Eligibility for health services.
In 1991 a two-tier system of eligibility for hospital inpatient and outpatient services was introduced. It provided for category 1, medical card holders and category 2, all others.
The population is divided into category 1 and category 2. Category 1 comprises medical card holders and dependants who are entitled to all health services free of charge. This covers one third of the population.
Category 2 covers the remainder of the population who are entitled to a more limited range of services free of charge.
People in Category 1 are entitled a free GP and hospital services in public wards of public and voluntary public hospitals. People in Category 2 are liable for GPs fees but entitled to free hospital services subject to amount maximum annual charge of €1200 max 2010.
In 2001, eligibility for medical cards was extended to all persons over 70 years of age irrespective of means. The automatic entitlement was removed in 2009. However, after significant protests 95 percent of persons over 70 retained their medical card, with remainder losing automatic entitlement.
A special medical card was introduced in 2005, providing for free GP service but not free drugs and medicine. The income level threshold for qualifications is 25 percent above the standard medical card threshold.
The Voluntary Health Insurance boards as established by the Voluntary Health Insurance Act 1957. Category 2, eligibility persons with eligibility for subsidised hospital services commonly takeout cover to provide private or semiprivate accommodation and private treatment in hospitals.
EU competition legislation required the introduction of competition into the private health insurance market. The Health Insurance Act 1994 ended the VHI monopoly. The British Union of Private Assurance commenced operating in 1997. By 2002 it had 300,000 subscribers. Its business was taken over by Quinn Insurance in 2007.
Aviva entered the market in 2004 was taken over by Hibernian Health in 2008 and became Hibernian Aviva. By 2009 VHI retained the largest market at 64 percent followed by Quinn Healthcare (Liberty Mutual) 22 percent and Hibernian Aviva Health 10 percent.
A 1999 White Paper on Private Health Insurance provided for a programme of reform to include the transformation of VHI into a commercial semi-state agency and the retention of revised community-based rating. The 1994 Act provided for risk equalisation to prevent insurers targeting low risk, relatively younger and healthier subscribers. The Health Insurance authority was established by legislation in 2001.
A system of community rating applies. All age categories are charged the same premium irrespective of age. Risk equalization was recommended by the Health Insurance Authority and involves transfer payments between insurers to spread the cost of higher risk older members.
In 2006 BUPA decided to withdraw from the Irish markets leading to its acquisition by Quinn following a failed challenge to risk equalization. The BUPA appealed the High Court decision and the 2008 Supreme Court rule that the system of risky equalization was invalid because it had been based on an incorrect interpretation of the provision in the Health Insurance Act 1994.
In 2010 the government announced an intention to invest €200 million in VHI prior to putting it for sale by 2013. The purpose was to bring VHI’s reserves up to a level that would enable it to be authorised on objective financial services grounds. By 2008 over half the population had VHI cover but this fell significantly following the financial crisis.
In principle there is full access to hospital services since 1991 for all. However, waiting lists for public patients have grown and the private health insurance system is perceived to provide quicker access to hospital care.
The Health Strategy [2000] proposed the creation of 3,000 beds by 2011 designated for public patients. The proposed employment of additional consultants. It promised a waiting time of not more than 3 months. It proposed a treatment purchase fund for treatment from private hospitals and abroad.
The National Treatment Purchased Fund is an independent agency, whose s purpose is to reduce waiting times for public patients waiting for surgery. Public patients on waiting list may contact the NTPFR, or may be referred to it, which may source treatment. The NTPF has a made a substantial difference to waiting list, decreasing waiting time for surgery considerably.
Under the 1997 hospital consultant’s contract, consultants were paid a salary for treating public patients of 33 hours per week. They could also charge fees to private patients.
In conjunction with the pre-designation of categorization in 1991 it was provided that private patients must generally be accommodated in designated private beds. 20 percent of beds were to be designated private although this percentage in fact increased. A report by the Controller and Auditor General noted that the 80-20 split was largely ignored to the detriment of public patients.
New consultants contract was finalised in 2008. It provides for a longer working week and public only type contracts, limits on private first, public practice and a common waiting list for diagnostic services including laboratory and radiology services. It provided for restricted monitoring of private practice.
In 2005 a proposal for development of private hospitals with tax relief on the site of public hospitals in a number of locations was proposed in order to provide additional bed capacity. The purpose was to increase the number private beds and free up private beds in public hospitals. The issue became controversial and most of the projects were not completed.
In 2009 Fine Gael brought forward proposals r a system to abolish the basis of health care entitlement and replace it with universal health insurance. This would involve free GP Care for the entire population with state funding of insurance premium for medical card holders. The Programme for Government contained a commitment to introduce a universal health insurance scheme with equal access to healthcare by 2016.
The choice of doctor schemes commenced under the GMS introduced in 1972. Until 1989 GMS doctors were paid a fee per consultation in accordance with the scale.
Under GMS, pharmacists who enter agreement with the HSE, are primary supplier of drugs to those with eligible for GMS cards. The pharmacy recoups the cost of drugs from the HSE and is paid a dispensing fee. A prescription charge of 50 cent per item subject to a maximum of €10 per month per person of family was introduced in 2010.
In 1989 a capitation payment was introduced for each panel patient weighted to gender, age, geographic factors. The has agreements with 2500 doctors, 1500 pharmacies, 1200 dentists and 550 optometrists as of 2007. Most doctors attend both public and eligible patients and “private” patients with variations in distribution.
The Health Strategy proposed an interdisciplinary themed approach to primary care in Primary Care a National Direction in 2001. It proposed greater liaison between care providers and proposed that many hospital services could be provided in the community.
It proposed that primary care teams would comprise GPs, nurses, midwives, healthcare assistants, home helps, occupational therapists, social workers, administrative personnel, working together from a single centre. The purpose was to provide a one stop shop to deal with 95 percent of health needs. Each team would cover a population of 8,000t to 10,000 population.
There have been 10 pilot schemes since 2006. As of 2010 progress has been significantly less than expected with only 222 teams of the 600 proposed teams. Half of these work were at an advanced functioning stage which was defined as holding clinical team meetings to discuss and plan integrated care for clients while other teams had not GPs in place.
In the 1980s, cutbacks in public expenditure forced rationalisation in the hospitals sectors. A number of public voluntary hospitals and smaller district hospitals were closed. Approximately , 6,000 beds were removed between 1984 and 1993. Many of closure occurred through the department reducing Health Board were just leaving no alternative but to close smaller hospitals.
The rationalisation of Dublin hospitals was undertaken at leading three major hospitals on the northside, Beaumont the Mater and James Connolly Memorial Hospital, and three on the south side St. Vincent’s, St. James and Tallaght.
The Hanly Report 2003 considered the Working Time Directive in the context of hospital doctors. It recommended the employment for larger number of consultants and revised working patterns. It recommended a consultant provided hospital service instead of the existing consultant led service.
The Hanly examined the Dublin and the Mid-Western areas. In 2009 the HSE proceeded with hospital services reconfiguration in the Midwest broadly along the lines in the Hanly report.
The Children Health First report commissioned by the HSE and compiled by McKinney’s was published in 2006. It recommended that the State c could justify one world class children’s hospital which it indicated should be in Dublin adjacent to an adult hospital. A task force in the Department of Health and HSE concluded that the project could be delivered most efficiently on the Mater side. The Boards of National Children’s Hospital, Tallaght and Crumlin Hospital expressed the view that the process was flawed and lacked transparency.
In 1989 Commission on Health Funding favoured public funding as the principal method of funding the health service. On the basis of public funding the choice was between general taxation and compulsory health insurance earmarked tax. General taxation was favoured on the basis that the earmarked tax constituted general taxation in substance. Ut recommended the abolition of health contributions introduced in 1971.
As of 2004, 85 percent of health services is derived from exchequer with outpatient charges accounting for 10 percent.-