Issues for reregulation of private hospital insurance in Australia

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.