Most of us haven’t heard of Istvan Szekely, but he may well have more influence on health spending in Ireland than our government. At the recent ICGP winter meeting, health policy analyst Sara Burke told us that when the IMF moves into financially troubled states, it focuses immediately on health spending as one of the ‘low-hanging fruits’ for big savings. In Ireland, the IMF didn’t focus much on health until the second year of the three-year bailout, which followed a visit by Mr Szekely, one of the Troika team, to a GP in Dublin for treatment of an infection. It appears he had to pay E70 for the consultation, which was far in excess of what he expected. Judging by the audience reaction in Athlone, it was also far in excess of what most GPs receive from their own private patients.

Dr Burke’s session on universal health insurance developed into a lecture on the financing of general practice and the increasing anxiety. Listening to the discussion, an outsider would think that the State was the sole purchaser of medical services from GPs through the GMS. That same outsider would be surprised to learn that up to 60% of patients finance their visits to the GP out of their back pocket and seem under Competition Law to be expected to shop around to find the best price.

Up to 45% of patients have private health insurance with the number decreasing by 62,000 last year due to premia becoming unaffordable. The main underlying driver is secondary care medical inflation which always outstrips ordinary inflation. All the evidence we have points to general practice as the single biggest moderator of costs in healthcare. Those countries with well-functioning general practice spend less of their gross national product on health than those countries, like ours, with less well-functioning general practice. Now if everyone knows that, why don’t our health insurers in Ireland know it?

A recent report¹ commissioned by the Minister for Health opens the door for general practice, especially in the area of chronic disease management. It is clear that most chronic disease care occurs in general practice and: “it has been shown that chronic illness can be better managed in a well-developed multidisciplinary primary care setting, provided the necessary supports are put in place for patients and their carers”. In a fairly radical conclusion, the report’s author Pat McLoughlin says “the public and private healthcare system would benefit from an enhanced implementation of chronic care programmes. The CEOs of the private health insurers have, in direct discussions, agreed to participate positively at CEO level in initiatives to examine how to incentivise more integrated care models for dealing with chronic disease”.

In the developed world, there’s a general consensus that secondary care is too expensive, often inappropriate and cannot be delivered effectively without a vibrant primary care sector. Does anyone know what our health insurance industry’s policy is on general practice? The debate at the winter meeting indicates that GPs do not expect the industry to become players in healthcare anytime soon. The insurance industry says it has to raise its premia in accordance with changes in hospital practice. It seems wedded to this reactive approach even as it loses members. As long as they continue to operate a simple money-in equals money-out business model, insurers will always be cashiers for secondary care. The introduction of competition has meant our insurers are more concerned with vying with each other for a declining market than they are with becoming players in the healthcare system. Instead of developing healthcare incentives that can leverage change, they market complex plans that confuse subscribers.

Do insurers want to become involved in delivering appropriate and affordable care to a growing number of patients? They are letting the modern world of cost-effective healthcare development pass them by. Government needs to facilitate the industry to become players in healthcare, giving them a place in policy development in return for a commitment to best international best practice. The boards of private health insurance companies need to pay their CEOs according to the amount of integrated care programmes they implement.

Strategically as GPs, we are in a vulnerable position. We have based our industrial relations on negotiations with one single purchaser who buys care for 40% of our patients. This has delivered well for GPs in the past but the GMS knows that as the main organised purchaser of healthcare, it calls the shots. No matter what business it is, with a single purchaser all the talk in the world will not prevent a steady lowering of fees for more and more work. We cannot ignore the fact that 45% of our patients have a health insurance plan that ignores us and distorts our practice of medicine. It is now up to organised general practice – the ICGP, IMO and NAGP – to demand that our health insurers engage with general practice in the interest of providing safe, cost-effective healthcare to a growing number of our patients. The report to the Minister opens the door for this. 

Reference

1. Pat McLoughlin. Review of measures to reduce costs in the private health insurance market 2013. Department of Health 2013