Competition in the Irish Private Health Insurance Market

More documents

Recommendations

Info

treatment of approximately 15,500 119 patients in Irish private hospitals in 2005. Given that the 16 participating Irish private hospitals have a minimum of 1650 in-patient beds between them, the NTPF paid for somewhere in the region of 9 patients per private hospital in-patient bed in 2005. 120 • Between them, the restricted membership schemes account for 93,900 individuals, less than 3% of the PHI market. By corollary, PHI firms, the only other purchasers of private healthcare services, contribute the lion’s share of demand for private hospital in-patient services. It is clear, therefore, that private hospitals are heavily reliant on custom generated by PHI rather than self-payers, the NTPF or restricted membership schemes. This suggests that open enrolment PHI firms hold buyer power in relation to private hospitals. Provider Negotiations 7.17 Vhi Healthcare’s position as the largest PHI firm affects contractual negotiations between private hospitals and other PHI firms. In its submission, Vhi Healthcare states that “There is evidence to suggest that both BUPA and VIVAS largely replicate the provider contract arrangements (but not necessarily all the rates) of Vhi Healthcare. ….. In so doing significant entry costs can be avoided by an entrant insurer. Furthermore, ‘free-riding’ on the economies of scale generated by a larger insurer will secure significantly better provider reimbursement rates. This ‘free-riding’ principle allows new entrants to continue to enjoy cost advantages into the future and is perhaps symptomatic of ‘second-mover’ advantages in the market.” 121 The OECD also states that Vhi Healthcare negotiates reimbursement levels which are followed by BUPA Ireland. 122 7.18 On the other hand, VIVAS Health has stated that “As VHI is their primary supplier of business, hospital and medical practitioners are very reluctant to fall out of contract. It has also been the experience of VIVAS Health when negotiating with these parties that they are extremely reluctant to give any insurer better rates than VHI as should VHI discover this then they would force the private hospital or medical practitioner to also lower their rates.” 123 Therefore, Vhi Healthcare’s buyer power may be undermining competition upstream between private facilities, and exaggerating the difference in competitive positions between competing PHI firms downstream. 7.19 It is clear from these submissions that, by virtue of its size and longstanding position in the market, Vhi Healthcare has established the “rules of the game” with respect to provider contracts. Vhi Healthcare claims this allows other PHI firms a second-mover advantage, while 119 90% of 18,197 = 16,377; 95% of 16,377 = 15,558. 120 Calculated in aggregate. The Authorities are aware that custom generated by the NTPF varies significantly from private hospital to private hospital. The largest customers of the NTPF are the Mater Private Hospital and Blackrock Clinic. “NTPF is good news for private hospitals”. Sunday Business Post, June 25 th , 2006. 121 Vhi Healthcare submission at p.24 122 OECD (2004) p.35 123 VIVAS Health submission, p.7 107
VIVAS Health claims that Vhi Healthcare provider negotiations set an effective price floor for reimbursement rates for other PHI firms. Either way, Vhi Healthcare exercises leadership in the negotiation of provider contracts which causes other PHI firms to alter their patterns of behaviour in the market. These firms constrict their behaviour either voluntarily, by following Vhi Healthcare’s provider negotiation model, or involuntarily, due to the effective price floor established by Vhi Healthcare, as VIVAS Health submits. 124 Is buyer power in the Irish PHI market problematic? 7.20 Of the three open enrolment insurers, Vhi Healthcare is in the best position to leverage its buyer power. This is because its customer base of over 1.5 million individuals and market share of 75% allows it to act as a “gatekeeper” of significant importance. Private hospitals are therefore constrained to agree terms with Vhi Healthcare to ensure access to the widest possible pool of consumers. If a private hospital fails to conclude terms with Vhi Healthcare, 75% of the PHI market 125 will be foreclosed to it. Furthermore, due to their risk profile, this 75% of the market requires a disproportionate higher level of health services. This gives Vhi Healthcare a position of considerable power among buyers, as having Vhi Healthcare as a client is necessary to enter the private hospital market, hence the term “gatekeeper”. 7.21 The OECD has found that “Providers…. cannot afford not to have a contract with one insurer, given the concentration of the PHI market and their high dependence on income from privately insured patients”. 126 New entrants to the private hospital market will find it difficult to prosper without securing Vhi Healthcare coverage. Only two of the 26 private hospitals offering in-patient facilities are covered by BUPA Ireland and VIVAS Health, but not Vhi Healthcare. Countervailing Efficiencies 7.22 Buyer power cannot be analysed by means of a per se approach. Instead, a rule of reason must be applied, balancing the potential anticompetitive effects of buyer power against efficiency benefits which may arise. In this respect, the exercise of buyer power in the Irish PHI market may generate efficiencies. Premium increases may be limited due to bargaining power, although price increases have nonetheless continued to be significant in recent years. It is unclear that other efficiencies are generated. 7.23 Vhi Healthcare has promoted the increased use of relatively more efficient day-care and side-room procedures, and is on record as stating that “in our negotiations (we) insist that internal efficiencies, rather than price, be the first point of focus for hospital management”. 127 However, the promotion of day-care and side-room procedures arises not from the exercise of buyer power, but from the cost control which any economically rational PHI firm would be 124 No submission was received from BUPA Ireland. 126 OECD (2004) p.38 127 “VHI's sole purpose is to serve its members” Irish Times, August 2 nd , 2005 108
Page 1 and 2:
A Report to the Minister for Health
Page 3 and 4:
CONTENTS TABLE OF FIGURES _________
Page 5 and 6:
CONSUMER ATTITUDES TO SWITCHING ___
Page 7 and 8:
EXECUTIVE SUMMARY AND RECOMMENDATIO
Page 9 and 10:
As a result it does not have to sat
Page 11 and 12:
Recommendation 7 The Minister for H
Page 13 and 14:
indicates that consumers of PHI hav
Page 15 and 16:
Recommendation 13 The Minister for
Page 17 and 18:
is quite unclear, so far as the Aut
Page 19 and 20:
1.4 For the next number of months t
Page 21 and 22:
other insurers were to enter the ma
Page 23 and 24:
2.6 Private health insurance (PHI)
Page 25 and 26:
2.17 Open enrolment and lifetime co
Page 27 and 28:
• 2001: The Health Insurance Auth
Page 29 and 30:
Figure 2: Annual Change in PHI memb
Page 31 and 32:
of medical inflation and the higher
Page 33 and 34:
VIVAS Health is rising steadily. In
Page 35 and 36:
• Table 1 below shows the annual
Page 37 and 38:
Figure 6: PHI Products BUPA Ireland
Page 39 and 40:
• Work-based group schemes where
Page 41 and 42:
from year to year and also during t
Page 43 and 44:
3. DEFINING THE PRIVATE HEALTH INSU
Page 45 and 46:
Figure 7: Key features of Related H
Page 47 and 48:
price increase unprofitable by a hy
Page 49 and 50:
4.6 Aspects of the exemption from i
Page 51 and 52:
and quarterly management accounts t
Page 53 and 54:
Table 4: Regulation of PHI Firms 48
Page 55 and 56:
4.31 This is a positive step. Just
Page 57 and 58: obliges Vhi Healthcare to seek appr
Page 59 and 60: 4.41 In the regulatory approval pro
Page 61 and 62: 4.50 However, the Authority is clea
Page 63 and 64: Unfunded Lifetime Community Rating
Page 65 and 66: President of the Society of Actuari
Page 67 and 68: − The main other deterrent at pre
Page 69 and 70: o The former members of the Advisor
Page 71 and 72: materially affected by any seasonal
Page 73 and 74: It may also be noted that the propo
Page 75 and 76: 4.94 There are 37 health insurers i
Page 77 and 78: Interviews with Possible New Entran
Page 79 and 80: have shown that new sales and switc
Page 81 and 82: not binding on incumbents and no in
Page 83 and 84: 5.33 In this context Vhi Healthcare
Page 85 and 86: 5.44 As the former incumbent monopo
Page 87 and 88: 5.52 Vhi Healthcare’s first mover
Page 89 and 90: • Psychological costs 6.5 Transac
Page 91 and 92: 18-24 9% 13% 25-34 34% 19% 35-44 31
Page 93 and 94: 6.24 The provision of renewal notic
Page 95 and 96: The HIA publishes on its website a
Page 97 and 98: Recommendation 10 Following consult
Page 99 and 100: Recommendation 11 The insurance com
Page 101 and 102: Regulations were established to aff
Page 103 and 104: transferred and the amounts require
Page 105 and 106: Buyer Power and Concentrated Market
Page 107: The Supply of Private Medical Facil
Page 111 and 112: approval on coverage of facilities
Page 113 and 114: Supplier-Induced Demand 7.36 The Vh
Page 115 and 116: Questions Relevant evidence Irish P
Page 117 and 118: to restrict individual choice of pr
Page 119 and 120: 8. CONCENTRATION AND MARKET POWER I
Page 121 and 122: gives us some indication of the com
Page 123 and 124: wishes to retain the flexibility to
Page 125 and 126: largest price increase that is prof
Page 127 and 128: scheme. Employees may be under the
Page 129 and 130: elevant regulatory requirements, ex
Page 131 and 132: Table 7 Vhi Healthcare Financial Re
Page 133 and 134: • There is limited buyer power fr
Page 135 and 136: Breaking up Vhi Healthcare would di
Page 137 and 138: expertise and other staff resources
Page 139 and 140: APPENDIX 1 Other forms of health re
Page 141 and 142: APPENDIX 2 Report of UK Government
Page 143 and 144: Australia Ireland Public hospital U
Page 145 and 146: Australia Ireland Risk equalisation
Page 147 and 148: 1.22 The Irish data is not split at
Page 149 and 150: Conclusion of normal claim payments
Page 151 and 152: APPENDIX 3 Consumer Attitudes to Sw
Page 153 and 154: Survey Respondent factors promoting
Page 155 and 156: APPENDIX 5 OECD Review of PHI The O
Page 157 and 158: not-for-profit insurers has posed c
Page 159 and 160:
114. Private insurers have not impl
Page 161 and 162:
APPENDIX 6 List of Submissions The
Page 163 and 164:
Understanding and Comparing Private
Page 165 and 166:
Benefits Outpatient Cover Cover for
Page 167 and 168:
Dobson, P., M. Waterson and A. Chu,
Page 169:
Vhi Healthcare (2005), Annual Repor
show all

Competition in the Irish Private Health Insurance Market

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?