Tag Archives: GU series II

Medical underwriting and risk adjustment practices: Spain

Health insurance models vary from country to country. As highlighted in our first series of articles on international health markets, governments often dictate the role of private and public health insurance within any country. Milliman has produced a new series of blogs focused on the medical underwriting and risk adjustment practices of eight countries: Australia, Ghana, Ireland, New Zealand, Saudi Arabia, South Africa, Spain, and United Arab Emirates. This is the second article in our series.

The Spanish National Health System (NHS) follows an integrated model in which the financing (through general taxes), purchasing, and provision of health services are mainly public. It offers universal coverage and, in accordance with the Spanish Ministry of Health and Social Policy, 95.8% of the total population was covered in 2011.

Since 2002, the organization of the NHS has been decentralized across the 17 autonomous communities in which the territory is divided. The central government is responsible for ensuring equitable access to health services across the territory and keeps its authority over areas such as regulation of pharmaceutical products.

Patients are required to visit the general practitioner assigned to their specific geographic health areas, who in turn refers patients to corresponding specialists as needed.

In April 2012, a health reform introduced different measures to control the public health expenditure, such as the regulation of the conditions to provide health services to undocumented immigrants and the extension of selective copayments on pharmaceutical products. The copayment is established taking into account the level of income and whether the person is retired or actively working. Copayments are not applied in only a few cases, for example the long-term unemployed and low-income groups.

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Medical underwriting and risk adjustment practices: Australia

Health insurance models vary from country to country. As highlighted in our first series of articles on international health markets, governments often dictate the role of private and public health insurance within any country. Milliman has produced a new series of blogs focused on the medical underwriting and risk adjustment practices of eight countries: Australia, Ghana, Ireland, New Zealand, Saudi Arabia, South Africa, Spain, and United Arab Emirates. This is the first article in our series.

The national public health system in Australia—”Medicare”—provides universal health coverage for all Australian citizens and most permanent residents. It provides free or subsidized access to most medical services and prescription pharmaceuticals. It is largely funded from general taxation, including a statutory insurance levy, which is 1.5% of taxable income (some low-income people are exempt or pay a reduced levy). Individuals and families on higher incomes who do not take out private hospital insurance pay an additional means- tested Medicare levy surcharge of 1%-1.5% of taxable income. The remaining funding comes from private out-of-pocket payments.

The benefits received from Medicare are based on medical and pharmaceutical fee schedules set by the government. Medicare usually pays the full schedule fee for general practitioner (GP) services, 85% of the schedule fee for other outpatient services, and 75% of the schedule fee for inpatient services when treated as a private patient in either a public or private hospital. Services provided to public patients in public hospitals are free of charge. GPs and specialists charge on a fee-for-service basis and can choose to charge more than the fees in the schedule.

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