ESTADO DEL ARTE, MARCO TEÓRICO Y MARCO CATEGORIAL
3.3. Marco Categorial
3.3.5. Diversidad e Infancia
This section outlines the characteristics of the Irish healthcare system under the headings of organisational structure; systems of financing, delivery and access; and proposals for reform. Irish healthcare structures and functions are similar to those in many developed countries, but there are some important differences, notably in the system of eligibility for public healthcare and the complex mix
between public and private financing and provision. In Chapters 5 to 11, we describe in greater detail the characteristics of specific sectors.
2.2.1 Organisational structures
The Department of Health provides strategic leadership for the Irish healthcare system, ensuring that government policies are translated into actions (1). It provides support to the Minister for Health and junior Ministers of State, who are politically accountable for the health service. The Department is responsible for policy and planning, evaluation of resource allocation and the development of the legislative and regulatory framework for the health system (1). The Health Information and Quality Authority (HIQA) was established in 2007 to monitor independently and to promote quality and safety in Irish health and social care services (2, 3). The Health Service Executive (HSE) was established in 2005, and manages the operation of the Irish health service, replacing former local health boards (4). The Department of Health and the HSE in Ireland are responsible for both health and social care services, which in some countries are separately administered and funded. The HSE was reorganised in 2013 when a regional division of responsibilities was replaced by a directorate structure organised along service delivery lines (5).
Hospitals in Ireland may have public, private or voluntary ownership. In 2013 the HSE assigned public and voluntary hospitals to seven hospital groups with group chief executive officers reporting to the HSE National Director of Acute Hospitals (6). The Programme for Government 2011-2016 proposed that these groups should become independent Hospital Trusts, in a new system of Universal Health Insurance (UHI) (7). Although the proposed UHI reform was abandoned in 2015 and there was a change of Government in 2016, the hospital group structure remains. The 2016 Programme for Government commits to further developing the Hospital Group Structure and proposes that the HSE should eventually be transformed into a Health Commission (8). It envisages that hospital groups would evolve to have greater autonomy in a system separating purchaser and provider functions with payment for activity replacing block grants (activity based funding). Hospitals would have to meet target waiting times for inpatient, outpatient and Emergency Departments, which would be agreed with the Performance Management Unit, a subdivision of the Health Commission (8). Primary and community care services are administered and some are delivered by a network of 32 Local Health Offices (LHOs), a structure which predates the establishment of the HSE. Re-organisation has changed the regional structures above the LHOs from 17 Integrated Service Areas (ISAs) between 2010 and 2013 to nine Community Healthcare Organisations (CHOs). Whereas ISA managers were responsible for overseeing hospital, primary, and community and
Background | 13
continuing care services in their areas, the CHOs no longer have responsibility for hospital services (9). CHOs are tasked with implementing nationally standardised models of care for each care group (i.e., primary care, social care, mental health, health and wellbeing services), but have scope to bring a local community focus to service delivery (10).
2.2.2 System of financing
Total current expenditure on health and social care combined has been estimated at €18.8 billion in 2013 and €19.1 billion in 2014 (10.1 per cent of gross domestic product (GDP) or 11.7 per cent of gross national income (GNI)) (11). This estimate by the Central Statistics Office (CSO) was compiled according to the OECD’s System of Health Accounts. This adopts an inclusive approach to social care services, which can affect international comparability since some other countries exclude a higher proportion of social service funding from estimates of health expenditure (12). Capital expenditure has been estimated at €914 million in 2013 and €894 million in 2014, 4.6 and 4.5 per cent of overall Irish healthcare expenditure for those years respectively (11). Current expenditure is financed from a mixture of public and private sources, with government financing (largely from taxation) contributing an estimated 69.3 per cent in 2014 (11). Private financing in the form of out-of-pocket (OOP) spending by users and private health insurance accounted for 15.4 per cent and 12.7 per cent respectively of current healthcare expenditure in 2014 (11). The remaining 2.6 per cent is accounted for by other voluntary schemes, i.e. non-profit institutional financing (e.g. voluntary donations and contributions) and enterprise financing schemes (e.g. employers providing healthcare and/or occupational healthcare to employees).
2.2.3 System of delivery
There are public, voluntary and private (for profit) providers of healthcare in Ireland. Public providers (e.g. public hospitals, public long-stay units etc.) are owned and directly funded by the HSE. Voluntary bodies are usually religious organisations or charities, and receive most of their funding from the state. Service level agreements with the HSE generally govern services to be provided in return for Exchequer funding. Many major acute hospitals are owned by voluntary organisations. Similarly, voluntary organisations provide mental health and addiction services. Private acute care is provided in both public and private hospitals. Private providers also deliver many primary and community health services, e.g. general practitioners (GPs), pharmacists and private providers of home care. Other areas of private delivery include private mental health and addiction services, and private nursing homes.
2.2.4 System of access
Ireland has the only European health system that does not offer universal coverage of primary care (13). Although the system is predominantly tax- financed, purchasing private health insurance offers preferential access to public hospital care despite the relatively low financing contribution made by such insurance, and much of primary care remains financed out-of-pocket (4, 14). There is evidence of financial barriers to access, unmet need for care and relatively high user charges for primary healthcare (15, 16).
All citizens are eligible for treatment in public hospitals. Public hospitals are funded by the state for public patients’ care and by private fees and insurance for private patients’ care. Care in private hospitals is generally financed by private insurance or out-of-pocket but the state has purchased private hospital care for public patients on waiting lists. GPs deliver care in a private market to the majority of citizens who purchase care out-of-pocket; and GPs are paid by the state by a mixture of capitation and fees for the care of people on lower incomes and in age or other categories, who qualify for free GP care. Ireland’s complex system of eligibility for publicly-financed care is summarised in Table 2.1.
TABLE 2.1 ELIGIBILITY FOR HEALTH SERVICES IN THE IRISH HEALTHCARE SYSTEM
Type of Care Category 1 (Full medical card holders) GP Visit Card Category 2 (Do not hold medical cards)
GP Free Free Out-of-pocket fee
Prescription Medicines Co-payment charge of €2.50 per
item. Capped at €25 per person (or family) per month (General Medical Services Scheme), at €20 if aged 70 or over
Drugs Payment Scheme: Free above €144 out- of-pocket payment per month per
family/individual.
For Specified Long-Term Illness (Long-Term Illnesses/ High Tech Drug Schemes): Free Acute public hospital
inpatient Free €80 per night (annually capped at €800 per person)1
Acute public hospital outpatient (includes
Emergency Department) Free
Free with GP referral. €100 per visit without
GP referral2 Free access to other outpatient
services.
Other Varied eligibility for community, personal and social care services, dental,
ophthalmic, aural care;3 other benefits
Source: Citizens Information, 2017.
Notes: 1. Exemptions to inpatient charge: Children up to six weeks of age; Children with a mental handicap or mental illness, phenylketonuria, cystic fibrosis, spina bifida, hydrocephalus, haemophilia and cerebral palsy; Children referred for treatment from child health clinics and school health examinations; People receiving treatment for prescribed infectious diseases; People who are entitled to hospital services because of EU Regulation; Women receiving maternity services.
2. Exemptions to Emergency Department charge: Those admitted as an inpatient from the Emergency Department (still liable for the inpatient charge); Children up to six weeks of age; Children with a mental handicap or mental illness, phenylketonuria, cystic fibrosis, spina bifida, hydrocephalus, haemophilia and cerebral palsy; Children referred for treatment from child health clinics and school health examinations; People receiving treatment for prescribed infectious diseases; People who are entitled to hospital services because of EU Regulation; Women receiving maternity services; People with Hepatitis C who have a Health Amendment Act Card
Background | 15
Individuals can qualify for a full medical card (Category 1) or a GP visit card on a means-tested basis8 under the General Medical Services (GMS) scheme (17, 18).
Full medical cards entitle holders and their dependants to largely free primary and public hospital services. Recipients also receive free medical appliances and a maternity cash grant on the birth of a child. However, since 2010, medical card holders have been charged co-payments for prescribed medications. Individuals aged 70 and older were automatically entitled to medical cards between 2001 and 2009. While means testing has been re-introduced for this age cohort they still qualify for cards at a higher income threshold than those aged under 70. GP visit cards, introduced on a means-tested basis in 2005, confer eligibility for free GP visits to the holder and their dependants.9 In August 2015 those aged 70
and older and above this threshold have been eligible for a GP visit card. Since July 2015, all children aged under six years have been eligible for GP visit cards. Due to changes in the relationship between the income thresholds for eligibility and the income distribution, there is fluctuation in the percentage of the population covered by medical and GP visit cards. From 2005 to 2015, the percentage of the population covered by cards increased from 29 to 47 per cent (20). Tax relief is available for all medical expenses, including costs of nursing home care, that are not otherwise reimbursed by public funding or by private health insurance (21).
Individuals who are defined as being in Category 2 do not meet the criteria for a full medical card. Generally, such individuals have to pay the full cost of GP care (unless they qualify for a GP visit card) and a charge for attending the Emergency Department (ED) or staying overnight in a hospital. Discretionary medical cards may be issued to those in Category 2 if they have certain health needs which are determined to cause them ‘undue hardship’.10
Approximately 46 per cent of the population purchased private health insurance in 2015 (22). Private health insurance mainly covers hospital services and is largely purchased to avoid long waits for public care (23). Private insurance can cover treatment both in public and private hospitals. The government supports the market by subsidising the cost of private health insurance through 20 per
8 Individuals living alone aged under 66 who earn less than €9,568 annually or a couple with two children aged under 16 who earned less than €17,810 annually are entitled to a medical card. Income cut-offs are slightly higher for those aged 66-69. The income limit for over 70s medical card is €26,000 for a single person and €46,800 for couples. The income thresholds for GP visit cards for under individuals living alone aged under 66 is €14,352 and €26,725 for a couple with two children aged under 16 (www.citizensinformation.ie)(17, 18).
9 Additionally, those with Health Amendment Act Cards, who contracted Hepatitis C through contaminated blood products, are entitled to GP visits and a variety of other services, free of charge (19).
10 The Health Act 1970, as amended, states that a person is eligible for a discretionary medical card if ‘considered by the chief executive officer of the appropriate health board to be unable, without undue hardship, to provide that service for himself or his dependants’ HSE (2014). Report of the Expert Panel on Medical Need for Medical Card Eligibility.
cent tax relief on private health insurance premiums.11 The system of access and
eligibility for long-term and intermediate care is outlined in Chapter 9.
2.2.5 Proposals for reform
The complex mixed public-private system persists despite repeated reform attempts, including the 2011 to 2016 Government’s proposal for UHI, which was abandoned in 2015 (20). More recently, an all-party Oireachtas (parliamentary) Committee was established in 2016 with the aim of achieving a single long-term vision for healthcare and the direction of health policy in Ireland. The Committee’s Sláintecare Report, published in May 2017, recommended the introduction of universal GP and primary care in stages, ending private practice in public hospitals, reducing or removing out-of-pocket fees and substantially increasing public healthcare expenditure and capacity in a tax-funded system (24). The Hippocrates model has been structured to facilitate modelling the effects of such proposed reforms, including modelling the effects of changing the composition of healthcare financing or changing eligibility; and modelling the capacity and expenditure implications of meeting unmet need or demand.
Reviews of literature and evidence
In the next sections, this chapter reviews the best available evidence on a number of important themes that inform the approach to analysis and modelling in this report. These themes include: the drivers of healthcare demand and expenditure; modelling methods to project healthcare demand and expenditure; defining, measuring and projecting unmet need; and trends in mortality and in the relationships of morbidity and disability to life expectancy.