Department of Health Public Consultation. Scope for Private Health Insurance to incorporate Additional Primary Care Service

Transcription

1 Department of Health Public Consultation Scope for Private Health Insurance to incorporate Additional Primary Care Service Submission by Aviva Health Insurance Ireland Limited January 2015

2 Summary This submission has been made by Aviva Health Insurance Ireland Limited to the Department of Health s consultation on primary care. We welcome this opportunity to put forward our views on this important topic, and we would be delighted to participate in a wider discussion with the Department of Health on the best way to proceed to develop a primary care insurance market. We fully support encouraging consumers to use purchase primary care services rather than receiving their treatment in a traditional acute hospital setting. We make this statement based upon the following observations: 1. Patient care has been demonstrated to be best provided at the primary care level, with continuity of care and more holistic management of diseases and chronic health conditions. 2. The cost of treating a patient in a primary care setting is often lower than that in an inpatient setting. 3. Patients, in general, prefer to receive care in the community and at home rather than in an institutional setting. 4. By discharging patients from hospitals greater capacity may be made available in hospitals to treat patients that need the care. Nonetheless, the transition from the current largely hospital based system to a hybrid system of both primary care and hospital based treatment is problematic. At present, as pointed out in the consultation document, a significant number of people have chosen not to purchase primary care services as part of their health insurance contracts. Individuals who purchase primary care insurance, either as part of a standalone contract or an integrated health insurance contract, make a discretionary choice to purchase the primary care insurance element and pay an additional premium to fund the cost of these additional services. The cost for an adult of the primary care insurance component can easily be over 300 per annum in some cases per annum. 1 If providing/purchasing primary care insurance was to be made a mandatory requirement for both insurers and consumers (through minimum benefits and in some other way) current health insurance premiums would need to increase commensurately with the cost of provision of the services. In a market environment, where affordability is already a key issue this does not seem sensible, nor will it be palatable for the market. We, therefore, propose that primary care insurance is only an optional benefit for health insurance undertakings to provide either on a standalone basis or as an integrated part of an inpatient indemnity contract. Notwithstanding this, the scope and level of benefit to be covered under any discretionary primary care package should be carefully considered. In this regard, we believe that the 1 Such products only pay a monetary benefit that does not cover the full cost of the service.

3 package should include general practitioner services (both minor surgical and consultations), tertiary specialist consultations and some allied health professions services. We believe cost sharing should be part of the system through the use of co-payments and benefit caps. We believe the state should put in place incentives to encourage the development of this market through tax concessions and direct action as appropriate. Furthermore, we believe that the negotiation of the tariff for these services should be undertaken centrally with a common contract being in place across the market. We believe it will be challenging to develop a primary care insurance market, given the affordability challenges, but we are committed to working with Government and the Department of Health on this important issue.

4 Responses to Questions 1. What is the optimal level of cover for primary care services and GP services that would be available in private health insurance contracts? We believe that general practitioner services should be covered under any primary care benefit package. It is also our view that specialist tertiary referral consultation services should be covered as part of the package. We also are of the view that there should be some coverage for certain allied health services including those regulated by CORU, though careful consideration should be made as to what gets included under this class of benefits given the cost implications. We already cover many minor surgical procedures provided by general practitioners, and we believe this should continue to be covered as a matter of course under any primary care package. It would be prohibitively expensive to include any contribution to outpatient pharmacy costs in any insurance package. The drug re-payment scheme that is already in place covers the cost of drugs where expenditure is above a defined threshold. While there may be some arguments for reducing this threshold we do not consider these costs should be covered under the voluntary insurance market. 2. Are there any measures that the State should take to mandate or incentivise the provision and/or purchasing of such cover? We believe that an incentive based system is the most appropriate mechanism to extend primary care coverage in the system. Options to do this include: I. The extension of tax relief beyond that currently provided. This would equate to effectively providing direct state subvention towards the cost of premiums, as a part payment of premiums. II. We also would consider the provision of separate incentives for the provision of appropriate disease management services under the risk equalisation system where subsidies could be made to insurers to provide disease management benefits. Such arrangements already operate in a number of countries including Australia and Germany. 3. Should any cover be compulsory (e.g. as part of the minimum packages that insurers must offer) or optional? This package should be optional, in the first instance, through the use of the incentives as outlined above. This is based upon the scale of the additional premium likely for the provision of any primary care package of benefits and its consequent impact on the affordability of premiums.

5 4. Should primary care cover be in a separate health insurance plan or as part of in-patient plans? As indicated in our response above, we are of the view that the package should be initially covered under a separate health insurance plan though insurers could continue to provide services as part of an inpatient indemnity health insurance contract also. As we move towards a Universal Health Care world it would become necessary to integrate the two packages together, but in the context, of the current voluntary health insurance market we believe it would be prohibitively expensive to unilaterally make the package mandatory. 5. To what extent should limiting terms be allowed (e.g. number of visits allowable, the amount payable per visit etc)? An important part of any insurance arrangement is to create the appropriate incentives for use by consumers. We believe that in this regard, cost sharing as a principle should be introduced. Amount payable per visit Limiting the cost of provision through the use of deductibles and co-payments is something that we would support. Within such a system, arrangements could be made for additional subvention for the very sick patients and also for low-income groups from the state through, perhaps the integration of the medical card system. These arrangements for such subventions are more appropriately part of the state system of eligibility and no further comments are made on them here as they are considered out of scope of this submission. Number of visits allowable While in principle, we would like to have no caps in terms of the services being provided from a cost containment perspective it is difficult to not have them in place for any insurance system in order to manage costs. 6. How can we encourage a real transfer of provision of services from the acute hospital setting to primary care, so that we are not simply adding to volume and costs? Health in the Home services We support any initiatives in this regard. We already have an early discharge programme in place through our Health in the Home service. One of the challenges we have with this service is to find suitable patients to be participants in this service. We would welcome the introduction of some arrangements jointly with the public and voluntary hospitals to identify such patients at an early stage as this could encourage their transfer from the acute hospital setting to primary care settings. Direct settlement with primary care providers Primary care services are currently reimbursed directly by insured persons rather than directly from insurers. If insurers were able to direct reimburse providers it would incentivise primary

6 care providers to provide more primary care services. There are a number of impediments to directly reimbursing members now including the individual business unit model of the primary care market and the overall small size of the existing primary care insurance market. This means the business case for investment in this market is not compelling, at present. The state could assist in making the business case more compelling through the continued strategic focus on primary health centres and development of national primary care technology platforms and the like. 7. What is the capacity of GP practices to deliver insurance-funded primary care of the type suggested here? We consider this issue in the context of the following: 1. Contracting and registration Processes and procedures are already in place for insurers to register and contract with general practitioners for primary care services. In principle, this could be extended for any primary care insurance system. 2. Contracting terms We believe it is essential to have a common contract across the system for the provision of primary care services. As indicated below, there would be considerable work needed before such a common contract could be put in place. We support an industry approach to these discussions and the introduction of a national tariff system for each primary care provider. Where possible, having a national mutually agreed tariff structure would make sense in terms of managing the costs of provision. The negotiation of a common contract needs to include representatives of the insurance industry, as well as the various professional bodies and the Health Services Executive and the Department of Health. In principle, we support the use of a capitated system of reimbursement for general practitioner services to align incentives within the system. The use of a capitated model for other services would largely not be meaningful given the relatively small size of these sub-markets. 3. Patient registration and reimbursement systems Once an agreed capitated reimbursement system has been put in place there needs to be a mechanism to register patients with a general practitioner, notify the insurer of their utilisation episodes and to reimburse the general practitioners through a direct payment system as outlined above. As identified above, the capacity and infrastructure for such a system is not in place at present and potentially would be quite complicated to introduce.

7 8. Any other comments on the proposal for private health insurers to cover a fuller minimum range of services provided by GPs? We believe that general practitioners should be at the heart of any primary care package development. In this regard, we would like to bring up the following additional points: 1. Healthy lifestyles and wellness We support individuals being encouraged to adopt healthy lifestyles including more use of exercise, better diet and through the use of detailed and defined health screenings. In this regard, we think it would be appropriate to provide access to general practitioner-led health reviews once every two years to insured persons under the primary care package. The nature of the reviews would need to be clinically defined so as to ensure a consistent approach throughout the system. It would also need to be affordable so this consideration would need to be allowed for in determining the particular services provided. 2. Digitalisation of provision of services We believe the provision of services, where clinically appropriate, through the greater use of technology and digital medium should be encouraged, where possible. 3. Common coding We support the introduction of a common coding system for use within the primary care space for general practitioners. This would include a common industry coding system for minor surgical procedures provided by general practitioners and, also, a coding system for description of the type of consultation provided. In the case of the latter, we support the use of the International Classification of Primary Care system (ICPC) published by the World Organisation of Family Doctors and approved for use by the World Health Organisation.