The Australian private health insurance sector has changed.
Whereas the sector once comprised member-owned not-for-profit mutuals, it is now dominated by large health corporations.
Australia’s largest health fund, Bupa, is an international UK based private health corporation.
Medibank Private, established by the Whitlam government in 1975 as a publicly owned health fund, is now a publicly listed health corporation.
NIB (nib), originally Newcastle Industrial Benefits (established in 1952 to provide health insurance for BHP steel workers), has been a publicly listed company since 2007.
The above 3 corporations now insure more than 60% of the Australian private health insurance market.
The dominance of these major corporations is now impacting on Australian healthcare.
The health fund lobby group Private Healthcare Australia (PHA) has published strategic plans to reduce the cost of healthcare in Australia by $100 billion over 10 years.
PHA identifies chronic illness as a major cost driver in Australian healthcare with proposals to keep people out of hospital. NIB supports the need to better manage ‘frequent flyers’ and reduce unnecessary volume.
Such measures will involve the ability to influence decisions about medical treatment that have traditionally been off-limits to healthcare financing organisations. The push to leverage doctors into health fund controlled networks is well advanced, as is the move to ensure that independent private hospitals have no ability to operate effectively outside of the health fund corporate network.
Australian healthcare has traditionally valued direct patient access and choice of GP, a clinical need based referral system to medical specialists and the ability to use both public and private hospitals.
Allowing health fund control of Australian healthcare, will undermine these foundational principles which have “achieved a successful blend of best practice approaches to provision of cost effective, equitable and high-quality healthcare for its citizens” (George Institute for Global Health)
Council of Procedural Specialists
Australian Society of Orthopaedic Surgeons, Interventional Radiology Society of Australasia, Australian Society of Anaesthetists, Australian Society of Plastic Surgeons, Australian & New Zealand Association of Oral & Maxillofacial Surgeons, Australian & New Zealand Society for Vascular Surgery, Australian Society of Ophthalmologists, Australian Association of Medical Surgical Assistants
The aim of the Council of Procedural Specialists (COPS) is to ensure the ongoing provision of the highest standards of procedural healthcare for all Australians. The Council comprises independent associations whose members have been trained in a procedural specialty.
Procedural Specialists Work as Part of a Broader Profession
The Australian medical profession is delivering world class standards of general, specialist and procedural medical treatment. In 2015-16, there were 10.6 million hospitalisations in Australia, of which 1 in 4 involved a surgical procedure.[i] 60% were same-day hospitalisations.
Procedural Specialists Work in both Public and Private Sectors
Procedural specialists contribute significantly to the quality of Australian healthcare in both public and private hospitals whether working as Staff Specialists in public hospitals or Visiting Medical Officers (VMOs) in both the public and private sector.
Australia’s Health is Improving
- “There is a lot of good news in the health front in Australia”. (AIHW, 2016[ii])
- We are living longer
- We are living longer free of disability
- Our death rates continue to fall
- Overall burden of disease has fallen
- Most Australians report their health as ‘good’ or better.
- “Improvements in medical care have also enabled us to live longer with illnesses and diseases, and have provided access to treatments not available in the past.” (AIHW, 2016)[iii]
Australian Healthcare is Internationally Recognised
- “The Australian healthcare system is generally recognised to have achieved a “successful blend of best practice approaches to provision of cost effective, equitable and high-quality healthcare for its citizens”, making use of a judicious mix of public and private care.” (George Institute for Global Health[iv])
- “The most remarkable thing about modern healthcare is not what goes wrong, or how much money is wasted but how successful we usually are.” (Prof Jeffrey Braithwaite, co-author of the CareTrack Australia[v])
There are Challenges Ahead and Much More Work to Do
- “Chronic diseases such as cancer, coronary heart disease and diabetes are becoming increasingly common in Australia due to a population that is increasing and ageing, as well as to social and lifestyle changes.” (AIHW, 2016[vi])
- “Indigenous Australians continue to have lower life expectancy, higher rates of chronic and preventable illnesses, poorer self-reported health, and a higher likelihood of being hospitalised than non-Indigenous Australians”. (AIHW, 2016[vii])
- Although much emphasis is rightly placed on lifestyle contribution to the incidence of chronic disease, many Australians, including those with rare and debilitating genetic based diseases, have no effective treatment options and are anxiously awaiting medical breakthroughs to relieve or cure their suffering.
Growth in Australia’s Healthcare Expenditure is Below 10 Year Average
- According to the AIHW, growth in spending on healthcare in 2014–15 (2.8% in real terms) “was the third consecutive year that growth in health expenditure was below the 10-year average (4.6% between 2004–05 and 2014–15). Growth in health expenditure per person was also relatively low, at less than a half of the average annual growth over the decade (1.4% compared with 2.9%).”[viii]
- According to OECD calculation methods, Australia ranked 10th of 22 comparable OECD countries in healthcare expenditure at 9.4% of GDP in 2013 (OECD average 9.3%)[ix] and according to the Federal Department of Health, Australia “ranks 15 out of 34 of OECD countries for out-of-pockets as a percentage of health expenditure”.[x]
Growth in Hospital Admissions for Elective Surgery is Below the 4-year Average
- The growth of elective surgery admissions in 2015-16 was 2.1%, below the 4-year average of 2.2%. The 3 most common elective admissions involving surgery were cataracts, malignant skin legions and in vitro fertilisation (IVF) procedures.
- The growth in emergency admissions involving surgery was 3.4%, above the 4-year average of 2.5%.[xi] The 3 most common emergency admissions were appendicitis, hip fracture and heart attack.
Australia’s Health Inflation is Historically Low
- The AIHW also shows that health inflation in Australia over the last decade (2004/05-2014/15 was 0.48% below general inflation (i.e. negative excess health inflation).[xii]
- A common misconception in the analysis of healthcare expenditure is to attribute increasing expenditure from growth in volume to healthcare price inflation. Rising health expenditure with low inflation indicates that greater volumes are driving costs. As respected Health Economist Roger Kilham explains, “Once upon a time, health prices were growing faster than general inflation but it is not true now. A very important point indeed. ‘Excess’ price inflation is not the driver of rising costs. The comparison between costs and inflation is a very dumb comparison.”[xiii]
Private Health Funds Manage 8.7% of Australia’s Total Healthcare Expenditure
- 67% of Australia’s healthcare spending is funded from Federal and State taxation revenue, applied to a number of programs including public hospitals, MBS, PBS, and the PHI rebate. Of total healthcare expenditure, 7% is made by health funds on behalf of members, and 17.7% came directly from individuals. The proportion of expenditure on healthcare by government, third party intermediaries and individuals has remained generally consistent over the last 15 years. [xiv]
Healthcare Delivery is a ‘Complex Adaptive System’
- Medical treatment, nursing and hospital care are delivered in response to a wide variety of health events, some of which require medical diagnosis and treatment. While often referred to as a ‘healthcare system’, in reality, the delivery of medical treatment is part of a ‘complex adaptive system’ requiring a high degree of flexibility and local decision making. It is therefore not surprising that policy interventions based on a ‘closed system’ approach have a history of failure. According to the US physicist, complex systems scientist and advisor to the Centers for Disease Control and Prevention Prof. Yaneer Bar-Yam, “In the medical system the practice of cost controls through managed care is a large force approach that started in the 1980’s. Today, the medical system quality of care is disintegrating under the stresses/turbulence generated by this strategy. Medical treatment is clearly one of the most complex tasks we are regularly engaged in. Across the board cost control should not be expected to work.”[xv]
The Search for Lower Healthcare Costs has a Long History
- The search for ways to “lower the cost of healthcare” has been ongoing in Australia and comparable countries over the last century. “At the 1926 American Medical Association (AMA) national convention, 15 frustrated delegates decided to investigate, and attempt to solve, the organizational problems leading to the rising costs of medical care. … A committee of the AMA produced the first estimate of national health care spending, about 4% of national income or $3.66 billion in 1929.”[xvi]
- In 1948, the SMH reported that, “The demand for free drugs, false teeth, spectacles, deaf aids, and surgical appliances available under Britain’s new health scheme is growing far beyond Government expectations.”[xvii]
- On 1st Nov 1978, the Australian Minister for Health Mr Hunt claimed that the then Federal government was “winning the fight to control rising health costs in Australia” and that new figures showed that “the rise between 1975-76 and 1976-77 was 14 per cent, compared with 36.6 per cent between 1974-75 and 1975-76” with spending now at 7.85 per cent of GDP, down from 7.96 per cent respectively.[xviii]
- In 1995, the objective of the Health Legislation (Private Health Insurance Reform) Amendment Act 1995 was to “reduce the cost of private health insurance premiums and reduce the ever-increasing cost of private health hospitalisation and treatment.” and “to provide better value for those who take out private health insurance”[xix]
Private Healthcare Australia Plan to Cut Healthcare Costs by $100 billion over 10 years
- At present, Private Healthcare Australia (PHA), which represents Australia’s major health funds, have published proposals “to reduce Australia’s healthcare costs by $100 billion over a ten-year period, while at the same time improving healthcare outcomes”.[xx] PHA claims that “health costs are increasing rapidly”[xxi] and proposes changes to “reduce costs and make PHI more sustainable”[xxii] including:
- increase the maximum excess level (from $500 to between $1,300 to $2,000),
- remove the requirement to provide minimum benefits for palliative, rehabilitation and psychiatric care,
- “address the unsustainable growth in benefits paid to public hospitals”[xxiii]
- remove the second-tier default benefit for non-contracted hospitals not located in rural and remote areas, the later to have “some form” of default benefit in the near term.[xxiv]
- Central to the PHA cost cutting plan is to address the issue on what NIB CEO Mark Fitzgibbon has described as the “frequent flyers”[xxv], namely the chronically ill who utilise the healthcare system the most. According to the PHA, “as few as 5-10% of patients consume as much as 50% of total hospital expenditure.” According to the AIHW, patients with chronic disease are suffers of arthritis, asthma, back problems, cancer, chronic obstructive pulmonary disease, cardiovascular disease, diabetes and mental health conditions. NIB has published plans to reform the Australian healthcare sector, including the long-term goals (by 2040) of “private sector operates entire public hospital system under contract”[xxvi].
Health Care Homes Are a Health Rationing Device for the chronically ill
- According to the private health insurance industry association Private Healthcare Australia, “as few as 5-10% of patients consume as much as 50% of total hospital expenditure”. Health Care Homes have been proposed as a means of reducing the cost of treatment for the chronically ill, concentrating primarily on keeping them out of hospital and in an alternate system of registered primary care facilities. Under the plan, GPs are contracted to a capped budget and patients are enrolled at one ‘Home’ (medical practice) to treat their multiple conditions. To contain costs, the patient must be discouraged from seeking treatment elsewhere.e. other GPs, hospital etc. In practice, the concept does not work since illness and disease does not obey the predetermined rules of budget holding. Furthermore, there may be incentives not to treat those who are likely to exceed their budget. The mentally ill are particularly vulnerable in these settings.
- Health Care Homes is essentially a rebadging of the previously abandoned ‘Coordinated Care’ trials completed in 2000 which found that ‘cost per client day for trial clients had not reduced’ and ‘coordination costs as a share of the total pool ranged from 11-22%’ and alarmingly ’some trial sights have recruited the wrong clients, tending to be those who did not need intensive coordinated care’.[xxvii]
- According to Prof J Michael McWilliams, Head of Healthcare Policy and Medicine at Harvard Medical School, “Studies of programs or practice models designed to enhance coordination and management of care for patients with multiple conditions and multiple providers have shown minimal, if any, consistent savings.”[xxviii]
- Furthermore, should the proposal by Private Healthcare Australia to “remove the requirement to provide minimum benefits for palliative, rehabilitation and psychiatric care”[xxix] be implemented, considerable demand will be shifted to Health Care Homes and public hospitals.
Australian Private Health Funds are Profitable and Growing
- Reporting by APRA on the prudential requirements of Australia’s health funds is conducted quarterly. According to the latest report for the March 2017 quarter[xxx]:
- The number of insured persons increased by 122,374 from the year ago quarter.
- Profit before tax increased by 19.1% to $1.759 billion from the previous year ended March.
- Net assets increased by $600.9 million in the last 12 months to $7.5 billion.
- Australia’s publicly listed health funds, Medibank Private and NIB achieved a return on equity of 26.62% and 30.70% respectively.[xxxi] Meanwhile Australia’s largest health fund, UK-based Bupa reported an underlying increase in profit for its Australian and New Zealand operation of £4 million, an increase of 9%[xxxii].
- According to Bupa’s financial results presentation for 2016 for Australia and New Zealand, Bupa has enjoyed “resilient growth in Health Insurance business, becoming Australia’s largest health insurer.” “Revenue up 7%; profit up 9%”.[xxxiii]
There is a Difference Between Lowering and Shifting Health Costs
- Proposals for ‘cost reduction’ in health are often proposals to shift ‘our costs’ to other sectors or parties. The proposals are often presented as ‘reforms’ or ‘quality measures’. These ‘cost shifting devices’ are well known and include: requiring pre-approval for treatment, not paying for known complications in hospitals, gutting insurance cover with exclusions that render the policy virtually useless (‘junk insurance’), treating patients to a fixed budget (budget holding), increasing policy excesses, restricting patient choice of doctor and hospital through ‘preferred provider’ arrangements, reducing/removing/downgrading cover for chronic conditions (including mental health) from health fund policies, creating waiting lists, enforcing early discharge policies with step-down payments, diversion of patients to other health providers, programs or charitable institutions.
Public Hospitals are Going Private and Vice Versa
- Australian public hospitals play an important role in Australian healthcare. Their public service obligations include providing emergency treatment, geographical spread, intensive and specialised care, training of health professionals, and high standards of medical, nursing and hospital care at no direct cost to the patient. If effect, public hospitals are a central part of the Australian healthcare safety net.
- Increasing reliance by Australian public hospitals on private patient revenue is an established practice condoned by Federal and State Health Departments. What is not so apparent is the increasing use of private hospitals for public patients. From 2011-12 to 2015-16, the average growth in private patient separations in public hospitals was 10.5%a. and the average growth of public patients in private hospitals was 10.2% p.a. (AIHW)
- Patients in rural and remote locations with private health insurance are unlikely to have immediate access to major private hospitals, however many value the ability to use their private health insurance should they elect to travel to a major regional private hospital for treatment.
Clinical Need Should Determine Priority of Treatment
- An established principle in Australian public hospitals is that patients are assessed and treated based on clinical need. AIHW data indicates that median waiting times for public patients in public hospitals for a range of elective procedures are longer than for those patients who have an alternate source of funding including private health insurance, DVA, self-funding, workers’ compensation and motor accident cover (42 days vs 20 days).[xxxiv] What is not in the statistics is an assessment of the clinical needs of the patients being treated, and hence further analysis of the clinical data would be required to reach a conclusion of preferential treatment by health insurance status.
- What is also established in public hospitals are programs designed to ‘encourage’ patients to use their private health insurance to maximise external revenue for the hospital. This practice includes promotional campaigns with brochures being used in some hospitals to espouse the benefits of using private health insurance but falling short of promising faster treatment.
Private Clinics are Being Established in Public Hospitals
- Public hospitals are also establishing private clinics through Licenced Private Practice Agreements with medical practitioners within public hospitals. The arrangement may involve the licensed doctor paying “the licence fee” within 7 days of the admission date of a patient. The fee or commission is detailed in the agreement, e.g. “the fee supports public defensibility in the allocation of public resources for use by the private sector and aims to ensure no competitive advantage to participating LLP practitioners and other practitioners not accessing public resources.”
- Schemes to facilitate cost shifting between public hospitals and the Commonwealth utilising the MBS exist in all States with a sophisticated degree of administrative coordination. Visiting Medical Officers have been asked to use their Medicare provider numbers to bill the MBS for some services (e.g. radiology or pathology) without approval from the CEO of Medicare or the Federal Department of Health. These costs shifting practices are well known to Federal and State regulators and have been analysed in detail by the Australian Centre for Health Research.[xxxv]
Public Patients Going Private are Under-reported
- In 2015/16, 84,000 separations “were reported as public hospital separations contracted to the private sector” and the majority of these separations were for care involving dialysis.[xxxvi] The AIHW warns that the data “should be interpreted” with caution as is omits separations under contract between private hospitals and jurisdictional health departments and Local hospital networks.
Public Hospital Elective Surgery Waiting List Blitzes Utilise Private Hospitals
- Using private hospitals to reduce public hospital elective surgery waiting lists has been an established practice over the last 10 years, and is supported by Federal and State Health Departments. Issues arising from the use private hospitals for public patients (outside of exceptional circumstances) include disruption to the education and training of Junior Doctors and Registrars, disincentives to increase or use public hospital capabilities and concerns over the provision and responsibility of after-care of patients when ‘the blitz’ is over.
The Medical Profession is Highly Regulated
- The Australian medical profession is regulated by the ACCC, AHPRA and extensive state and federal legislation, regulations and guidelines. Under ACCC regulations, doctors must independently set their own fees and there are strong prohibitions on advertising medical services that do not exist in other sectors. These advertising prohibitions are designed to protect the public from advertising induced demand and making false claims about the efficacy of treatment. The GP gatekeeper role plays an important part in ensuring clinical need based referral, and access to medical specialists after preliminary diagnosis rather than patient self-diagnosis and advertising information.
There are now over 100,000 Doctors in Australia
- The Australian Medical workforce now exceeds 100,000 medical practitioners and is one of the fastest growing health workforces in the world, graduating around 3,000 doctors per year. Doctors train their own competitors under a fellowship system, which allows for steady progression of knowledge and skill in order to maximise patient safety.
Household expenditure on medical care and health expenses is monitored by the ABS
- The latest published statistics by the ABS on household expenditure was in 2009/10. The category entitled ‘medical care and health expenses’ comprises 53 classifications including a range of health insurance products, health practitioner’s fees, medicines, pharmaceutical products, and other medical care and health expenses. The data shows that in 2009/10, average weekly household expenditure on Specialist’s fees was $6.23 per week, or 0.5% of average weekly household expenditure.[xxxvii]
The Cost of Medical Services is No Secret
- Australians’ spending on medical services is closely monitored and widely reported. The Medicare Benefits Schedule and use of item numbers provides historic data on the quantity and trends in medical treatment and allied healthcare. In addition, APRA monitors medical fees and rebates, which are published in quarterly reports.
- The Australian fee-for-service model is well established and operates in an environment where patients have choice-of-doctor and where Australia’s public hospitals provide Salaried Medical Officers at no direct cost to the public patient (non-Medicare eligible patients are charged fee-for-service). Public hospitals also contract VMO doctors on a fee-for-service basis to treat public patients, particularly in non-teaching hospitals.
- Doctors in private practice charge fees and patients receive rebates from Medicare and/or private health insurance funds. When any rebate is less that the fee charged, the patient makes a co-payment for the service. The gap between a patient’s hospital costs and their health insurance cover is called an ‘insurance excess’ or deductable.
87% of Medical Services Do Not Involve a Co-payment
- According to APRA, currently 86.6% of medical services do not involve a co-payment and 93% of services involved no-gap or a known gap arrangement. Of the 7% of services involving a co-payment, without a health fund agreement, the average gap was $204.69.
|March Quarter||Proportion of services with no medical gap||Average gap|
(where there was a gap)
(gap and no agreement)
Patients Are Penalised (Lower Rebate) for Choosing a Non-Health Fund Doctor
- Patients who exercise their right of choice-of-doctor who is not part of a health fund controlled ‘preferred provider’ network, are punished with a lower rebate (larger gap) than a patient who chooses the health fund preferred provider, even though the patient has paid the same premium. This practice is designed to leverage both patients and doctors into health fund controlled networks. As leading Australian health economist Roger Kilham has stated, “preferred provider arrangements are solidly anti-consumer. They reduce consumer choice of hospital and doctor and they reduce consumer say in treatment”.[xxxviii] In its latest report to the Australian Senate, the ACCC has acknowledged this practice, which it says, “further complicates the range of matters a consumer must consider when purchasing and using private health insurance” [xxxix]
Informed Financial Consent is Strongly Supported
- The Council of Procedural Specialists and the medical profession strongly supports the right of patients to be fully informed of the cost of their medical treatment prior to their surgery and the right of patients to have a second opinion on any aspect of their medical treatment. Of the 4,416 complaints about private health insurance in 2015/16 to the Commonwealth Ombudsman, 35 involved inform financial consent by doctors (0.79%).
- According to the Commonwealth Ombudsman, the top 5 consumer complaints for the quarter ending 31 March 2017 were: premium payment problems, membership cancelation, rate increases, general service issues, and verbal/oral advice.[xl]
Competition and Advertising Induced Demand for Medical Services
- One of the advantages of Australian healthcare is the right of patients to choose their own doctor and a medical referral system using General Practitioners in a preliminary diagnosis and referral role. Although far from perfect, great caution should be exercised, in considering any proposal to dismantle the central role of the GP as a primary referrer and gate keeper. In addition to medical services being regulated under competition law, AHPRA has stipulated various standards associated with advertising and making claims concerning the expertise of doctors and therapies. In general, competition concerning price and cost have been discouraged, e.g. special offers, deals, discounts, loyalty schemes, advertised loss leaders, bulk deals and various arrangements which are acceptable and practised in the retail sector have not been acceptable practice in the presentation of medical services.
Out of Pocket Spending on Healthcare Has Been Consistent Over Many Years
- In 2014, the Federal Department of Health told the Senate, “A number of submissions have highlighted the absolute value of out of pockets as evidence of an issue across the system. The trend over the last couple of years for out-of-pockets as a percentage of total health expenditure is down. It peaked at 19 per cent some years ago; it was 18.3 per cent in 2010–11; and in 2011–12 it was 17.3 per cent. It is lower than the OECD average, and Australia ranks 15 out of 34 of OECD countries for out-of-pockets as a percentage of health expenditure. The absolute dollars in many ways are an indication of the wealth of a society, rather than the appropriateness or inappropriateness of the level of out-of-pockets being charged. The extent to which out-of-pockets are discretionary is highlighted when an analysis of the out-of-pocket data is undertaken. The largest and fastest-growing area is non-prescription medicines, including complementary medicines. They are nearly one third of the total out of pocket costs. Medical services are about 12 per cent, and prescription pharmaceuticals are less than seven per cent of the total.”[xli]
Medical Associations are Prohibited from Publishing Fee Schedules
- The ACCC advises medical associations that the publication of fee lists would contravene the Trade Practices Act. Hence, with the exception of the AMA fee schedule, medical associations are prohibited from giving members advice on fees. The AMA fee schedule (which has historically been indexed in line with practice costs) is made available only to members. Meanwhile, non-medical organisations can publish information on medical fees. It would appear that the availability of the AMA schedule has not resulted in a substantial number of doctors charging the AMA fee. Nevertheless, the ACCC has maintained its prohibition on medical associations publishing fee schedules.
The Patient and the Doctor are Being Left Out of “The Data Gold Rush”
- It is now becoming apparent that data in a clinical setting has a substantial potential commercial value and third parties are designing plans for doctors to collect clinical information from patients for electronic transfer. In October 2016, the Unified Healthcare Group was reported to have “secured the exclusive support from the RACGP for the exchange of health information from GPs to businesses and government agencies.” The UHG Chief Executive Brandon Carp said, “We are confident with our strategy and vision to be the go-to platform connecting businesses and healthcare providers. … And to accelerate the growth we will be raising a multi-million-dollar sum to drive increased sale into new business sectors, expand the healthcare provider marketplace and potential bolt-on acquisitions.”[xlii] Recently Prof. Grahame Samuel (Chair of Data Governance Australia) in his address to the National Press Club (12/7/17) claimed that the release of government data (including health data) could create value of up to $25 billion per year. He is promoting an industry led model for the regulation of this data.
- On 17 July 2017, Australia’s largest health insurer Bupa reported a major data leak caused by a malicious employee in the UK, involving the personal information of 19,995 Australians, who are among the 547,000 customers affected worldwide.
- The regulation, confidentiality and control of clinical data is now a major issue for doctors and patients, along with rising concerns of identity theft and potential insurance discrimination against patients through knowledge of their health history.
- Maintain a viable default benefit for all ACHS accredited healthcare facilities to ensure the survival of independent private hospitals and to encourage continued private health infrastructure investment in rural, regional and remote Australia.
- Change private health insurance rules to ensure that patients with private health insurance receive the same rebate regardless of choice of doctor or healthcare facility i.e. end the rebate penalties for choosing a doctor who is not part of a health fund network
- Maintain ‘essential cover status’ for mental health, rehabilitation and palliative care in health fund policies
- Consider a Senate Inquiry into the use and ownership of clinical data
- Consider a Senate Inquiry for the implementation of Health Savings Accounts (Self-managed Health Funds), as an additional option to current health financing arrangements
- Consider the implementation of a system that allows health fund members to use their health insurance at any accredited (ACHS) health care facility
Council of Procedural Specialists
[i] AIHW, Hospitals at a Glance.
[ii] AIHW, Australia’s Health 2016, p. 9
[iii] AIHW, Australia’s Health 2016, p.13
[iv] The George Institute for Global Health, Australia-China healthcare opportunities, November 2015
[v] Jeffrey Braithwaite, Future-proofing healthcare – press the reset button, SMH, 30 September 2015
[vi] AIHW, Australia’s Health 2016, p.13
[vii] AIHW, Australia’s Health 2016, p.228
[viii] AIHW, Health expenditure Australia 2014–15, 2016
[ix] AIHW, Australia’s Health 2016, p.32
[x] Community Affairs References Committee, Out-of-pocket costs in Australian healthcare, August 2014, p.11
[xi] AIHW, Admitted patient care 2015-16: Australian hospital statistics, p, 169 &182.
[xii] AIHW, Health expenditure Australia 2014–15, 2016, p. 11
[xiii] Roger Kilham, in advice to the Australian Society of Orthopaedic Surgeons, 16 May 2016
[xiv] AIHW, Health expenditure Australia 2014–15, 2016, p. 37
[xv] Yaneer Bar-Yam, Unifying Principles in Complex Systems, in Converging Technologies for Improving Human Performance, Nanotechnology, Biotechnology, Information Technology and Cognitive Science, M.C. Roco and W.S. Bainbridge, Eds. (Kluwer, 2003), New England Complex Systems Institute, http://www.necsi.edu/projects/yaneer/ComplexSystems.pdf
[xvi] Linda Gorman, The History of health care costs and health insurance, Wisconsin Policy Research Institute, October 2006, p. 5.
[xvii] ‘Government Health Costs Soaring’, Sydney Morning Herald, 23 Aug 1948, p 3.
[xviii] ‘Fall in Health Costs: Hunt’, The Canberra Times, 1 Nov 1978, p. 3
[xix] Review of the Health Legislation (Private Health Insurance Reform) Amendment Act 1995, http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Completed_inquiries/1996-99/health/report/c02
[xx] Private Healthcare Australia, Private Health Insurance Consultations 2015-16, 4 December 2015, p. 14, http://www.privatehealthcareaustralia.org.au/private-health-insurance-consultations-2015-16/
[xxi] Private Healthcare Australia, Private Health Insurance Consultations 2015-16, 4 December 2015, p. 14
[xxii] Private Healthcare Australia, Private Health Insurance Consultations 2015-16, 4 December 2015, p. 2
[xxiii] Private Healthcare Australia, Private Health Insurance Consultations 2015-16, 4 December 2015, p. 4-5
[xxiv] Private Healthcare Australia, Private Health Insurance Consultations 2015-16, 4 December 2015, p. 9
[xxv] Private Health Insurance: Evolution or Revolving Door?, Mark Fitzgibbon, 8 Nov 2016, https://www.nib.com.au/shareholders/announcements/2016/Presentations
[xxvi] Private Health Insurance: Evolution or Revolving Door?, Mark Fitzgibbon, 8 Nov 2016
[xxvii] Prospects for managed healthcare in Australia, David Marcus, Parliamentary Library, 20/6/2000, p/16
[xxviii] J. Michael McWilliams, Cost Containment and the Tale of Care Coordination, N Engl J Med 2016; 375:2218-2220, December 8, 2016, http://www.nejm.org/doi/full/10.1056/NEJMp1610821
[xxix] Private Healthcare Australia, Private Health Insurance Consultations 2015-16, 4/12/2015
[xxx] APRA, Private Health Insurance Quarterly Statistics, March 2017, http://www.apra.gov.au/PHI/Publications/Pages/Quarterly-Statistics.aspx
[xxxi] Yahoo Finance statistics for MPL and NHF, accessed 27 July 2017
[xxxii] Using constant exchange rates from Bupa, Full Year Results 2016, https://www.bupa.com/corporate/our-performance/financial-results
[xxxiii] Bupa, Financial Results, Results presentation for the Full Year 2016, https://www.bupa.com/corporate/our-performance/financial-results
[xxxiv] AIHW, Admitted patient care 2015-16: Australian hospital statistics, p. 204
[xxxv] David King, Private Patients in Public Hospitals, April 2013, http://www.achr.org.au/private-patients-in-public-hospitals/
[xxxvi] AIHW, Admitted patient care 2015-16: Australian hospital statistics, p. 218
[xxxvii] ABS, 6530.0 - Household Expenditure Survey, Australia: Summary of Results, 2009-10
[xxxviii] Roger Kilham of Access Economics in a paper delivered in Melbourne on 13 May 1995.
[xxxix] ACCC, Report to the Australian Senate On anti-competitive and other practices by health insurers and providers in relation to private health insurance for the period 1 July 2015 to 30 June 2016, p.28
[xl] Commonwealth Ombudsman, Private Health Insurance Ombudsman Quarterly Bulletin 83
[xli] Officials from the Department of Health quoted in Senate Report, Out-of-pocket costs in Australian healthcare, 22 August 2014, http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Australian_healthcare/Report
[xlii] The Australian, Thodey, Bassat back the UHG health info bridge technology, 25 October 2016.
NB: bolding and emphasis have been added EE&OE