Universal Health Insurance (UHI) RCPI response to the White Paper

Transcription

1 Employee Handbook of the Royal College of Physicians of Ireland Universal Health Insurance (UHI) RCPI response to the White Paper May 2014

2 Table of contents Executive Summary Background Universal Health Coverage and Ireland Concerns with UHI model Multi-payer Model Waiting Lists Costs Equity under the UHI Model Private Hospitals The UHI Package and Premium The UHI Basket Regulatory Burden Considerations for Clinical Care Useful concepts from the UHI proposal Introduction of Universal Health Coverage on a phased basis References Appendix Institute of Obstetricians and Gynaecologists (IOG) Submission

3 Executive Summary RCPI supports the concept underpinning the Universal Health Insurance White Paper; that of universal health coverage. The aim of providing access to all on the same basis that privately insured patients currently enjoy is laudable. However, we have some concerns as to whether the model proposed in its current form, particularly with respect to the multi-payer model, will bring about the desired effect. In particular the multi-payer model may not be appropriate for Ireland s small population. RCPI is of the view that incremental improvements over an extended period are more effective than large scale reform over a short timeframe. The challenge of introducing this reform within a very ambitious timeframe, and subject to ongoing financial constraints may carry a risk of deterioration of quality at some point in the system. The future demographic picture of Ireland requires a health coverage model that can address the challenge of the ageing population and provision of complex care for elderly, multi-morbidity patients. Efforts will be needed to ensure this is the case under the proposed UHI system, or any future system of coverage. There are a number of specific areas where clarification and further discussion are needed: Role of co-payments and cost to the user. Composition and process for defining the basket. Rationale for inclusions/exclusions in the basket, particularly with respect to pharmaceuticals and Assisted Reproductive Technologies (ARTs), including In Vitro Fertilisation (IVF). Implications for clinical care. Irrespective of introduction of UHI, there are many valuable aspects of the current proposal that should be retained as building blocks for moving towards a system of quality healthcare provision based on need. Central to this is the introduction of the Money Follows the Patient system of prospective funding, and using clinical expertise and international best clinical practice to determine best practice pricing thereby ensuring quality. RCPI is committed to developing that system in collaboration with the HSE. 2

4 Other principles of UHI that should be retained include: The principle of guaranteeing timely access to essential services for all is welcome, even if it requires the explicit recognition that some services must be excluded from the UHI basket to achieve affordability. Proposals under UHI represent an opportunity for transparency in defining the national health basket, thereby eliminating any lack in transparency regarding entitlements to care. Addressing the issue of private care subsided by the state is positive. Private patients in Ireland pay very little in comparison to international averages, not reflecting the true cost of care. Improved regulatory oversight of care is welcomed, so long as it actively supports improved clinical standards and applies equally to all providers, both public and private. There are also a number of pre-requisites for UHI implementation that are not explicitly discussed in the White Paper, such as strengthening of primary care and introduction of an integrated IT system across the health service. 3

5 1. Background This paper was prepared as a RCPI submission to the public consultation on the White Paper on Universal Health Insurance, published by the Government in April The Royal College of Physicians of Ireland, as a training and professional body is committed to improving patient care and equipping doctors with the skills needed for safe and efficient healthcare systems. RCPI seeks to work proactively with relevant stakeholders to improve quality in clinical care, and to ensure better outcomes for patients. 2. Universal Health Coverage and Ireland RCPI supports the World Health Organisation (WHO) definition of the concept of universal health coverage: Ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. 1 Healthcare provision in Ireland in certain situations is characterised by a two-tier system whereby those who can afford private healthcare insurance can avail of more rapid access to treatment in the independent private system while those without may experience delays at multiple points within the public system. The situation is more complex for the majority of care in certain areas such as emergency care, paediatric care and complex cancer care where the majority of care is provided within the public system equally to both private and public patients. Approximately 1.8 million people have full medical cards in Ireland, while a further 400,000 have GP visit cards. Those who cannot afford private insurance, but are above income limits for a medical card, bear the burden of out of pocket payments towards hospital costs, and pay 100% of the cost of GP care and up to 144 per month a for necessary drug treatments. In recent years, co-payments for services provided by the public system have been increasing, and even people with medical cards have seen an increase in their co- a Under the HSE Drugs Payment Scheme 4

6 payments for prescribed medication. At the same time, the economic downturn has seen a significant increase in the number of people qualifying for medical cards in recent years, combined with declining numbers paying for private health insurance. The Irish Health Service has undergone an unprecedented reduction in healthcare expenditure, which is almost without parallel in developed countries. Despite the reduction in funding there have been considerable improvements in care (e.g. National Stroke Programme, Acute Medicine Programme, National Cancer Control Programme). This has been driven by a clinical leadership model involving the postgraduate colleges, the HSE and the Department of Health and the outstanding commitment by front line clinical and non-clinical staff. Nonetheless, the system is still under considerable strain and significant risk remains with respect to the health of both patients and staff. Sustained attention to quality improvement is necessary to ensure the system is safe, cost-effective and responds adequately to the health needs of the population. The attention to quality improvement will be significantly undermined by unrealistic targets for a reduction in staffing levels and overall expenditure either as part of the current or future budgetary cycles. Such an approach is likely to lead to a disproportionate increase in clinical risk and a potential reduction in costeffectiveness. This should be considered in the context of changing demographics which will bring additional demand and complexity in the delivery of chronic care for an ageing population. It is recognised that the state continues to operate in an environment of economic uncertainty and with limited financial resources in a variety of areas. Regardless of the mechanism of insurance, the Irish health system will still require capital and manpower investment. Investment focused on evidence-based clinical services should underpin the future model of universal health coverage in order to maintain quality and financial sustainability in the long term. 5

7 3. Concerns with UHI model 3.1. Multi-payer Model There appear to be considerable difficulties associated with the multiple payer model, especially in the context of Ireland s small population. Under the proposed UHI model, the expectation is that the operation of multiple payers in the system would ensure competition. A number of countries operate a multi-payer system. While not the only multi-payer model analysed in the White Paper, the Dutch experience is often noted with concern as health care spending per capita in Holland increased by 46% between 2005 (when reforms were introduced) and The UHI proposals may offer many improvements over the current health system. However, many of the benefits could also be achieved with a single-payer system that contracts services from multiple providers, which would obviate the difficulties associated with multiple insurers. The multiple payer model of funding care imposes a heavy regulatory burden. Regulation is necessary to counter the incentives insurers have to select low risk patients. Recent experience with regulating the private health insurance market in Ireland demonstrates that the legal and other difficulties of correcting and compensating for these incentives are considerable. The expansion of the multipayer model to the whole population will widen the scope of the problem of risk selection and the corresponding regulatory burden Waiting Lists The proposals imply that the new system of UHI will effectively eliminate waiting lists by allowing patients to be treated wherever capacity is available in a timely manner. While the elimination of waiting lists would be welcome, it is unclear whether this goal is feasible. The additional resources required to ensure that everybody can access care with the same speed that privately insured patients currently do will be considerable. The concern is that without sufficient resources waiting lists under UHI may not level-up to current private care, but rather that 6

8 waiting lists will remain, and so there will be a levelling-down in timely access to care for many in the population. Waiting lists are not currently a problem within primary care in Ireland, but could develop under the UHI proposals. The expansion of primary care coverage at no costs to the user (or at much lower cost than currently) may result in many more people being able to access the system, driving up waiting times in primary care. The UK NHS is an example of free at the point of use primary care service that is burdened by long waiting lists: The Royal College of General Practitioners has stated that more than 26 million people in England had to wait for a week or more to see or speak to their GP last year Costs Implementation of UHI will undoubtedly require substantial investment and financial resources, which are currently unavailable to the Irish government. According to the White Paper, UHI should not cost the state more than the current model, but it is difficult to see how this is the case. At present almost 2 million people have access to free care in the public healthcare system (medical card coverage) 4. The number of people eligible under UHI will be more than double the current system. It is unclear if the private payments under the mandatory health insurance will be sufficient to finance this marked increase in coverage. Regarding cost-control, international experience shows that social insurance based models have higher costs than taxation based models, (including Ireland s current model). Any cost inflation would likely prove unsustainable to the Irish health system. Providing a common standard of care for all insured implies a trade-off between the resources required and the scope of coverage. The challenge will be to provide an adequate level of cover to all insured without requiring considerable increases in public and private expenditure. The proposals need to be seen in light of current entitlements of both those with and without health insurance; reducing the level of care to below what is currently provided is unlikely to be workable. The background policy paper that forms part of the support documentation for the White Paper outlines how resources will be raised for UHI. It does not however indicate how the transition to UHI is to be resourced. Such a massive change 7

9 cannot be done without an associated cost, and this must be acknowledged. Failure to resource this massive change may result in the system bearing the cost elsewhere, with potential for deterioration in quality of services Equity under the UHI Model The White Paper refers to the principle of equity as follows: The system should provide financial protection against catastrophic out of pocket expenditure through universal coverage of the entire population. A system of compulsory UHI should ensure universal access to healthcare for all citizens based on need rather than ability to pay. 5 This definition of equity should be expanded to adequately address the issue of health inequities in the Irish context. Goal 2 of the Healthy Ireland Framework for Improved Health and Wellbeing is to reduce health inequalities and as such, a broad definition of health equity should be central to any improvements to the current health system. Equity in health is greater than the ability to access healthcare treatment. Rather it encompasses additional active supports including preventive measures, as well as measures to reduce social and economic inequalities that impact negatively upon health outcomes. This applies to all ages in socio-economically disadvantaged groups, but is of particular importance in relation to the elderly and children with disability or chronic disorders Geographical equity is also not explicitly discussed within the UHI system. Geographic access to services will always have to be balanced with quality service provision in adequately resourced facilities. Such regional concerns are particularly acute in Ireland given the proportion of the population that live far from the main urban areas and the needs of older people in accessing necessary transport. An aspect of the proposed model that is not entirely equitable is the system of copayments. While it is clear that co-payments of some form will exist, the level of these co-payments is not yet defined. Co-payments have a place in a healthcare system to prevent moral hazard and overuse of services by those not in clinical need. However, a set co-payment is by its very nature regressive, costing those on lower incomes proportionally much more than those with higher incomes. 8

10 3.5. Private Hospitals There is a fear that private hospitals may decide to opt out entirely of the UHI system. The proposals state that the cost of care funded under UHI will be tightly regulated. If the regulated prices are below the cost of delivering care in private hospitals it is likely that they will withdraw their services. Consequently, there is a fear that instead of enhancing supply and reducing waiting lists, the UHI proposals may result in the reduction of overall supply and increased waiting times. Further discussion is needed to understand any potential impact of private hospitals opting out of UHI The UHI Package and Premium Costs to the User Co-payments/excess payments will be allowed under UHI. It is unclear how this will be determined and regulated. Both co-payments and excesses will disproportionally affect those on lower incomes. In addition, co-payments and excesses can reduce transparency for consumers. Subsidy It is not entirely clear exactly how the subsidy system will operate. Ideally, the subsidy would be provided on a sliding scale, rather than a set cut off point for a subsidy. Competition The extensive price regulation in the current proposals limits the scope for competition on cost. Experience in other European countries suggests a lack of price competition for consumers, where the price of premiums increased since the introduction of a similar model. A 2012 study 6 on the financing of health insurance in the Netherlands, Germany and France found that between nominal premiums rose by 5-10%. Preferred Providers and Safeguards Under the UHI system, insurers will be allowed to specify preferred providers. This may mean that patients will have to pay a premium to use the provider of their choosing (where that provider is not the preferred one). Safeguards to ensure patients get quick access to care within an acceptable geographical area have yet 9

11 to be defined. Patients should be allowed to access services at their local hospital without penalty. Equally, if the waiting time at the preferred provider is in excess of a defined maximum threshold, patients should be allowed to access treatment elsewhere. Risk Selection and Adverse Selection Under UHI, there is a very real risk that insurers may practice risk selection, attracting low risk customers by means of marketing and plan design. The problems of adverse selection are well understood in health insurance markets and there are already compensating mechanisms in place in Ireland. However, the expansion of UHI to all portions of society, especially those of lower socioeconomic status who tend to suffer worse health than other groups, means that the scale of adverse selection could worsen. Risk equalisation measures need to be sufficiently robust to ensure the provision of insurance for such groups and the financial position of the insurers that offer them cover both remain adequate. Continuation of Single Tier The UHI proposals have the aim of eliminating two-tier access to care in Ireland. The proposals contain a number of constraints to prevent some patients gaining faster access than others under UHI. Despite this, it seems that aspects of two tier access will remain. This is because it appears unfeasible to constrain individuals from getting faster access or better care from private hospitals outside the UHI system. Consequently, UHI will not in itself eliminate the single tier system as some element of multi-tier access will continue to exist The UHI Basket Values Framework The values framework sets out a sensible set of considerations when determining what should be covered by UHI. However, the competing values outlined in the framework will need to be carefully balanced to determine which services are covered and which are not. From the standard health economics perspective, it makes sense to adopt the most cost-effective interventions first; that is, to prioritise the most cost-effective treatments and then cover progressively less cost-effective interventions as budgets allow, up until the point that the available resources are fully allocated. 10

12 Such an approach will achieve the maximum possible health gain for whatever level of funding is available. One concern with the values framework is that it risks double-counting certain benefits or giving undue weight to characteristics of certain interventions. For example, the framework includes effectiveness and cost-effectiveness as proposed values. By the standard definition an intervention must be effective to be costeffective; however, the clinical view is that there should be consideration of clinical effectiveness as distinct from cost-effectiveness. Discussion will be needed to ensure clear understanding as to what extent these two criteria overlap and how they are balanced when assessing the benefits of an intervention. Without this understanding, an intervention may risk counting effectiveness as a benefit twice. Similarly, the values framework mentions resource impact on the overall economy. Conceivably prioritising care for those of working age brings a benefit to the economy, but this can discriminate against children or older people. The formulation and operation of the values framework is likely to be under considerable lobby pressure from drug and device manufacturers to support the inclusion of their products. Safeguards will be required to ensure the framework is developed and implemented judiciously. Safeguards for the appropriate development of the framework include an open discussion of the elements included in the value framework and a full disclosure of submissions regarding the framework. Similarly, regarding the implementation of the framework, it is important that the discussions around the choice of which interventions to include and add to the basket over time are published. This will provide oversight regarding the way the values in the framework are traded-off against each other when determining which interventions are accepted and which are rejected. Supplementary Insurance It remains unclear what will be covered by supplementary insurance. The proposals imply supplementary insurance will largely be for non-essential aspects of care such as rooms with TVs or cosmetic surgery. However, there is likely to remain considerable scope for care not covered by UHI or other public funding. This has not been adequately addressed in the White Paper. Ideally supplementary insurance would provide cover for non-clinically significant treatments only. This, however, is only likely to be achieved if the standard UHI package is particularly comprehensive, which in turn implies large overall costs. It 11

13 is worth noting that in 2006 in the Netherlands, 92% of people purchased supplementary insurance policies, indicating that the basic coverage package was not considered sufficient 7. Again, there is a risk that the (perceived or real) need for supplementary coverage will result in a continuation of our two tiered health system, albeit in another form. Basic and Preferred Basket The UHI proposals provide two illustrative examples of baskets of care that could be provided. These are outlined in the supporting document Background Policy Paper on Designing the Future Health Basket (p. 140) and are termed the basic and preferred package. There is comparatively little difference between the two baskets of services; the preferred basket additionally includes community nursing services, chronic disease and case management, and step-down care. The provision of examples of possible baskets is a useful approach to illustrating the policy proposals. However, the particular examples provided are unclear. For example, it is not conceivable that if the basic package was adopted that community nursing services and chronic disease management would cease, rather it seems they would be publicly funded outside of UHI. Consequently, the differences between the example of the basic and preferred package do not really seem to represent why types of coverage decisions might be taken. Furthermore, the additional examples included in the preferred package do not appear to illustrate applications of the values framework. Exclusions from Basket RCPI has concerns in relation to some treatments which are not explicitly included under UHI. Assisted Reproductive Technologies (ART), for example should be included as the core principles justifying UHI are in agreement with and echo the argument for public ART services b. Provision of ART would also bring entitlements in Ireland in line with those of most other European counties. Of 21 EU countries, Ireland and Lithuania are the only 2 which do not have public funding of ART treatments 8. b For further discussion on inclusion of ART in the UHI basket, see the separate submission made as part of this consultation by the Institute of Obstetricians and Gynaecologists (included as appendix) 12

14 While the inclusion of pharmaceuticals in the basket has not been decided, it would seem appropriate to subject pharmaceuticals to the same conditions for inclusion in the basket as non-drug components of care. The area of pharmaceuticals is the fastest growing portion of care in terms of cost, and it is conceivable that exclusion from the basket could permit further excess inflation in the longer term. Similarly, it is unclear how services provided by allied health professionals (such as physiotherapy, occupational therapy, speech therapy, prosthetics and orthotics) will be treated, as the are not explicitly mentioned under the UHI basket. It is also unclear as to whether aspects of care that are publicly funded outside UHI will enjoy the benefits of being able to ensure provision by alternative suppliers, or whether recipients will be restricted to certain providers and subject to the associated waiting lists. In the case of public community and primary care services currently only available to those with medical card, discussion is needed as to what happens with these - that is whether access will be open to all. Care relating to chronic conditions in children should be covered under the UHI package of services. It is not clear whether this is the intention under the current proposals. Health promotion is not covered within the basket. While it largely makes sense to fund health promotion centrally from tax revenues, there are some health promotion activities, such as those delivered directly to patients, which may be appropriate for inclusion in UHI, for example, smoking cessation counselling sessions upon GP referral. Discretionary Clause While the UHI basket will explicitly state the interventions to be provided, a degree of discretion will need to be retained to allow for individual need (and societal expectation). In the UK, for example the treating physician may apply on behalf of the patient for a treatment outside of the basket. High-Cost Care State provision outside of UHI for high-cost care may be a necessary response to political pressure for expensive treatments that cannot demonstrate good value. The use of such a fund should ideally be maintained at a minimum. Indeed, it is 13

15 instructive to assess the UK s experience with special schemes to fund treatments that have failed to demonstrate good value. Although these schemes serve a relatively small number of patients, their expenditure has grown to approximately 10% of the overall NHS drugs spend 9.Some controls may need to be imposed on the high cost care fund to ensure it does not grown uncontrollably. Public Consultation on the Basket It may be useful to extend the consultation on the basket composition to the public in a formalised way. As the documentation supporting the UHI proposal notes, a successful model for this is the UK s Citizen s Council. The Citizen s Council provides the National Institute for Health and Care Excellence (NICE) with a public perspective on overarching moral and ethical issues that NICE has to take account of when producing guidance. The council's recommendations and conclusions are incorporated into a Social Value Judgements document, and, where appropriate, into NICE's methodology. Adopting such as system in Ireland could ensure public transparency in the process of deciding the basket composition. However, it is not likely to avoid political controversies around funding of care Regulatory Burden A market-based approach with multiple payers requires regulation to achieve the desired outcomes. This is reflected in the UHI proposals, which envisage a strong role for regulation, especially of UHI funded services and their prices. Indeed, the degree of regulation set out in the White Paper indicates that the regulatory burden of a UHI funded system is likely to be high. While it has to be acknowledged that the provision of adequate care will always require rigorous regulatory oversight, it is of concern that the proposed multiple payer model will probably require more oversight than other models of provision. The expansion of regulatory powers outlined in the UHI proposals largely involves consolidating the position of existing bodies, such as the Health Insurance Authority and the HIQA. However, the report also envisages the establishment of new regulatory authorities. The proliferation of new bodies with potentially overlapping functions would be unwelcome. It is hoped that the expansion of regulation could be achieved with clarity of responsibility between roles, a clear emphasis on 14

16 ensuring the highest clinical standards and the minimum impediment to the delivery of care. In addition to the potential regulatory burden, there is a concern that regulation may inhibit providers from delivering the envisaged benefits. In particular, the proposals contain a strong emphasis on price regulation. While there is a need to ensure costs remain reasonable, excessive regulation may inhibit supply that can only be provided at costs above regulated prices. Conversely, regulated prices serve not as maximum prices, but as standardised prices that must be levied. This means that care providers will not be able to pass on savings to the insurers, and so the competitive pressures to achieve savings will be weakened. 15

17 4. Considerations for Clinical Care The White Paper is not explicit as to how clinical views regarding treatment will be considered in the ongoing design of the healthcare basket. Although reference is made to the Clinical Programmes and to the National Clinical Effectiveness committee, the White Paper does not elaborate on their role. RCPI as a professional body is primarily concerned with maintaining high standards in clinical care. To this end, RCPI has an excellent collaborative relationship with the HSE in the design and delivery of National Clinical Programmes. The RCPI is committed to working with the HSE (and DOH) via the National Clinical Programmes to develop the suite of evidence-based clinical rules and coding which are required to underpin propsective funding. In addition, the National Clinical Programmes will continue to develop decision support tools (in the form of guidelines, care pathways, standard operating procedures) and metrics which will be available to support front line staff in the provision of high quality and cost-effective care. During the consultation process for designing the future health basket process, it is likely that many of the points outlined below would be addressed. Nonetheless, RCPI s concerns regarding implications for clinical care are outlined explicitly here: Inclusion of Assisted Reproductive Technology (ART) services in the UHI basket would be appropriate and in keeping with principles underpinning UHI. There is a concern that more explicit rationing will limit the ability of the clinician to initiate evidence-based treatment. If numbers of patients accessing services increased, there is a fear that doctors will be forced to see more patients, with less time per patient resulting in increased risk for the patient and doctor. Cost-control measures (such as the setting of maximum prices) should not be allowed to impact on either the quality of care or on timely access to clinical care. It is unclear how this will be guaranteed under the UHI system. 16

18 Data on clinical care usefully informs research and service planning. It is important that data gathering be protected and enhanced under a multiple payer and provider system. Given ongoing dissatisfaction with consultant contracts and the continued loss of medical talent to overseas training programmes and posts, the potential for costs competition leading to salary reductions needs to be acknowledged and addressed. It is likely that introduction of UHI would lead to increased demand for certain types of clinicians and training places. Workforce planning should be aligned with requirements under UHI. An insurance based system provides less scope for direct policy control to address health inequalities and other social objectives. UHI may place potential restrictions on providers that provide care funded by supplementary insurance regarding what they can provide to UHI funded patients. There are concerns for misaligned incentives at the margins between UHI and non-uhi funded care. Given the current situation in Ireland where many people inappropriately access care through Emergency Departments, incentives may exist for example, for insurance companies (UHI funded) to push patients toward non-uhi funded services. (EDs vs. primary care) 17

19 5. Useful concepts from the UHI proposal The call for a national consultation on UHI is to be welcomed. Many of the pertinent issues will need to be considered in the coming years irrespective of the introduction of UHI. The consultation usefully acknowledges that aspects of the current system are sub-optimal, and a number of concepts should be retained in a UHI system as currently proposed, or another system. These useful concepts include: The principle of guaranteeing timely access to essential services for all is welcome, even if it requires the explicit recognition that some services must be excluded from the UHI basket to achieve affordability. Proposals under UHI represent an opportunity for transparency in defining the national health basket, thereby eliminating any lack of transparency regarding entitlements to care. Addressing the issue of private care subsided by the state is positive. Private patients in Ireland pay very little in comparison to international averages, not reflecting the true cost of care. Improved regulatory oversight of care is welcomed, so long as it actively supports improved clinical standards and applies equally to all providers, both public and private. 18

20 6. Introduction of Universal Health Coverage on a phased basis It is our position that improvements to the health system should be incremental and when possible based on existing elements of good practice. While the promise of ending the two-tier system is appealing, any change should be done on a phased basis to ensure quality is maintained in the system. Before a system of Universal Health Insurance would be introduced, there are a number of areas that need to be addressed as pre-requisites. Strengthening of Primary Care Exactly what primary care means under UHI is not explicitly described. It is necessary to define or describe the concept of Universal Primary Care, and then to strengthen all aspects of delivery of that care, before moving to a UHI system. The proposed introduction of free GP care for under-6 s is already meeting resistance from General Practitioners. If this situation is not addressed satisfactorily before progressing to free GP care for all, and UHI, there will be substantial damage to primary care in Ireland. Similarly, there are many other aspects of primary care that should be strengthened before UHI is introduced. IT Systems An integrated ICT system across the health service should be in place to underpin the changes in UHI. While the White Paper alludes to information systems as a building block for UHI, the importance of the IT system should be emphasised. Resourcing for UHI The background policy paper that forms part of the support documentation for the White Paper outlines how resources will be raised for UHI. It does not however indicate how the transition to UHI is to be resourced. Such a massive change cannot be done without an associated cost, and this must be acknowledged. Failure to resource this massive change will result in the system bearing the cost elsewhere (whether at cost to the user, or a reduction in salaries of staff) with the potential for deterioration in quality of services. 19

21 Money Follows the Patient Implementation of the Money Follows the Patient (MFTP) system of prospective funding is to be welcomed, with or without introduction of the UHI system. While there are some limitations, it will give a more transparent view as to where money is being spent within the health system. It allows allows the opportunity to adjust the incentives to support the health of the total population. Effort is needed however to develop this system as a building block for UHI to ensure that price setting includes an emphasis on quality. At the moment, prices are being set based on 2012 activity and funding in However, this may be an inappropriate marker for prices as many services were delivered at unprecedented low cost because of a lack of resources, which may have resulted in less than optimum quality standards. This needs to be addressed before full roll-out of MFTP. In particular, the interface between the clinical programmes and the MFTP model should be developed to ensure quality criteria are considered in price setting ( best practice prices ) and financing under this model. As mentioned RCPI is committed to engaging in this process via the Clinical Care Programmes. In addition, when setting prices, preventive services need to be built into cost (eg Brief Interventions for smoking cessation). Learning from the experience with National Treatment Purchase Fund The NTPF has been in operation since 2004, and purchases treatments in private hospitals for public patients who have been on waiting lists for exceptionally long periods. In its basic operation it has many similarities to the proposed UHI system, and there may be lessons to be learned which will inform future development of UHI. To move towards the provision of Universal Health Coverage on a phased basis, leading eventually to a modified version of UHI, the above measures should be implemented on a phased basis, with adequate time at each stage for reflection, learning and redesign. In the case where UHI is not progressed, these measures will remain essential building blocks for reform of the Irish Health Service. 20

22 References 1 World Health Organisation. Health financing for universal coverage [accessed 20/05/14] 2 Turner, B. (2013) Health System Funding in Ireland: Universal Health Insurance and the Options. Fianna Fáil, Dublin. 3 Put Patients First Back General Practitioners, Campaign News, February 2014, Five Facts about the funding crisis in general practice. Royal College of General Practitioners [available online at: 4 HSE National Service Plan serviceplan2014.pdf 5 The Path to Universal Health Care -White Paper on Universal Health Insurance. DoH Turquet, P. (2012), Health insurance system financing reforms in the Netherlands, Germany and France: Repercussions for coverage and redistribution?, International Social Security Review. 7 Rosenau, P. V. and Lako, C.J., (2008), An Experiment with Regulated Competition and Individual Mandates for Universal Health Care: The New Dutch Health Insurance System, Journal of Health Politics, Policy and Law, Vol. 33, No 6 8 ESHRE. Comparative analysis of Medically Assisted Reproduction in the EU. RegulationandTechnologies,onlinewww.eshre.eu/media/emagic%20files/guidelines /MAR%20report.pdf. 9 Rafters J. Value based pricing: can it work? BMJ Oct 11;347(oct11 3):f5941 f

23 Royal College of Physicians of Ireland Frederick House 19 South Frederick Street, Dublin 2 Telephone: Facsimile: Website: JUSTIFICATION FOR INCLUSION OF EVIDENCE-BASED FERTILITY SERVICES IN THE UNIVERSAL HEALTH INSURANCE (UHI) HEALTH BASKETS. AN OPINION BY THE EXECUTIVE COUNCIL OF THE INSTITUTE OF OBSTETRICIANS AND GYNAECOLOGISTS RCPI ON AN ASPECT OF THE WHITE PAPER ON UNIVERSAL HEALTH INSURANCE THE PATH TO UNIVERSAL HEALTHCARE. Robert F Harrison MA.MD.DSc.FRCS(Ed).FRCOG.FRCP(I).DCH. Chairman Institute of Obstetricians and Gynaecologists RCPI. On behalf of the INSTITUTE EXECUTIVE COUNCIL. 26 th May 2014.

24 EXECUTIVE SUMMARY 1. Subfertility is classified by the WHO as a medical disease with significant physical, mental and social implications. Fertility treatment is, therefore, an essential component of good medical care. 2. Assisted reproductive technology (ART) in particular in vitro fertilisation (IVF), is the only effective treatment for some causes of infertility, and the safest and most cost-effective therapy for many other types The core principles justifying UHI are in agreement with, and echo the argument for public ART services. 4. In Ireland, assisted conception units are based in the private sector only. ART is not funded by the public health system. This current situation is inequitable as it excludes a huge number of patients who cannot afford treatment. The current situation is in direct contrast to the stated aims of UHI which is to provide equal access based on need rather than ability to pay. 5. Of 27 EU countries, Ireland and Lithuania are the only 2 which do not have public funding of ART treatments There is a clear trend, nationally and worldwide, towards an increased need for fertility services. Causes include higher rates of fertiity problems among survivors of childhood cancer and medical illnesses such as cystic fibrosis. Any planning for future healthcare developments should be cognisant of future needs and consider the needs of such groups. 7. The unregulated nature of an exclusively private service leaves Irish patients potentially vulnerable to commercially driven medical practice. Any planning for future healthcare developments should consider the demerits of the status quo, and the potential public health benefit by provision of evidence-based public ART services. 8. A lack of state funding for Assisted Reproductive Technology (ART) treatments forces some couples to access cheaper ART treatment in countries with less stringent medical practices than Ireland. We are aware of many patients who access inappropriate treatment abroad which results in high risk high order multiple pregnancies and deliveries which become a major financial burden for the Irish state. 9. Multiple pregnancies with its associated medical and financial burdens are a major complication of ART treatments. International data shows a trend towards more singleton deliveries in countries with higher levels of state reimbursement. 10. A unique opportunity to assist subfertile patients is now presented by the integration of all ART services into the Obstetric and Gynaecology health baskets.

25 1. PROLOGUE The Institute of Obstetricians and Gynaecologists RCPI (Institute) is the body that officially represents Obstetrical and Gynaecological opinion in Ireland. It acts as the advisory body and amongst other things strives to promote excellence in the area of patient care and professional standards. It acknowledges the right of individual members to have their own opinions but, on situations such as the publication of The Path to Universal Healthcare where the contents have the potential to affect member s practice and the lives of the patients we serve, the Institute as a corporate whole feels it is important to examine proposals in depth, come to an opinion on contents and supply that opinion to the appropriate authorities. 2. REASON FOR SUBMISSION. In-vitro Fertilisation(IVF) is cited specifically as an Entitlement in other Jurisdictions in the Background Government Policy Paper Designing the Future Health Basket for Universal Health Insurance dated March However there is no mention of it at all in the Government White Paper itself and specifically Chapter 4 The Future Health Basket. IVF does not fit under the heading new technology s4.3 p 61 as it commenced in Ireland in Indeed, members working in the field of Infertility have found it difficult to envisage where any infertility management including Assisted Reproductive Technology (ART) procedures fits into the policy proposals s 4.4 as discussed in pages This omission has prompted this submission, trusting that when the proposed Commission (s4.2 p53) to work in tandem with the Joint Oireachtas Committee on Health and Children is established, that the Institute s voice will be heard as a Health Care Stakeholder and advocate for the patients we serve. 3. MODUS OPERANDI. The White paper was supplied to all our members after publication in April and comments sought by mid May. Those made in terms of the overall generalities of the paper have been passed on for inclusion in an RCPI overall submission entitled Universal Health Insurance. RCPI response to the White Paper. This Institute

26 submission paper is confined solely to the essential need, as we see it, to have all Fertility Services including the Assisted Reproductive Techniques (ART) such as Invitro fertilisation (IVF) included as an integral part of the UHI Health care Basket. It was put together by a sub-group working in the field of Infertility from comments received from members and the final document approved by the Institute Executive Council on 25 th May INTRODUCTION Healthcare provision is an area of constant change due to advances in medical practice and changing patient populations. The needs of a community do not remain static, as is evident in many of the sub-specialty areas of Obstetrics & Gynaecology. Reproductive medicine, particularly assisted conception, has been the area within Gynaecology that has undergone the greatest growth and change over the past three decades. This is due to advances in laboratory technology, improved pharmacotherapeutics, and patient demand for best treatment. Assisted Reproductive Technology methodologies (ART) are now a standard treatment option for many cases of subfertility, offering medical therapy that is safer and more effective than non-art approaches 1. Indeed it is the only treatment option for many cases of subfertility. ART, specifically in-vitro fertilisation (IVF) and Gamete-intrafallopian transfer (GIFT) commenced in Ireland in ART now accounts for approximately 1% of all pregnancies in the Eurozone and USA, rising to 5% in some countries. In Ireland, it is estimated that at least 1% of all births result from ART 4. With global demand for ART treatment likely to increase, it is important that any planning for healthcare for Irish patients is informed by what has been learned about best practice, patient safety, health outcomes, ethical considerations and equitable access to services for patients. The White Paper on Universal Health Insurance issued by the Department of Health aspires to provide comprehensive and equitable access to medical care for all Irish citizens. The White paper states laudable objectives and core principles for a better health service. It is imperative we submit that all fertility treatments will be included in the Obstetrics and Gynaecology basket.

27 5. PRINCIPLES OF UHI = PRINCIPLES FOR PUBLIC ART PROVISION 5.1. National health and well-being enabling people to prosper and to realise their full potential socially, economically and creatively.improving the health and well-being of the people of Ireland. (page 16) Infertility is a recognised medical condition that can affect people of any age and has a potentially devastating effect on people's lives. The WHO definition of Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity in all matters relating to the reproductive system and its functions and processes. Approximately 15% of couples in Ireland will experience subfertility and require medical help. The current health service in Ireland provides for basic fertility investigations at primary and secondary care level. However, any form of tertiary level management / assisted conception is not available through the public health system. Patients often need treatment such as IVF. Such treatments are not accessible except through privately funded clinics. It should be noted that some ART treatments currently provided can result in highrisk obstetric cases. Indeed, the majority of complications of ART are associated with multiple pregnancy and the consequent increased risks of medical complications for mothers and infants. The practice of elective single embryos transfer (eset) in a number of countries has dramatically reduced ART multiple birth rates 5,6. However ART in Ireland remains unregulated, and in many cases the market incentive to attract patients may over-ride more conservative embryo transfer practices. This situation undoubtedly contributes to the complexity of feto-maternal and neonatal cases resulting from multiple pregnancies, placing excessive stress on obstetric, midwifery and neonatal services, and worsened perinatal outcomes, and increased expenditure to the public purse. This situation requires immediate reappraisal in the interest of improving the health and well-being of the people of Ireland. Experience from Belgium and Norway has demonstrated that patient safety in ART, particularly the incidence of multiple pregnancies, improves vastly when ART services are part of a comprehensive and integrated public health plan 7.

28 5.2. Fairness and equity...health service with access based on need, not income, provide equal access based on need rather than ability to pay (page 3) Most European countries provide access to ART treatment in appropriate clinical situations as IVF is recognised as the safest and most cost-effective therapy for certain types of subfertility problems 1. Despite this, ART services in Ireland remain unfunded. Of 27 EU countries, Ireland and Lithuania are the only 2 which do not have public funding of ART treatments 2. Since service inception in 1986, the Irish situation is largely the result of historic bureaucracy and has been widely criticised. Some minimal taxation relief is claimable and help is given for the cost of drugs but private insurances exclude IVF from cover. The costs of ART therefore have to be borne by the infertile patients themselves, a situation whereby lower socioeconomic groups find themselves totally unable to access the medical treatment recommended for their condition. Infertility support groups have in the past alleged issues of social injustice in healthcare resourcing. In any case, the inequitable situation for low-income patients in Ireland highlights an important question in ethical healthcare provision Medical ethics The government is committed to ending the unfair, unequal and inefficient two-tier system. (page 6) We are not advocating the end to private medical practice in the field of Infertility for those who wish to choose such an option but, the rationale for excluding fertility treatment provision under the public system is unclear to members of the Institute. Such exclusion is highly questionable on ethical grounds. Failing to provide mainstream, evidence-based treatment for Irish patients suffering from infertility could arguably be construed as discrimination Cost efficiency of services making efficient use of resources. (page 3) The maternal and infant costs of a twin pregnancy during the perinatal period are approximately three times that of singletons. In addition, the costs of caring for multiple birth infants have been shown to extend beyond the perinatal period. A strategy to reduce multiple pregnancies is likely to result in substantial cost-savings for the hospital involved in the short-term, and for the state in the long-term 8. The