements, p.100

2018-19 Target

2018-19 Result

Provide targeted financial contributions to the capital cost of radiation oncology linear accelerators2 located in priority areas as agreed between the Commonwealth and relevant States and Territories.

In 2018-19, the Department provided targeted financial contributions, with an increase of six approved facilities.

Presently there are only two states with self-identified priority areas, being Western Australia and South Australia.

Result: Met

In 2018-19, there was an increase of six approved facilities since 2017-18, with a total of 102 approved radiotherapy facilities funded under the Radiation Oncology Health Program Grant scheme.

Program 4.2: Hearing Services

The Department substantially met the performance target related to this program.

The Hearing Services Program provides eligible Australians with a range of hearing services to help manage their hearing loss and improve their engagement with the community. In turn, this benefits their families, society and the economy.

During 2018-19, a thematic review of the Hearing Services Program legislation was completed in consultation with consumer and hearing industry stakeholders to ensure the efficient and fit for purpose legislation. The Department also engaged with consumers, providers and industry to establish the Hearing Health Sector Committee and supported the Committee to develop the Hearing Health Roadmap, setting out future directions and priorities.

The Department worked collaboratively with the National Disability Insurance Agency to develop and implement a strategy for transition of Community Service Obligation clients from the Hearing Services Program and the National Disability Insurance Scheme.

An online hearing screening tool for all Australian school aged children was provided by funding licenses for the use of SoundscoutsTM from 2018-19 to 2021-22.

In 2018-19, research into hearing health, rehabilitation and prevention activities was supported through funding of the National Acoustics Laboratories.

Supporting access to high quality hearing services and research into hearing loss prevention and management

Support access to high quality hearing services through the voucher and Community Service Obligations components of the Hearing Services Program.

Source: 2018-19 Health Portfolio Budget Statements, p.101

2018-19 Target

2018-19 Result

2017-18

2016-17

2015-16

2014-15

811,000 clients

796,000 clients3

733,400
voucher clients

713,182 voucher clients

692,283 voucher clients

669,793 voucher clients

Result: Substantially Met

Through the voucher and Community Service Obligations components of the Hearing Services Program, 1.58 million hearing services were delivered to 796,000 clients in 2018-19.

Program 4.3: Pharmaceutical Benefits

The Department met or substantially met all performance targets related to this program.

The Department works with the Government to provide reliable, timely and affordable access to cost-effective, high quality medicines and pharmaceutical services, which is key to improving the health of all Australians.

In 2018-19, the Department supported the Government to strengthen the Pharmaceutical Benefits Scheme (PBS) to ensure it remains affordable into the future through implementation of strategic agreements with the medicines industry.

The Department supported the Government to continue to ensure that patients with life threatening conditions had access to essential medicines through the Life Saving Drugs Program (LSDP) and supported access to PBS-funded medicines and medicines data. The Department also supported the Pharmaceutical Benefits Advisory Committee (PBAC) to ensure new medicines are considered for listing on the PBS in a timely manner. This ensures the Australian public has access to new and affordable innovative medicines.

Providing access to new and existing medicines for patients with life threatening conditions

Ensure new eligible patients have access to the Life Saving Drugs Program.

Source: 2018-19 Health Portfolio Budget Statements, p.104

2018-19 Target

2018-19 Result

New patient applications are processed within 30 calendar days of receipt.

In total 95% of all new completed patient applications for new patients were processed within 30 calendar days of receipt.

Result: Met

The LSDP processed new applications in accordance with the LSDP guidelines4.

Ensure continued access to eligible patients to medicines under the Life Saving Drugs Program.

Source: 2018-19 Health Portfolio Budget Statements, p.104

2018-19 Target

2018-19 Result

Facilitate continued eligible patient access to life saving medicines.

The Department facilitated access to life saving medicines for all eligible patients.

Result: Met

The LSDP provides fully subsidised access for eligible patients to expensive and life saving medicines for rare and life threatening medical conditions. Eligible patients had timely access to subsidised treatment.

There are currently 16 drugs funded on the LSDP (three new drugs listed in 2018-19), at no cost to patients. The new drugs cerliponase alfa and migalastat were made available to provide treatment to Australian patients who have rare medical conditions known as Batten disease and Fabry disease. A new brand and a new strength of nitisinone, Nityr, was also made available to provide life saving treatment to Australian patients with Hereditary Tyrosinaemia Type 1 (HT-1). As at 30 June 2019, there were 434 patients being treated on the LSDP.

Ensuring access to cost-effective, innovative, clinically effective medicines through the Pharmaceutical Benefits Scheme

Percentage of submissions for new medicines that are recommended for listing by Pharmaceutical Benefits Advisory Committee, that are listed on the Pharmaceutical Benefits Scheme within six months of agreement of budget impact and price.

Source: 2018-19 Health Portfolio Budget Statements, p.104 and Health Corporate Plan 2018–19, p.6

2018-19 Target

2018-19 Result

2017-18

2016-17

2015-16

2014-15

80%

100%

88%

85%

92%

N/A

Result: Met

Negotiations with product sponsors and listing activities for new listings of medicines on the PBS were completed in a timely manner, with 100 per cent being listed on the PBS within six months of agreement on price and cost to Government.

The Department uses this metric because agreement must be reached with a sponsor on price and budget impact before a listing can be finalised by Government. Discussions regarding the finalisation of price and budget impact following the PBAC recommendation are often complex and in limited circumstances may require further PBAC consideration.

Case Study
Improving access to medicines – Pharmaceutical Benefits Scheme (PBS) process improvements

During 2018-19, the Department collaboratively developed and, on 1 July 2019, implemented improvements to PBS listing processes. These process improvements delivered the first stage of the Government’s commitment under the Strategic Agreement with Medicines Australia to improve the efficiency, transparency and timeliness of the PBS listing process. The first stage included changes to pre-submission meetings, introduction of a mandatory intent to apply step and introduction of new pricing pathways following a positive Pharmaceutical Benefits Advisory Committee (PBAC) recommendation.

These process improvements aim to facilitate increased patient access to medicines on the PBS by providing industry with improved guidance and support for submissions to the PBAC, ensuring submissions can be considered by the PBAC in a timely way and by providing industry with transparency and greater clarity on the post PBAC process for listing a medicine on the PBS.

Simultaneously, the PBS cost recovery arrangements were updated to better reflect the real costs and activities associated with PBS processes and to align the arrangements with the current Australian Government Charging Framework. The Australian Government provided $64 million over four years to progress reforms to the listing of subsidised medicines for Australian patients.

Additional work and consumer consultation on improvements to processes and transparency are underway, with further changes expected to commence from 1 July 2020.

This image depicts a pharmacist consulting with a consumer inside a pharmacy.


Supporting timely access to medicines and pharmacy services

Deliver an increased suite of reporting and data related to pharmacy and Pharmaceutical Benefits Scheme (PBS) funded medicine access and cost made available to Parliament, consumers and business.

Source: 2018-19 Health Portfolio Budget Statements, p.105

2018-19 Target

2018-19 Result

Periodically increase the volume and nature of data on the Department of Health website.

During 2018-19, six additional reports of medicine utilisation reviews undertaken by the Drug Utilisation Sub Committee (DUSC)5 of the PBAC were made available on the Department’s website.

Expenditure and Prescriptions twelve months to 30 June 2018 report was published6 and made available on the Department’s website.

Result: Met

Each month, more information in relation to the volume and type of medicines dispensed in pharmacies is released on the PBS website. Businesses, pharmaceutical industry stakeholders and researchers use this information to create a better understanding of pharmacy and the pharmaceutical sector in Australia.

The Department now reports prescription information based on the date of supply of the PBS medicine, as opposed to the date at which a prescription was processed for payment. In addition, a number of tables in the annual Expenditure and Prescriptions Report now include Section 100 data7, which were not previously publicly available.

Percentage of Urban Centres8 in Australia with a population of 1,000 persons or more with an approved supplier9 of Pharmaceutical Benefits Scheme medicines.

Source: 2018-19 Health Portfolio Budget Statements, p.105

2018-19 Target

2018-19 Result

2017-18

2016-17

2015-16

2014-15

>90%

91.13%

90.56%

91.96%

91.8%

N/A

Result: Met

Ongoing monitoring of PBS approved suppliers in Urban Centres helps to ensure suppliers are being approved in appropriate locations.

Percentage of Urban Centres in Australia with a population of 1,000 persons or more with a resident service provider of, or recipient of, Medscheck, Home Medicines Review, Residential Medication Management Review or Clinical Intervention.

Source: 2018-19 Health Portfolio Budget Statements, p.105

2018-19 Target

2018-19 Result

2017-18

2016-17

2015-16

2014-15

>80%

87.9%

89.1%

90%

97%

N/A

Result: Met

In 2018-19, 87.9 per cent of Urban Centres with a population of 1,000 persons or more had access to medication management advice and reviews when needed. These activities support the quality use of medicines and aim to reduce medicine related problems.

Percentage of subsidised Pharmaceutical Benefits Scheme units delivered to community pharmacy within agreed requirements of the Community Service Obligation.

Source: 2018-19 Health Portfolio Budget Statements, p.105

2018-19 Target

2018-19 Result

2017-18

2016-17

2015-16

2014-15

>95%

98.2%

98.4%

97.5%

96%

N/A

Result: Met

The aim of the Community Service Obligation (CSO) is to ensure there are arrangements in place for all Australians to have access to the full range of PBS medicines via their community pharmacy, regardless of where they live and usually within 24 hours. Payment is provided to eligible CSO Distributors who meet agreed compliance requirements and service standards that underpin the CSO arrangements.

In 2018-19, the Department conducted an Approach to Market to appoint eligible wholesalers to support implementation of the CSO arrangements. This Approach to Market appointed four national wholesalers and two state-based wholesalers, which will ensure continuity of CSO arrangements and support timely and affordable access to PBS medicines for all Australians.

Maintaining the effectiveness of the Pharmaceutical Benefits Scheme through monitoring and post-market surveillance

Post-market reviews deliver relevant and high quality advice to the Pharmaceutical Benefits Advisory Committee (PBAC) and Government.

Source: 2018-19 Health Portfolio Budget Statements, p.106

2018-19 Target

2018-19 Result

Established working groups will engage with professional and community stakeholders to conduct reviews on:

  • chronic plaque psoriasis (CPP); and
  • pulmonary arterial hypertension (PAH) medicines.

Commence new post-market reviews and research projects recommended by PBAC.

Established reference groups continued to engage constructively with professional and community stakeholders to conduct post-market reviews on:

  • the use of biologics in the treatment of CPP; and
  • PAH medicines.

Research projects were undertaken on:

  • proton pump inhibitor (PPI) medicines for gastric disorders; and
  • 5-aminosalicylic acid (5-ASA) medicines for ulcerative colitis and Crohn’s disease.

Result: Met

For each review, the reference group included members with clinical and technical expertise, industry representatives and consumer advocates to ensure relevant and high quality advice was provided. Reference Group members provided input through meetings, teleconferences and emails.

A PAH stakeholder meeting was held in June 2019 to provide advice to the PBAC on PBS restrictions for dual combination PAH medicine therapy.

Pharmaceutical sponsors and clinical experts provided input to the research report on the PPI project and the 5-ASA research project prior to consideration by the PBAC. This promoted transparency and ensured the PBAC was provided with any additional information on the clinical use of these medicines.

PBAC-agreed PBS restriction changes to PBS listed biologics for CPP and PPIs were implemented on 1 May 2019 and revised PBS restrictions to treat PAH were agreed for implementation.

Percentage of post-market reviews completed within scheduled timeframes.

Source: 2018-18 Health Portfolio Budget Statements, p.106

2018-19 Target

2018-19 Result

2017-18

2016-17

2015-16

2014-15

90%

96%

94%

100%

100%

N/A

Result: Met

In 2018-19, two post-market reviews were progressed:

  • the use of biologics in the treatment of severe CPP; and
  • medicines for PAH.

Reports on the two reviews were completed in 2018-19 and considered by the PBAC. The Department continues to progress and implement the PBAC’s recommendations from both reviews.

Percentage of Government-accepted recommendations from post-market reviews that have been implemented within agreed timeframes.

Source: 2018-19 Health Portfolio Budget Statements, p.106

2018-19 Target

2018-19 Result

2017-18

2016-17

2015-16

2014-15

>80%

94%

100%

85%

80%

N/A

Result: Met

In response to the post-market review of the use of biologics in the treatment of severe CPP, the PBAC recommended a full cost-effectiveness review of biologics for CPP, as well as a change to the Pharmaceutical Benefits Scheme (PBS) restriction. The PBS restriction change was implemented on 1 May 2019 and the cost-effectiveness review is in progress.

In response to the post-market review of PAH medicines, the PBAC recommended changes to PBS restrictions to allow earlier patient access to certain PAH medicines, extend subsidies to include all types of World Health Organization Group 1 PAH conditions and improve alignment of restrictions with treatment guidelines.

The PBAC requested stakeholder meetings were held to progress PBS restrictions for PAH combination therapy. The PBAC also recommended a review of the guidelines for approving PAH Designated Treatment Centres.

Information regarding quality use of medicines is provided to health professionals and consumers to support use of therapeutics wisely, judiciously and safely to achieve better health and economic outcomes.

Source: 2018-19 Health Portfolio Budget Statements, p.107

2018-19 Target

2018-19 Result

The Government will continue to provide funding for the provision of quality use of medicines information to be available in a variety of formats throughout the year, designed to support health professionals and consumers.

The scope of activities provided through NPS will be reviewed.

In 2018-19, the Department continued delivery of funding to improve the quality use of medicines for health professionals and consumers.

The Review of NPS MedicineWise’s delivery of the Quality Use of Medicines Program was completed during the year and provided to Government for consideration early in 2019-20.

Result: Met

NPS MedicineWise has provided quality use of medicines information to health professionals in the form of educational visits, online modules, resources and publications. Targeted consumer information campaigns included antibiotic awareness and a range of other targeted topics. NPS MedicineWise continued to deliver the Choosing Wisely Australia initiative, publish Australian Prescriber and evaluate NPS MedicineWise programs.

As a part of the Review of NPS MedicineWise’s delivery of the Quality Use of Medicines Program, over 50 public submissions were received. These consultations assisted in forming recommendations to improve NPS MedicineWise’s performance in implementing the grant program. The recommendations focus on governance, transparency, accountability, delivery of programs and evaluation methodology.

Percentage of eligible medicines assessed in accordance with PBS price disclosure requirements.

Source: 2018-19 Health Portfolio Budget Statements, p.107

2018-19 Target

2018-19 Result

2017-18

2016-17

2015-16

2014-15

100%

100%

N/A

N/A

N/A

N/A

Result: Met

As a part of price disclosure requirements, medicines with multiple brands are assessed.

Program 4.4: Private Health Insurance

The Department met all performance targets related to this program.

The Department assists the Government to promote affordable, quality private health insurance and to provide greater choice to around 13.6 million Australians who hold some form of private health insurance cover.

In 2018-19, the Department supported the Government and industry to deliver private health insurance reforms to improve the sustainability of the health system as a whole, simplify private health insurance and to contribute to lower the annual premium increase. Legislation to support the reforms commenced in October 2018, enabling the private health insurance industry to implement most reforms from 1 April 2019.

The Department works to increase access to clinically effective and cost-effective prostheses. Through the agreement between the Government and the Medical Technology Association of Australia (MTAA), privately insured Australians have improved access to breakthrough medical technology and affordable medical devices.

The Department continues to work on the listing arrangements for medical devices on the Prostheses List to provide access for privately insured patients to clinically effective technology that has been assessed as cost-effective.

Supporting a viable, sustainable and cost-effective private health insurance sector, including through the private health insurance rebate

Support the provision of more affordable and simpler private health insurance for all Australians.

Source: 2018-19 Health Portfolio Budget Statements, p.108

2018-19 Target

2018-19 Result

Support private health insurers to implement the remaining private health insurance reforms from 1 April 2019.

Lower annual premium changes across the sector as a direct result of the reforms.

Undertake regular stakeholder communications with insurers and other regulatory agencies to provide two-way dissemination of information.

In December 2018 the private health insurance reforms contributed to delivering the lowest annual premium change in 18 years, at 3.25%.

By 1 April 2019, there had been widespread adoption of voluntary private health insurance reforms by private health insurers, including age based discounts, increased voluntary excesses and travel and accommodation benefits.

The Department undertook regular communication with insurers, private hospitals, consumers, clinicians and regulatory agencies in the development of legislative changes and implementation of the reforms. The Department also involved these groups in the development and delivery of a communications campaign for consumers, general practitioners and medical specialists about the changes.

Result: Met

Legislation to support the reforms commenced in October 2018, enabling the private health insurance industry to successfully implement the changes from 1 April 2019. The Department communicated with key stakeholders to ensure successful implementation of the reforms.

The 2018-19 Portfolio Additional Estimates Statements10 included funding of $5 million for the delivery of a private health insurance reform information campaign. The campaign, which launched in February 2019, was developed with input from stakeholders.

Insurers have a 12-month period, by 1 April 2020, to transition all hospital products into Gold, Silver, Bronze and Basic tiers and apply standard clinical categories. They are on track to meet this requirement. The Department also successfully took over the responsibility for assessing private hospital second tier default benefit eligibility from an industry based committee.

The Department, assisted by the Australian Prudential Regulation Authority, supported the Minister for Health in his consideration of private health insurers 2019 premium change applications.

On 19 December 2018, the Minister announced his approval of an average premium change of 3.25 per cent to take effect from 1 April 2019.

Case Study
Private health insurance reforms – making private health insurance simpler for everyone

Although more than half of the Australian population currently has private health insurance, many people still find buying health cover confusing. That’s why the Australian Government, supported by the Department of Health, introduced reforms to make private health insurance more affordable, easier to understand and simpler to choose.

Commencing 1 April 2019, private health insurers have begun classifying private hospital cover into four tiers, Gold, Silver, Bronze and Basic, so consumers can easily see what’s included when choosing cover. Health insurers have until 1 April 2020 to transition their products into the tiers.

Insurers are now able to offer discounts to young people aged 18–29, travel and accommodation benefits to those who need to travel long distances for hospital treatment and higher excesses in exchange for lower premiums. Changes have been made to improve access to mental health treatment by allowing consumers to upgrade their hospital cover without re-serving a waiting period. Additionally, the Private Health Insurance Ombudsman has new powers to investigate complaints and other issues.

A national consumer information campaign was launched on 17 February 2019 to help people better understand what the reforms mean for them. Advertising featured across radio, newspapers, digital channels and general practitioner clinics. Independent evaluation research has found that six in ten policy holders and those considering private health insurance are now aware of the reforms.

The private health insurance reforms deliver a range of benefits to all Australians, including greater clarity and choice when selecting the right cover, greater affordability and better cover and support for people with mental health conditions or those living in rural and remote areas.

 Private health insurance made simpler.

Ensure privately insured patients have access to clinically and cost-effective prostheses under the Private Health Insurance Act 2007.

Source: 2018-19 Health Portfolio Budget Statements, p.109

2018-19 Target

2018-19 Result

Support the Prostheses List Advisory Committee to reform the Prostheses List arrangements.

Publish the Prostheses List enabling access to devices for privately insured patients.

The Department supported the Prostheses List Advisory Committee to reform Prostheses List arrangements.

The Prostheses List was updated in August 2018 and March 2019.

Result: Met

A key outcome of the reforms to date has been the listing of cardiac ablation catheters for atrial fibrillation. In addition, the reform work focused on refining the assessment of medical devices to ensure evidence-based clinical outcomes and cost-effectiveness for the health system.

Program 4.5: Medical Indemnity

The Department met all performance targets related to this program.

The Department supports the Government to deliver a number of schemes that provide stability to the medical insurance industry, and ensure medical indemnity insurance products are both available and affordable. Medical indemnity insurance provides financial protection to privately practicing medical practitioners, private midwives and patients.

The Premium Support Scheme supports doctors and eligible midwives to reduce the cost of medical indemnity insurance through a government-funded subsidy assisting to keep medical care accessible and affordable to the community.

In 2018-19, the Department worked with industry stakeholders on recommendations which arose from the First Principles Review. This included working with key practitioner groups and medical indemnity insurers on developing legislation in response to the Government’s 2018-19 Mid-Year Economic and Fiscal Outlook decision to improve the seven schemes that support privately practising practitioners to afford professional indemnity insurance.

Ensuring the ongoing stability of the medical insurance industry and that insurance products are available and affordable

Enable continued availability of professional indemnity insurance for eligible midwives.

Source: 2018-19 Health Portfolio Budget Statements, p.110

2018-19 Target

2018-19 Result

Maintain a contract with an indemnity provider for the provision of professional indemnity insurance to eligible midwives.

A contract has been maintained with a medical indemnity provider for the provision of professional indemnity insurance to eligible midwives.

Result: Met

Eligible midwives were able to purchase Commonwealth supported professional indemnity insurance from Medical Insurance Group Australia.

Maintain or reduce the number of doctors who require support through the Premium Support Scheme.11

Source: 2018-19 Health Portfolio Budget Statements, p.110

2018-19 Target

2018-19 Result

2017-18

2016-17

2015-16

2014-15

<1,400

1,004

985

1,268

1,237

1,400

Result: Met

Eligible doctors receive a subsidy towards the cost of their medical indemnity insurance, assisting to keep medical care accessible and affordable to the community.

Program 4.6: Dental Services

Data sets were not available at the time of publishing for the performance target related to this program.

The Child Dental Benefits Schedule continued to support Australian children’s dental health and access to essential dental services. It is a demand-driven, calendar year program, providing access to basic dental services for eligible children aged 2–17 years.

Through an extension to the existing National Partnership Agreement on Public Dental Services with states and territories, adult public dental patients will have improved access to dental services.

Improving access to dental services

Support eligible children to access essential dental health services through the Child Dental Benefits Schedule (CDBS).

a. Percentage of eligible children accessing the CDBS.

Source: 2018-19 Health Portfolio Budget Statements, p.111

2019 Target

2019 Result

2018

2017

2016

2015

37.8%

Data not available12

38.4%

36.4%

34.6%

33.1%

Since the CDBS Program commenced in 2014 the take-up rate has continued to steadily trend upwards from 29.5 per cent of eligible patients using the CDBS in 2014 to 38.4 per cent in 2018.

Program 4.7: Health Benefit Compliance

The Department met the performance target related to this program.

Under this program, the Department ensures Medicare is serving the needs of Australian patients by protecting Australia’s health payments system. This is achieved through the prevention, identification and treatment of incorrect claiming, inappropriate practice and fraud by health care providers and suppliers. The Department also manages pathology rents regulation.

Ensuring the integrity of health provider claiming

Deliver a quality health provider compliance program that prevents non-compliance where possible and ensures audits and reviews are targeted effectively to those providers whose claiming is non-compliant, so that the following proportions of audits and reviews that are undertaken by the Department find non-compliance:

Source: 2018-19 Health Portfolio Budget Statements, p.112 and Health Corporate Plan 2018-19, p.6

2018-19 Target

2018-19 Result

2017-18

2016-17

2015-16

2014-15

>90%

>90%

N/A

N/A

N/A

N/A

Result: Met

During 2018-19, the Department delivered a quality health provider compliance program through:

  • consultation with professional bodies and stakeholder groups on compliance strategies, assisting health providers to meet their compliance obligations when claiming benefits to ensure the integrity of health provider claiming;
  • continued to strengthen and update data analytics to identify irregular claiming patterns and non-compliance;
  • employed behavioural economics-driven approaches to treat non-compliance and support appropriate practice;
  • strengthened debt recovery processes; and
  • continued to strengthen compliance approaches through investment in data analytics, investigations, provider education and debt recovery capabilities.

Program 4.8: Targeted Assistance – Aids and Appliances

The Department met all performance targets related to this program.

The National Diabetes Services Scheme (NDSS) aims to enhance the capacity of Australians with diabetes to have timely, reliable and affordable access to the supplies and services they require to effectively self-manage their condition. This includes services and products for people with type 1, type 2, gestational and other diabetes and fully-subsidised continuous glucose monitoring (CGM) products for eligible groups with type 1 diabetes, including children.

Diabetes Australia is funded by the Department to assist in the administration of the NDSS, overseeing the provision of subsidised diabetes products and delivering educational and training programs to people with diabetes, carers and related health professionals. The current Funding Agreement with Diabetes Australia runs from 1 July 2016 until 30 June 2020 and has a value of $173,055,804 (excluding GST).

In 2018-19, the Department assisted the Health Minister to continue supporting Australians managing a number of other specific health conditions, including stoma13 and Epidermolysis Bullosa14. The Stoma Appliance Scheme provides support to people with a stoma by ensuring they have timely access to stoma products through the 21 Stoma Associations. The National Epidermolysis Bullosa Dressing Scheme provided nearly 200 people with over $3 million of products to manage their condition.

Improving health outcomes through the provision of targeted assistance for aids and appliances

The National Diabetes Services Scheme (NDSS) meets the needs of registrants.15

Source: 2018-19 Health Portfolio Budget Statements, p.113

2018-19 Target

2018-19 Result

Annual NDSS registrant survey demonstrates that the needs of 70% of registrants surveyed are being met.

91% of surveyed registrants indicated that the NDSS met their needs, by improving their knowledge and

understanding of diabetes and helping them manage their condition more effectively.

Result: Met

In 2018-19, the number of people with type 1, type 2, gestational diabetes and ‘other’ diabetes who received a benefit from the NDSS was 1,309,070. There were a further 174,176 people registered on the post gestational diabetes register who were also eligible to receive services (but not products) from the NDSS. The NDSS is a demand-driven program and all eligible individuals were provided access throughout the financial year.

Surveyed registrants returned a high number of positive responses due in part to the changes implemented on 1 December 2018 that reduced co-payments on subsidised products for over 600,000 Australians.

The Department of Health works in partnership with community pharmacies to provide subsidised products to people with diabetes. Products subsidised under the NDSS include blood glucose test strips, needles and syringes, urine test strips, insulin pump consumables and continuous glucose monitoring products.

At 30 June 2019, over 95 per cent of community pharmacies across Australia were registered as NDSS Access Points. In 2018-19, over 5.7 million products, with a total value of over $183 million, were provided to Australians with diabetes.

Support children and young people under 21 years of age, with type 1 diabetes, through the National Diabetes Services Scheme.

Source: 2018-19 Health Portfolio Budget Statements, p.114

2018-19 Target

2018-19 Result

Provide eligible children and young people under 21 years of age with subsidised continuous glucose monitoring (CGM) products through the National Diabetes Services Scheme to assist in the management of their type 1 diabetes.

A total of 10,364 children and young people under 21 years of age were provided access to fully subsidised CGM consumables.

Result: Met

CGM devices assisted users with type 1 diabetes to manage their blood glucose levels and control their diabetes. The devices sound an alarm to warn the user when their blood glucose is not controlled – this functionality is particularly important for children with type 1 diabetes and their parents or carers.

Participation in the CGM Initiative has been higher than anticipated, with enrolment in the program now reaching a steady state.

As a result of the 2018-19 Mid-Year Economic Fiscal Outlook, from 1 March 2019, the Government expanded the CGM initiative to include three additional patient cohorts, with over $277 million being allocated over four years.16

The expanded CGM cohorts include:

  • children and young people with conditions very similar to type 1 diabetes, such as cystic fibrosis related diabetes and neonatal diabetes, who require insulin;
  • women with type 1 diabetes who are planning for pregnancy, pregnant, or immediately post-pregnancy; and
  • people with type 1 diabetes aged 21 years or older who have concessional status and have a high clinical need to access CGM products.

As a result of the expanded eligibility criteria from 1 March 2019 to 30 June 2019, an additional 1,843 people have participated in the scheme.

Support Australians to assist in the management of specific chronic health conditions (diabetes, stoma and Epidermolysis Bullosa).

Source: 2018-19 Health Portfolio Budget Statements, p.114

2018-19 Target

2018-19 Result

Ensure provision of subsidised aids and appliances to assist eligible Australians in the management of their chronic health conditions.

Subsidised aids and appliances were provided to eligible Australians.

Result: Met

In 2018-19, 17 new products were listed on the Stoma Appliance Scheme Schedule. Newly listed products provide people with a stoma access to alternative products to better manage their condition.

More than 200 recipients were supplied with $2.8 million worth of products under the National Epidermolysis Bullosa Dressing Scheme.

Outcome 4 - Expenses and Resources

Budget Estimate 2018-19

$’000 (A)

Actual 2018-19

$’000 (B)

Variation

$’000

(B) - (A)

Program 4.1: Medical Benefits

Administered expenses

Ordinary annual services (Appropriation Act No. 1)

117,635

113,543

(4,092)

Special account

Medicare Guarantee Fund - medical benefits

24,146,392

24,028,269

(118,123)

accrual adjustment

(36,934)

77,772

114,706

Departmental expenses

Departmental appropriation1

29,788

29,750

(38)

Expenses not requiring appropriation in the budget year2

1,077

1,423

346

Total for Program 4.1

24,257,958

24,250,757

(7,201)

Program 4.2: Hearing Services

Administered expenses

Ordinary annual services (Appropriation Act No. 1)

542,704

538,853

(3,851)

Departmental expenses

Departmental appropriation1

6,587

6,447

(140)

Expenses not requiring appropriation in the budget year2

1,775

1,933

158

Total for Program 4.2

551,066

547,233

(3,833)

Program 4.3: Pharmaceutical Benefits

Administered expenses

Ordinary annual services (Appropriation Act No. 1)

846,826

813,362

(33,464)

Special account

Medicare Guarantee Fund

- pharmaceutical benefits

12,090,202

12,001,589

(88,613)

accrual adjustment

(209,351)

(183,616)

25,735

Departmental expenses

Departmental appropriation1

50,918

55,536

4,618

Expenses not requiring appropriation in the budget year2

1,322

1,874

552

Total for Program 4.3

12,779,917

12,688,745

(91,172)

Program 4.4: Private Health Insurance

Administered expenses

Ordinary annual services (Appropriation Act No. 1)

8,224

7,953

(271)

Special appropriations

Private Health Insurance Act 2007 - incentive payments and rebate

6,170,602

6,061,727

(108,875)

Departmental expenses

Departmental appropriation1

15,035

12,804

(2,231)

Expenses not requiring appropriation in the budget year2

431

538

107

Total for Program 4.4

6,194,292

6,083,022

(111,270)

Program 4.5: Medical Indemnity

Administered expenses

Ordinary annual services (Appropriation Act No. 1)

842

265

(577)

Special appropriations

Medical Indemnity Act 2002

80,900

83,021

2,121

Midwife Professional Indemnity (Commonwealth Contribution) Scheme Act 2010

2,021

-

(2,021)

Departmental expenses

Departmental appropriation1

1,689

1,605

(84)

Expenses not requiring appropriation in the budget year2

51

69

18

Total for Program 4.5

85,503

84,960

(543)

Program 4.6: Dental Services3

Administered expenses

Ordinary annual services (Appropriation Act No. 1)

-

-

-

Special appropriations

Dental Benefits Act 2008

345,112

321,938

(23,174)

Departmental expenses

Departmental appropriation1

2,374

2,700

326

Expenses not requiring appropriation in the budget year2

77

123

46

Total for Program 4.6

347,563

324,761

(22,802)

Program 4.7: Health Benefit Compliance

Administered expenses

Ordinary annual services (Appropriation Act No. 1)

18,835

18,487

(348)

Departmental expenses

Departmental appropriation1

81,039

79,203

(1,836)

Expenses not requiring appropriation in the budget year2

2,612

3,418

806

Total for Program 4.7

102,486

101,108

(1,378)

Program 4.8: Targeted Assistance – Aids and Appliances

Administered expenses

Ordinary annual services (Appropriation Act No. 1)

1,592

1,570

(22)

Special appropriations

National Health Act 1953

- aids and appliances

374,941

350,102

(24,839)

Departmental expenses

Departmental appropriation1

4,442

4,532

90

Expenses not requiring appropriation in the budget year2

144

208

64

Total for Program 4.8

381,119

356,412

(24,707)

Outcome 4 totals by appropriation type

Administered expenses

Ordinary annual services (Appropriation Act No. 1)

1,536,658

1,494,033

(42,625)

Special appropriations

6,973,576

6,816,788

(156,788)

Special account

36,236,594

36,029,858

(206,736)

accrual adjustment

(246,285)

(105,844)

140,441

Departmental expenses

Departmental appropriation1

191,872

192,577

705

Expenses not requiring appropriation in the budget year2

7,489

9,586

2,097

Total expenses for Outcome 4

44,699,904

44,436,998

(262,906)

Average staffing level (number)

941

964

23

1 Departmental appropriation combines ‘Ordinary annual services (Appropriation Act No. 1)’ and ‘Revenue from independent sources (s74)’

2 Expenses not requiring appropriation in the budget year are made up of depreciation expense, amortisation, make good expense, operating losses and audit fees.

3 This Program excludes National Partnership payments to state and territory governments by the Treasury as part of the Federal Financial Relations (FFR) Framework.

Footnotes

  1. The decline in claim processing times is due to additional staff training and quality checking processes.
  2. The device most commonly used for external beam radiation treatments for patients with cancer.
  3. The target has been updated to include both Voucher and Community Service Obligation clients in 2018-19. The target has also been adjusted in the 2019-20 Portfolio Budget Statements to reflect change in definition.
  4. These guidelines are available at: www.health.gov.au/internet/main/publishing.nsf/Content/lsdp-criteria
  5. Further information on the DUSC reviews is available at: www.pbs.gov.au/info/industry/listing/participants/public-release-docs/du...
  6. Further information available at: www.pbs.gov.au/info/browse/statistics
  7. Further information available at: www.pbs.gov.au/info/browse/statistics
  8. Further information available in the Urban Centres and Localities and Significant Urban Areas Fact Sheet, available at: www.abs.gov.au/websitedbs/D3310114.nsf/home/ASGS+Fact+Sheets
  9. For this criterion, an approved supplier includes a pharmacy, a medical practitioner (in rural/remote locations where there is no access to a pharmacy) or an Aboriginal Health Service, approved to supply PBS medicines to the community. It does not include an approved hospital authority, approved to supply PBS medicines to its patients.
  10. Available at: www.health.gov.au/resources/publications/health-portfolio-budget-stateme...
  11. A decline in doctors accessing the Premium Support Scheme is an indication of medical indemnity insurance being affordable.
  12. Data sets for this performance measure were not available at the time of publishing. A confirmed result for the 2019 calendar year will not be available until January 2020.
  13. A stoma is a natural or surgically-created body opening, to allow bodily waste to leave the body.
  14. Epidermolysis Bullosa is a rare genetic disease that primarily affects children and is characterised by extremely fragile and blister prone skin.
  15. Registrants are people with type 1, type 2, gestational or other diabetes who are registered on the NDSS.
  16. Further information available at: www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/a-28-million-focu...