An unprecedented standoff between health insurerNIB and the St Vincents Health Australiahas captured headlines for the potential high out-of-pocket costs for thousands of hospital patients.

Perhaps more importantly, it should also raise questions about whether there is room in our health system for rich profits flowing to private insurance companies.

St Vincents Health is Australias largest non-profit hospital operator with 10 private hospitals on the east coast. NIB is Australias fourth-biggest health insurance company.

It was demutualised and listed on the Australian Stock Exchange in 2007 with the usual demutualisation result of much higher salaries for top executives.

Benefit payouts

According to the most recent Commonwealth Ombudsman_State of the Health Funds Report_, of the Big Five insurers, NIB pays out the lowest percentage of contributions as benefits, leaving the biggest percentage for management expenses and profits.

Within those five, there is a marked difference in benefit payouts between the two mutual companies and the three for-profit operations.

The two mutuals HCF and HBF respectively pay 87.7 and 87.9 per cent of contributions as benefits for members, the balance going on management expenses.

The three for-profits Medibank, BUPA and NIB pay 83.4, 80.9 and 79 per cent of contributions as benefits.

(Medibank and BUPA have the benefit of scale with 27.1 per cent and 24.9 per cent market share. NIB has 9.6 per cent. HCF and HBF have 12.5 and 7.7. BUPA runs as a for-profit company in Australia, feeding its profits back to subsidise its British non-profit parent.)

Public interest

Given the tens of billions of dollars in annual insurance premiums, never mind the federal governments $7 billion subsidising the industry through the private health insurance rebate, each of those percentage points is a very large amount of money and a matter of public interest.

Industry superannuation funds have demonstrated clearly superior performance of profit-for-members funds over profit-for-shareholders funds the key difference being the profit margin demanded by shareholders, an expense mutuals dont have.

All other things being roughly equal and if private health insurance wasnt so complicated, opaque and something of a protected species you would expect mutual insurers to outperform for members compared with what profit-driven insurers do for customers.

The percentage of contributions paid out indicates that is exactly the case, but customers tend to see the marketing campaigns and frequent flyer points offers rather than an ombudsmans report.

Hard edge

The breakdown in negotiations between NIB and St Vincents represents a new hard edge by an insurer out to protect its profit margin and potentially a spotlight on the mutual versus for-profit difference.

In the first half of the 2023-24 financial year, NIB recorded group underlying profit of $144 million, up nearly 22 per cent, on total group revenue of $1.7 billion, up 12.4 per cent.It is doing well enough to pay its CEO, Mark Fitzgibbon of the Hunter Valley Fitzgibbon Labor political dynasty, $4.8 million a year.

Mr Fitzgibbon, who oversaw the demutualisation, owns $20 million worth of NIB shares. Before NIB, he had been a local government general manager and CEO of the NSW and national licensed clubs industry bodies.

Mr Fitzgibbon has made headlines before, famouslywanting Medicare scrapped and everyone forced to take out private health insurance.

Yet NIB is playing hard ball with St Vincents, negotiations breaking down when the insurer told the hospital group it had made its final offer.

Indexation disagreement

Interestingly, the breakdown is over the final years annual indexation in a three-year agreement. Within the past year, St Vincents successfully reached much more complicated comprehensive agreements with both mutual and for-profit health funds. Indexation is relatively straight forward by comparison.

Also interestingly, St Vincents has not actually been negotiating with NIB, but with Honeysuckle Health, a 50-50 joint venture by NIB and the American managed health care industry giant, Cigna. Cigna posted a $US5.2 billion profit last year on revenue of $US195 billion. ($7.7 billion and $289 billion.)

As theHoneysuckle Health website puts it: Our dedicated team of hospital negotiators and relationship managers have over 30 years combined experience in negotiating hospital contracts.

In a statement announcing St Vincents was giving NIB 65 business days notice,CEO Chris Blake said it was the first time in its 167-year history that negotiations had collapsed.

There is a crisis in private healthcare in Australia, he said.

Over the last five years, more than 70 private hospital services have closed. Weve now got a major federal government review into the survival of the sector.

For private health care to operate effectively, health funds and hospitals need to work together, and on an even playing field, for the benefit of our members and patients. Thats certainly the St Vincents commitment.

In the last 12 months, St Vincents has negotiated major new agreements with Medibank, HCF and the Alliance group of health funds. As with all negotiations, while they were robust, both sides gave ground in order to achieve a fair result.

But nib has given us no choice but to make this call.

Coverage at risk

Being one of the Big Five gives NIB considerable bargaining power. It would hurt St Vincents if nearly 10 per cent of its patients had no private health cover and had to pay full fare themselves.

But in a more genuinely competitive industry, rather than a sheltered workshop, this would be an opportunity for other insurers to grab NIB clients.

A quick, well-advertised campaign to waive waiting periods for NIB clients wanting to swap providers would have an impact NIB couldnt afford either.

Unfortunately, many NIB customers may not know their coverage is at risk. NIB also operates under the Qantas, APIA, AAMI, GU and Suncorp brand names.

Having said it had made its final offer,NIB now says its committed to continuing negotiations.

Republished from THE NEW DAILY, July 10, 2024