Response by Chatham House Health Group, Trinity College Dublin to request for submissions by the Department of Health. 30/01/2015

Transcription

1 RE: PUBLIC CONSULTATION ON THE SCOPE FOR PRIVATE HEALTH INSURANCE TO INCORPORATE ADDITIONAL PRIMARY CARE SERVICES We welcome the opportunity to make this submission which is based on international experience and discussion at the Chatham House meetings and feedback from general practitioners. The Chatham House Health Group is drawn from public and private healthcare leadership and national and international policy makers and has had five meetings over the last year to discuss a greater role for primary care in the current system. The Chatham House group has developed principles of advanced healthcare which are the basis of this submission. Implicit in any case for the involvement of the private health insurers in primary care is a reduction in costs to the individual patient and to the healthcare system. Any involvement of private health insurance has to align itself with Government policy on the promotion of primary care and on prevention and wellbeing. Many of the pieces for effective healthcare in Ireland are already in place. We now have a well-trained general practitioner workforce that wishes greater involvement in services to patients. Importantly we have a referral system whereby patients need to consult their general practitioner before proceeding to secondary care in either the public or private sector. Barbara Starfield has shown that those countries with a referral system in place spend considerably less of their gross domestic product on health than those countries that do not have such a system in place, where patients can refer themselves directly to hospital specialists. Additionally government policy is to expand and invest in primary care and the engagement of the private health insurance industry is, in our view, an important aspect of primary care development. Our Group emphasises that involvement of private health insurance must align itself with Government and Health policy on the promotion of primary care and on prevention and wellness (Ref Primary Care Strategy, Future Health and Healthy Ireland). Providing access to bundles of care underpinned by models of care that focus on prevention and integrated care must add value to the health system and support/provide optimum outcomes for patients and is consonant with the role of primary care. Over 75% of all mortalities in Ireland are from cancer, cardiovascular, respiratory or diabetes. It is estimated that the prevalence of these conditions will increase by 20% by Integrated models of care are currently in various stages of development or implementation e.g. diabetes. The roll out and 1 P a g e

2 implementation of these models of care could easily be supported via private health insurance in order to integrate prevention and intervention. This approach will help address the increasing pressures that will be placed on primary care, if existing model of service provision continues, such as population size and trend and geographic distribution. Increasing common disease prevalence will lead to an increased demand for diagnostics some of which can be safely provided in primary care settings from a cheaper cost base. Our Group is of the considered opinion that access to diagnostics should be part of any level of agreed bundles of care. Prevention measures as part of overall integrated models should be included in these bundles as these will address lifestyle risk factors e.g. smoking cessation, anticoagulation for atrial fibrillation. The recent McLoughlin report commissioned by the Department of Health concluded that private patients are poorly served by a model of care that lacks an integrated and comprehensive approach by both doctors and the insurers. Sixty percent of patients attending general practitioners have to pay the doctor directly as health insurance does not extend to general practice. Our current health insurance industry has no history of engagement with general practice and as a consequence little or no expertise in this area. Our contacts with the industry through the Chatham House meetings lead us to believe that the industry would welcome an extension into primary care but that it must be financially viable. The terms primary care and general practitioner are used interchangeably in modern literature. However primary care in Ireland is largely GP oriented giving rise to either general practice or GP led primary care. These are the terms we use in this document. Principles in healthcare We think there are a number of principles that need to be adopted if patients are to receive cost effective care through health insurance. We also think that private health insurance can leverage increased standards, higher quality and better accessibility through appropriate incentivisation for general practice as a whole. The principles are discussed below : 1 Key role of GP led primary care. Developments in the United States shows that the trust patients have in their family doctor has clinical and health economic benefits. Such developments allow them to compare before and after primary care was introduced and shows considerable benefits along a range of peer 2 P a g e

3 reviewed and industry metrics (The patient centered medical home s impact on cost & quality. An annual update of the evidence, ). Advice given by a trusted family doctor is accepted more readily by the patient, than from a doctor they meet occasionally, which prevents unnecessary referral to expensive secondary care and minimises iatrogenic illness. There are ongoing difficulties especially in our cities of finding doctors outside normal working hours. This is being addressed through the GP co-ops which now see over one million patients per year. This development is highly valued by patients and is an alternative to attending emergency departments in our hospitals. Having involvement of the out of hours cooperatives as part of a private health insurance package would allow the co-ops to increase their capacity and extend their hours. 2 Unplanned admissions Good primary care minimises the effects of ill-health and prevents the patient from having an unplanned admission to hospital for issues such as: Acute infection Acute medical problems Chronic disease or multiple chronic diseases Flare up of a chronic disease Mental health issues Substance misuse issues Lifestyle issues Vaccination against disease Ante-natal care Additionally, well organised and co-ordinated team based primary care can facilitate early discharge from the acute hospital. Involvement of private health insurance, particularly in chronic disease management, needs to target unplanned admissions as a marker of quality. To demonstrate the impact of good GP led care on admissions needs high quality data across both primary and secondary care 3 P a g e

4 including from private hospitals. It also needs to be incentivised to leverage the provision of relevant, accessible and responsive GP led primary care. 3 Comprehensive care Providing GP led primary care in a private health insurance bundle or basket needs to provide incentives for ensuring that the GP will take responsibility for overall care of the patient. This includes care for all stages of life, including acute care, chronic care, disease prevention and end of life care. 4 Co-ordinated Care General practitioners have invested heavily in IT in their own practices and the next phase of development is to ensure that such systems are integrated with secondary care, hospitals and facilities in either the public or private care system. As part of a GP insurance offering it will be important that the patient s comprehensive records are computerised and capable of coordination and integration across all elements of our overly complex healthcare system. This will require start-up costs which can be targeted towards those general practices and hospitals that are willing to provide such a level of co-ordinated care. 5 Accessible care We see enhanced access to healthcare being available through flexible appointments, expanded hours and out of hours co-operatives. Use of responsive electronic communications between patients, their GP and other primary care professionals providing enhanced access to GP led care needs to be part of a healthcare bundle that is incentivised appropriately. Access to diagnostics This is a perennial bugbear for publicly funded patients. Access to diagnostics needs to be reimbursable to patients to allow general practitioners to investigate their patients. Patients themselves need to know that such tests will be reimbursed with private health insurance bundles of care. 4 P a g e

5 Access to hospital specialists It needs to be emphasised that patients can only be seen by secondary care specialists in the public or private sectors following referral by their general practitioner according to the Medical Council guidelines. Increasingly referral pro-formas are being used in order to ensure minimum levels of information such as the nature of the referral and the patient s current medications. Integrated referral using IT will make such a process efficient and effective for the patient. With the creation of larger primary care centres relevant hospital specialists should be incentivised to conduct clinics in general practice along agreed service level agreements. The Group emphasises that such care is not secondary care/hospital provider driven but along the lines of local patient needs. This needs to be done on a contractual basis with some specialities lending themselves to such a level of care more easily than others. Again, this can be included and incentivised in the bundle of private health insurance care. 6 Quality and safety GPs have an electronic register of patients whose use needs to be extended for alerts, recalls and the monitoring of chronic illnesses. The development of disease registers to ensure that patients get safe, necessary care where and when they need it and in an appropriate manner is an important quality and safety measure which is necessary in any bundle of care for private health insurers. 7 Fair and reasonable payments We recognise that patients differ in their ability to afford and to pay for daily expenses and for health insurance. The inability to pay should never to be a reason for the patient not to receive healthcare or obtain required medicines. When health insurance is available patients are to be made aware of such a fund that supports their health and are made aware of its benefits to them and their illnesses. The commitments outlined in this document will add value to all patients and should attract fair and reasonable payments to GPs and other healthcare professionals. These commitments: 5 P a g e

6 i) Need to reflect the value of work that falls outside face to face interaction with the patient such as on , Skype etc. ii) Will reward services associated with the co-ordination of care between the practice and other healthcare professionals and providers. iii) Will support the maximum adoption and use of health information technology for service delivery and quality improvement. iv) Will support the provision of responsive communications with patients and their care such as secure and telephone consultations. v) Will recognise the value of managing comprehensive patient data including data maintained by the patient if appropriate. vi) Will recognise that some patients are more complex and require collaboration with other professionals which is time consuming. vii) Will allow for additional payments for achieving measurable and continuous quality improvements. viii) Will need to be continuously reviewed and improved such that it delivers the services and outcomes of an advanced healthcare systems. Specific issues for consideration as per the consultation request : i) What is the optimal level of cover for primary care services and GP services that would be available in private health insurance contracts? Internationally the private insurance sector private payers are increasingly working with clinical providers to move away from fee for service towards bundled or global payment contracts. This needs to include elements of risk adjustment for more complex patients and quality incentives such as greater use of IT and use of data to guide services. Practices with live chronic disease registers with recall and alerts are clearly able to provide a level of cover that needs to be incentivised appropriately. ii) Are there any measures that the State should take to mandate or incentivise the provision and / or purchasing of such cover? Incentives for quality improvement show that they bring change quickly as was seen in the Medicare Pioneer Accountable Care Organisations over the first 2 years of activity. ( As part of the 6 P a g e

7 incentivisation, savings on claims spending should be utilised to reflect improved clinical change and outcomes. The passing on of such savings to GP led primary care has precedent in Ireland with the prescribing savings which helped to resource general practice and develop its computing in particular. In particular concern has been expressed in our group about the further fragmentation of clinical information with increased PHI involvement if information does not flow easily and electronically between primary and secondary care providers. We think the electronic record is an essential criterion in the purchasing of care or of bundles of healthcare which will give an impetus to electronic communication between primary & seco0ndary care. iii) Should any cover be compulsory, as part of the minimum packages that insurers must offer or optional? Insurance cover is price sensitive and to be attractive needs to be able to provide a good service at a reasonable price. The recent initiative to encourage younger people to join health insurance schemes needs to be observed to see how it has worked out. Having compulsory cover will create a rather pointless debate that will delay action on the introduction of any changes. iv) Should primary care cover be in a separate health insurance plan or as part of an inpatient plan? It is possible that such an insurance plan can range from Primary Care Max to Primary Care Lite with the Max covering general practice care out of hours and other health professionals such as physiotherapy. Primary Care Lite is a more restricted bundle of services that is dominated by hospital care. v) To what extents should limiting terms be allowed e.g. no. of visits, amount payable per visit etc.? The insurance industry has to move away from the costly fee per item of service and to think much more about baskets of care or bundled care. Applying restrictions means developing even more complex plans than we already have at the moment. The insurance industry is medically dominated and primary care by its definition has a number of other clinical players such as nurses, physiotherapists & psychologists. If packages of care are to be dominated by clinicians they will be extremely expensive, indeed unaffordable, 7 P a g e

8 especially if on a fee per item basis. If packages of care are to be viable they have to be part of a bundle of care that attracts a capitation fee based on the complexity of the patient s illnesses. vi) 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? The limiting steps for primary care are currently staffing and premises. However, there are a number of options that are available such as increasing practice hours, developing out of hours services and making sure that such services are GP led rather than always being GP provided. The experience of most healthcare systems is that if patients can be tracked in their use of services it changes clinical behaviour and allows better planning. The best scenario is that patients attend their general practice and are dealt with there on as many occasions as possible. The worst scenario is that they attend their general practice and also attend the acute hospital for additional advice. Additionally the Group is of the opinion that inter referrals in general practice need to be encouraged especially where GPs have skills in minor surgery, dermatology and joint injections and where log jams occur in secondary care. vii) What is the capacity of GP practices to deliver insurance funded care of the type suggested here? Considerable investment has gone on in GP training over the last 3 decades. We now have a cohort of well-trained general practitioners who cannot deliver on that investment because of the perverse incentives both in the insurance industry and in the acute hospital sector, especially when it comes to diagnostics. If we view the delivery of insurance funded primary care as primarily by a medical clinician then the capacity is much more limited than if it is delivered by a range of clinicians in primary care such as nurses, therapists, psychologists and phlebotomy technicians among others. Getting hospital specialists to work from primary care in selected specialities such as rheumatology, dermatology and diabetes increases capacity and will upskill primary care clinicians and give hospital specialists a feel for the community. 8 P a g e

9 viii) Any other comments on the proposals for private health insurers to cover a fuller minimum range of services provided by GPs. It will require a significant cultural change for our health insurers to develop primary care packages. The industry has unfortunately invested in marketing hospital services to a reducing number of patients and our insurers do not have in-house competencies to deliver insurance funded primary care at present. If they develop an interest in primary care they have an opportunity to leverage significant improvements in services for patients and in overall healthcare. 9 P a g e

10 This document has been considered and endorsed by: Tom O Dowd Professor of General Trinity College Dublin Practice Brendan O'Shea General Practitioner Newbridge, Co Kildare Darach O Ciardha General Practitioner Tallaght, Dublin 24 Fergus O'Kelly General Practitioner Rialto, Dublin 8 Tom Kelly Director Talacare Limited, Ringsend, Dublin 4 Joe Barry Professor of Trinity College Dublin Population Health Medicine Tom Fahey Professor of General Royal College of Surgeons in Ireland Practice Fiona Timmins Associate Professor, Trinity College Dublin School of Nursing & Midwifery Noel Brett Chief Executive Banking and Payments Federation, Ireland Tina Joyce Programme Director, Royal College of Surgeons in Ireland RCSI Institute of Leadership Karena Hanley General Practitioner Donegal Ronan Fawsitt Chair, ICGP-St Luke's Carlow Kilkenny Liaison Committee Garry Courtney Clinical Director St Luke's General Hospital, Kilkenny Chris Goodey CEO National Association of General Practitioners Joe Gallagher General Practitioner Gorey, Co Wexford Ambrose Healthy Ireland McLoughlin Peter A Sloane General Practitioner Galway Pat Durcan General Practitioner Ballina, Co Mayo George Mellotte Consultant Nephrologist Regional Lead Nephrologist, HSE Dublin Mid-Leinster Andrew Jordan Chairman National Association of General Practitioners Ray Power Group Medical Centric Health, Dublin 14 Director Rita Doyle General Practitioner Bray, Co Wicklow Velma Harkins General Practitioner Banagher, Co Offaly 10 P a g e