ICGP submission to the public consultation on the scope for private health
insurance to incorporate additional primary care services
Established in 1984, The Irish College of General Practitioners (ICGP) is responsible for post
graduate specialist medical education, training and research in the specialty of General
Practice. The College has a national advisory role in relation to medical standards and
interacts regularly with a number of bodies including the Medical Council, Department of
Health and Children, the Health Service Executive and the Health Information & Quality
Authority amongst others. As a membership organisation the ICGP is responsible for
providing continuing professional development (CPD) for established GPs numbering over
3,000 at present. The mission of the ICGP is to serve the patient, and its members / general
practitioners by encouraging and maintaining the highest standards of general medical
practice. The core values of the College are quality, equity, access and service to the patient.
The ICGP welcomes the opportunity to contribute to the public consultation on the scope for
private health insurance to incorporate additional primary care services. Currently primary
care services covered by private health insurers are very limited as the health insurance
industry has a strong hospital focused service approach. 24 million consultations take place in
general practice in Ireland every year and 90-95% of the patients that present are managed in
general practice without need for further referral.
Government policy is to move to a Universal Healthcare Insurance (UHI) model but it has
been acknowledged that this may take some time to achieve. The ICGP supports reform of
the healthcare system and is in favour of access based on need and not on ability to pay. The
ICGP supports the concept of UHI but has expressed its reservations in relation to the
proposed funding of UHI based on private commercial health insurers.
This submission focuses on the scope for private health insurance in the current service
delivery model in Ireland to be expanded to incorporate additional primary care services.
Chronic Disease Management in Irish General Practice
Chronic diseases are the leading cause of death and morbidity in developed countries. A
recent report from the Institute of Public Health in Ireland (Balanda et al, 2010) provides
useful data on chronic disease in the Irish context. In recent years life expectancy in Ireland
has increased, however, the quality of life in the extra years gained has been reduced by the
burden of chronic disease. The poor and vulnerable in our society are more likely to suffer
from chronic disease due to a variety of interrelated social determinants of health and
environment. It is estimated that by 2020 the number of adults with chronic disease will
increase by around 40% in the Republic of Ireland. The implications for funding health
services to cope with this increase in demand will impact on both the public and private
health care industry. Delivering this care at the lowest level of cost centre will be a priority
for success. As we plan for the future it is essential that private health insurers consider the
1
impact of chronic disease and the need to expand cover in primary care to include structured
chronic disease management and multi-morbidity.
Most of the care of patients with chronic disease in Ireland takes place in primary care
(Department of Health and Children, 2009). Internationally chronic disease accounts for a
significant proportion of the disease burden and an increasing workload for GPs accounting
for up to 60% of visits by patients 45 years and older (Britt et al. 2009).
Primary care (with general practice at its core) has a central role in the management of
chronic disease. Specialist care is best utilised for the management of patients with unstable
conditions and the management of complications. Integration of care provision across acute
hospital and primary care while developing the community services supporting the patient
will make the best use of limited financial resources. Investment in IT will be essential to
enable seamless care for patients. General Practice has been to the forefront in the
development of computerised medical records with 92% of practices using electronic records.
This is in stark contrast to the hospital sector where patient records remain predominantly
paper based. GPs have largely funded these developments themselves with little state support.
There is a need to enhance data collection in the general practice setting to enable planning of
services and improvements in patient care. The development of the Irish Primary Care
Research Network (IPCRN) should enhance this capability. The recent development of
Healthmail allowing secure email between health professionals is also a welcome
development. However the need for significant investment in IT remains. Private health
insurers could support this development.
In a recent Irish study, the main barriers to delivering chronic care in the general practice
setting are an increased workload and a lack of appropriate funding for chronic disease
management (Darker et al, 2011). Private health insurance could help to address these
barriers.
Multi- morbidity
Most patients presenting to primary care have multiple problems – physical, psychological
and social. Most clinical trials exclude patients with multi-morbidities. Primary care is best
placed to address multi- morbidity as hospital based care becomes more and more
specialised. GPs can integrate care, personalising care provision depending on the personal
circumstances and capabilities of the individual patient and prioritising perceived problems
(Heath et al, 2009). A recent European Commission report (2014) recommended a ‘spiral’
model of referral for patients with chronic conditions, and particularly those with multiple
conditions. This means that these patients get the best care through a combination of referral
horizontally within primary care and vertically to secondary/tertiary care on an ongoing basis.
The report suggests that co-ordination of care at a primary care level is essential for effective
care delivery. Co-ordination of care and continuity of care are essential and unique
components of general practice health care delivery. Continuity of care is valued by patients
and leads to improved outcomes, lower rates of hospital and emergency department
attendances, lower complication rates and reduced healthcare expenditure (Wallace et al,
2015). In a study based in the West of Ireland (2011) Glynn et al found the prevalence of
multi-morbidity was 66.2% in those over 50 years of age. Health care utilization and cost
was significantly increased among patients with multimorbidity, with the addition of each
chronic condition leading to an associated increase in primary care consultations; hospital
out-patient visits; hospital admissions and total health care costs.
2
GPs have the unique ability to provide continuity and co-ordination of care for patients with
multiple chronic diseases. Private Health insurance could target support for co-ordination of
care and continuity of care at the general practice level with a particular focus on care of
patients with multi-morbidity.
Secondary Prevention of Cardiovascular Disease
International evidence shows that secondary prevention of cardiovascular disease can be
enhanced by structured organisation of primary care for patients with established heart
disease.
In the Irish setting the Heartwatch programme commenced in 2003 on a pilot basis with 20%
of general practices involved in a structured schedule for secondary prevention of
cardiovascular disease. A number of studies have been published clearly demonstrating
marked improvement in morbidity and mortality in the cohort of patients in the Heartwatch
programme. McGrath et al (2012) found that after five years, 5 per cent of the study patients
in Heartwatch practices had died compared to 14.8 per cent in the non-Heartwatch practices.
There were also very positive results regarding the outcomes of cardiovascular death, heart
attack, stroke or heart failure, at 8 per cent in Heartwatch practices compared to 14 per cent in
non-Heartwatch practices. Murphy et al (2009) demonstrated an absolute reduction of almost
10% over an 18 month period in hospital admissions in patients on the Heartwatch
programme. The potential for private health insurance to support a model akin to Heartwatch
with proven outcomes should be explored.
Diabetes Structured Care
5.6% of the adult Irish population have diabetes (190,000). The Institute for Public Health
(2012) estimates that “there are approximately two adults aged 45+ years with undiagnosed
diabetes for every five adults aged 45+ years with clinically diagnosed diabetes”. 10% of the
Irish Health Care budget is spent on diabetes – €1.35 billion annually with 60% of this budget
spent on complications (Canavan, 2013).
Irish GPs have demonstrated their ability to successfully deliver diabetic chronic disease
management in a structured care programme addressing recording of processes of care,
achievement of treatment targets, risk factor targets, reduction in complications and
glycaemic control (Marsden et al, 2010). Structured care, with relatively limited but wellfocused investment, achieved quality of care for patients with diabetes, comparable to
international best practice (Brennan, 2008). Private health insurance cover should be
expanded to cover structured diabetic chronic disease management in general practice as Irish
GPs have clearly demonstrated their ability to provide high quality effective care for these
patients given appropriate resources and supports to do so.
Answers to specific questions asked in the public consultation process:
1) What is the optimal level of cover for primary care services and GP services that
would be available in private health insurance contracts
For an optimal level of cover to be in place a unique health identifier and universal patient
registration would first have to be in place. Additional services that could be covered include
structured chronic disease management and management of patients with multi-morbidity (as
3
outlined above). Access to diagnostics is a key issue. GPs have limited access to diagnostics
for public patients in stark contrast to their access for private patients. Access to diagnostics
should be based on need rather than on ability to pay. Irish GPs believe and international
evidence concurs that increased access to diagnostics will lead to reduction in diagnostic
delay, reduce the number of referrals to both emergency and out patient departments, reduce
unnecessary admissions and improve the quality of referrals overall (O’Riordan et al, 2013).
This in turn will lead to more effective use of the hospital services and improve the quality of
service for Irish patients.
The provision of additional services and inter- referral between General Practices should be
incentivised for services such as:
-
Ambulatory blood pressure monitoring
Spirometry
Womens Health: Mirena insertion, Implanon insertion, diaphragm insertion, STI
screen
Minor Surgical procedures
Phlebotomy
Venesection for patients with Haemochromatosis
Vaccination in specific groups
Screening if there is a family history of specific conditions
Structured health promotion particularly on lifestyle interventions
If properly resourced the above services could be provided at a lower cost and equivalent
quality compared with secondary care. There will need to be recognition that these services
may be GP led and provided by the practice nurse. The role of allied health professionals in
the primary health care team and using a team based approach to patient care should also be
supported.
2) Are there any measures that the State should take to mandate or incentivise the
provision and/or purchasing of such cover
Younger patients could have cheaper cover. If one does not avail of insurance when
younger, comparative premiums could rise when older. Tax incentives would
encourage purchasing of such cover.
3) Should any cover be compulsory ( as part of minimum packages ) or optional
Minimum cover should be compulsory. What is covered by this minimum cover will
be a difficult decision. It goes against the ethos of a comprehensive GP service if
some illnesses or conditions are not covered.
4) Should primary care cover be in a separate health insurance plan or as part of inpatient plans.
Funding of primary care services has traditionally suffered when combined with
hospital sources in the same budget. Therefore primary care cover could be separate
4
and offer competitive rates when compared with equivalent services in secondary
care. For example there would be no “bed day” charge for minor surgery in primary
care. Alternatively the cover could encompass both primary and secondary care with
extension to secondary care if referred by a primary care physician.
5) To what extent should limiting terms be allowed (e.g. number of visits allowable,
the amount payable per visit etc )
The average visiting rate for GMS patients at present is 5-6 visits per year. This figure
could be used to cover attendances for acute problems in the GP surgery. Visitation
rates above this would need to be justified on the basis of specific conditions .There
are patients who require more visits than the norm. For example patients on warfarin
with unstable blood tests (INRs) requiring frequent attendance and patients requiring
palliative care. Patients with chronic disease, multi- morbidity and those from poorer
socio-economic backgrounds will also require more frequent visits. A reasonable
amount should be paid commensurate with the work done.
6) How can we encourage a real transfer of provision of services from the acute
hospital setting to primary care
Patients should be made aware that comparative packages are cheaper in primary than
secondary care. Insurance companies will also be paying for the hospital care so the
drive for the provision of care at the lowest cost centre may come from them. It is
essential that the administrative burden for claiming for work done and associated
staff and IT cost be kept to a minimum.
7) What is the capacity of GP practices to deliver insurance funded primary care of
the type suggested here
Teamwork will be key to solving the current manpower shortage in general practice.
Insurance bodies will need to acknowledge the role of the GP in leading on care
provision with direct provision of care by other team members particularly practice
nurses. This is the model currently used in Heartwatch and structured diabetes care
programmes. Insurance companies will have to recognise that the practice nurse is a
vital member of the practice team in delivering a primary care service.GP services
have the capacity and flexibility to deliver this type of care if properly resourced to
do so
8) Other comments ?
A package of health insurance that incorporates elements of GP visits, additional
services and chronic disease care is a welcome initiative. In view of the
undifferentiated nature of general practice visits and providing care as the initial point
of contact, it is important that insurance coverage for GP visits commences with a
commitment to core service provision for a standard consultation. Additional services
incorporating health promotion, prevention, structured chronic disease management
can then be added to the core provision.
5
References
Balanda KP, Barron S, Fahy L, McLaughlin A. Making Chronic Conditions Count:
Hypertension, Stroke, Coronary Heart Disease, Diabetes. A systematic approach to
estimating and forecasting population prevalence on the island of Ireland: Executive
Summary. Dublin: Institute of Public Health in Ireland, 2010.
Brennan C, Harkins V, Perry IJ. Management of diabetes in primary care: a structured-care
approach. European Journal of General Practice. 2008; 14(3-4): 117-22. doi:
10.1080/13814780802689154.
Britt H, Miller GC, Charles J, Henderson J, Bayram C, Harrison C, Valenti L, Fahridin S, Pan
Y, O’Halloran J. General practice activity in Australia 1998–99 to 2007–08: 10 year data
tables. General practice series no. 23. Canberra: Australian Institute of Health and Welfare,
2008.
Canavan R. National Diabetes Programme. Presentation at NAGP AGM November 2013.
Darker C, Martin C, O’Dowd T, O’Kelly F, O’Kelly M, O’Shea. A National Survey of
Chronic Disease Management in Irish General Practice. Dublin: Irish College of General
Practitioners, June 2011.
Department of Health & Children. Health in Ireland: Key Trends 2009. Dublin: Department
of Health and Children, 2009.
Glynn LG, Valderas JM, Healy P, Burke E, Newell J, Gillespie P, Murphy AW. The
prevalence of multimorbidity in primary care and its effect on health care utilization and cost.
Family Practice. 2011 Oct; 28(5): 516-23. doi: 10.1093/fampra/cmr013. Epub 2011 Mar 24.
Expert panel on effective ways on investing in health. Definition of a frame of reference in
relation to primary carewith a special emphasis on financing systems and referral systems.
European commission 2014.
Heath I, Rubinstein A, Stange KC, van Driel ML. Quality in primary health care: a
multidimensional approach to complexity. BMJ. 2009 Apr 2; 338: b1242. doi:
10.1136/bmj.b1242.
Institute of Public Health in Ireland. Diabetes Briefing: Chronic Conditions Hub. Dublin:
Institute
of
Public
Health
in
Ireland,
2012.
http://chronicconditions.thehealthwell.info/diabetes
Marsden P, Brennan C, McHugh S, Harkins V. Audit Report of the HSE Midland Diabetes
Structured Care Programme. Dublin: Department of Public Health, Health Service Executive
Dublin Mid-Leinster, 2010.
McGrath ER, Glynn LG, Murphy AW, O Conghaile A, Canavan M, Reid C, Moloney B,
O'Donnell MJ. Preventing cardiovascular disease in primary care: Role of a national risk
factor management program. American Heart Journal. 2012 Apr; 163 (4): 714-9. doi:
10.1016/j.ahj.2012.01.027.
6
Murphy AW, Cupples ME, Smith SM, Byrne M, Byrne MC, Newell J; SPHERE study team.
Effect of tailored practice and patient care plans on secondary prevention of heart disease in
general practice: cluster randomised controlled trial. BMJ. 2009 Oct 29; 339: b4220. doi:
10.1136/bmj.b4220.
O’ Riordan, M, Collins, C. and Doran, G. 2013 Access to Diagnostics – a key enabler for a
primary care health service. ICGP May 2013.
Wallace E, Salisbury C, Guthrie B, Lewis C, Fahey T, Smith, S.M. Clinical Review:
Managing patients with multimorbidity in primary care. BMJ 2015;350:h176 doi:
10.1136/bmj.h176 Published 20 January 2015.
Submitted on behalf of the ICGP Board January 2015
7