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Objective: Lifetime Health Cover (LHC) was introduced in mid-2000 to increase participation in private health insurance that includes hospital cover (PHI-HC) and improve the risk profile of PHI-HC participants. It initially achieved both objectives, but since 2001 the PHI-HC population has aged faster than the general population. The aim of this study was to determine if the excess ageing of the PHI-HC risk pool has been due to passive age-based adverse selection, an inherent risk of LHC. This study has potential implications for the retention of LHC. Methods: A descriptive population-level analysis of publicly available administrative datasets was performed. Data relating to PHI-HC were obtained from the Australian Prudential Regulatory Authority. National population data were obtained from the Australian Bureau of Statistics. Trends in demography, PHI-HC participation rates and LHC loading payments were analysed. Results: By 2021, age-based adverse selection had returned to the pre-LHC level. Based on the available data, this was due to passive age-based adverse selection not active age-based adverse selection. Specifically, it reflected the combination of an avoidable unintended consequence of the introduction of LHC (the over-representation, in 2001, of individuals aged 45–59) and one of LHC's intended effects (incentivisation of insured individuals to retain PHI-HC). Conclusions: This study supports the retention of LHC. Nonetheless, it highlights the risk of passive age-based adverse selection created by incentivising insured individuals to retain PHI-HC in the presence of distortions in the age distribution of the PHI-HC risk pool. Early targeted interventions are required when such distortions arise. What is known about the topic? Since the introduction of Lifetime Health Cover (LHC) in mid-2000, the participation rate for private health insurance that includes hospital cover (PHI-HC) has remained relatively stable, but the PHI-HC population has aged faster than the general population. What does this paper add? This paper makes a novel distinction between 'active' and 'passive' age-based adverse selection to explain LHC's role in the excess ageing of the PHI-HC risk pool. What are the implications for practitioners? Governments need to be vigilant for the emergence of distortions in the age distribution of the PHI-HC risk pool and respond with targeted interventions to normalise the age distribution, or risk problematic passive age-based adverse selection. [ABSTRACT FROM AUTHOR]

Objective: This study set out to present data on out-of-pocket payments for Medicare mental health services provided by general practitioners (GP), psychiatrists, clinical psychologists and other psychologists, to explore how much is spent on out-of-pocket payments for mental health; if any trends could be seen; and what variations exist across regions. Methods: We performed secondary analysis of publicly available data on Medicare-subsidised GP, allied health and specialist health care across Australia. We merged and interrogated data covering the period 2013–19 and 2019–21 to create a data set covering eight full years of Medicare mental health services, arranged by profession and by region. Results: Out-of-pocket payments for mental health care in Australia have been rising consistently over the period 2013–21, at a considerably faster rate than overall expenditure on mental health care. There is wide variation in out-of-pocket payments depending on where you live. Conclusions: The impact of out-of-pocket payments on community access to mental health care is growing. This has implications, especially in poorer communities, for access to care. This should be an important consideration taken as the Australian Government considers next steps in national mental health reform, including the Better Access Program, currently under evaluation. What is known about the topic? A$35 m is spent on Medicare mental health services every week but there has been little research on the out-of-pocket payments charged to Australians. What does this paper add? Looking at Medicare data from 2013 to 2021, this paper answers three main questions: how much are out-of-pocket payments for mental health in Australia; what trends can be seen; and what variations exist? What are the implications for practitioners? Medicare's Better Access Program is under current review and this research can help practitioners, funders and policy-makers understand the significant investment made in mental health services. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study is to explore policy paths towards private health insurance (PHI) reform that might reduce out-of-pocket costs, restore public confidence and allow insurers to finance value-based care. Methods: This study used thematic analysis of semi-structured interviews with informed opinion holders, including a politician, three former senior public servants and an industry lobbyist. Critical analysis of peer reviewed and grey literature was also conducted. Results: PHI regulation is contributing to unexpected out-of-pocket expenses and low-value care. Modification of existing tax incentives would be incapable of significantly increasing PHI coverage. Regulatory reform could restore confidence among policy holders by promoting value-based care, wherein health outcomes are measured and incentivised with remuneration. Conclusions: Targeted relaxation of out-of-hospital restrictions should be explored to promote value-based competition and facilitate bundled payments for chronic disease management and community services. To address out-of-pocket diagnostic and procedural costs, insurers should have more responsibility for private specialist's fees, including by financing the entire provider's bill through insurance and redirecting the Medicare Benefits Schedule fee to the insurer. What is known about the topic?: Healthcare expenditure and out-of-pocket costs have grown rapidly, while confidence and depth of coverage in private health insurance has declined, as has the fiscal appetite for expanding public financing for health care. What does this paper add?: This paper outlines the regulatory and policy factors that are contributing to low-value care and unmet expectations from insurance policy holders. It also maps the strategic terrain of the non-government health sector and considers feasible policy options for reforming the PHI industry that do not increase drawings on the public purse. What are the implications for practitioners?: An appreciation of the ongoing challenges to financing value-based care provision will inform key stakeholders, including policymakers and health service providers, as reforms are debated and implemented. [ABSTRACT FROM AUTHOR]

Objective Although Australia's service and policy context differs from that of the US, studies have highlighted potential for individual placement and support (IPS) to support competitive employment outcomes for people with severe and persistent mental illness. The aim of the present study was to explore why the model is not yet widely available.Methods A document analysis was conducted to discern reasons for challenges in implementation of IPS practice principles within the Australian service context.Results The document analysis illustrated that although policy acknowledges the importance of increasing employment rates for people with severe and persistent mental illness, consistent measures, change indicators, direction and time frames are lacking in policy and strategy documentation. Further, IPS principles are not consistently evident in guiding operational documentation that government-funded Disability Employment Services (DES) programs are mandated to adhere to.Conclusions For IPS to be readily implemented, it is necessary for government to offer support to agencies to partner and formal endorsement of the model as a preferred approach in tendering processes. Obligations and processes must be reviewed to ensure that model fidelity is achievable within the Australian Commonwealth policy and service context for programs to achieve competitive employment rates comparable to the most successful international programs. [ABSTRACT FROM AUTHOR]

Objective. There are many medicines listed on the Australian Pharmaceutical Benefits Scheme (PBS) in which point of sale price is less than the level of the general patient co-payment. In these circumstances, the patient covers the total cost of the medicine from their own pocket with no government subsidy. The aim of the present study was to compare the consumer prices of under general co-payment prescription medicines between banner group pharmacies with open discounting policies and community pharmacies without; and to assess the impact of the April 2012 PBS price disclosure policies on the discounts offered. Methods. The consumer prices of 31 under co-payment medicines were collected from banner group pharmacy websites and individual pharmacies both before and after April 2012. PBS maximum prices were obtained from the PBS website. Absolute and relative price differences between PBS and pharmacy groups were calculated. Results. Before April 2012, banner group pharmacies provided discounts to patients of around 40% per prescription, whereas other pharmacies provided discounts of around 15%. Total price savings were on average $9 per prescription at banner group pharmacies and $3.50 at other pharmacies. Percentage discounts did not change greatly after April 2012, when price decreases occurred on the PBS. Conclusions. Banner group pharmacies with pricing strategies are able to provide greater discounts to patients compared with other pharmacies. Community pharmacies still have the ability to provide substantial discounts after the April 2012 price reductions. [ABSTRACT FROM AUTHOR]

Objective We investigated the completeness of recording of pathology tests in Australian Medical Benefits Schedule (MBS) claims data, using the example of the prostate-specific antigen (PSA) test. With some exceptions, MBS claims data records only the three most expensive pathology items in an episode of care, and this practice ('episode coning') means that pathology tests can be under-recorded. Methods The analysis used MBS data for male participants in the 45 and Up Study. The number and cost of items in each episode of care were used to determine whether an episode contained a PSA screening test (Item 66655), or could have lacked a record of this item because of episode coning. Results MBS data for 1 070 392 episodes involving a request for a pathology test for 118 074 men were analysed. Of these episodes, 11% contained a request for a PSA test; a further 7.5% may have been missing a PSA request that was not recorded because of episode coning. Conclusions It is important to consider under-reporting of pathology tests as a result of episode coning when interpreting MBS claims data. Episode coning creates uncertainty about whether a person has received any given pathology test. The extent of this uncertainty can be estimated by determining the proportion of episodes in which the test may have been performed but was not recorded due to episode coning. [ABSTRACT FROM AUTHOR]

Objective. To create and report survey-based indicators of the affordability of prescription medicines for patients in Australia. Method. A cross-sectional study of 1502 randomly selected participants in the Hunter Region of NSW, were interviewed by telephone. Main outcome measure. The self-reported financial burden of obtaining prescription medicines. Results. Data collection was completed with a response rate of 59.0%. Participants who had received and filled at least one prescription medicine in the previous 3 months, and eligible for analysis (n=952), were asked to self-report the level of financial burden from obtaining these medicines. Extreme and heavy financial burdens were reported by 2.1% and 6.8% of participants, respectively. A moderate level of burden was experienced by a further 19.5%. Low burden was recorded for participants who said that their prescription medicines presented either a slight burden (29.0%) or were no burden at all (42.6%). Conclusion. A substantial minority of participants who had obtained prescription medicines in the 3 months prior to survey experienced a level of financial burden from the cost of these medicines that was reported as being moderate to extreme. [ABSTRACT FROM AUTHOR]

The provision of health services in Australia currently is primarily financed by a unique interaction of public and private insurers. This commentary looks at a loophole in this framework, namely that private insurers have to date been able to avoid funding healthcare for some of their policy holders, as it is not a requirement to use private insurance when treatment occurs in Australian public hospitals. [ABSTRACT FROM AUTHOR]