National Disability Authority Submission

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1 National Disability Authority Submission Universal Health Insurance The National Disability Authority, the independent statutory advisory body on disability policy and practice, welcomes the opportunity to make a submission to this stage of the public consultation process on the White Paper on Universal Health Insurance the Path to Universal Healthcare. This submission represents the National Disability Authority s preliminary views on Universal Health Insurance based on the information which is currently available. The National Disability Authority supports the vision statement underpinning the high level objectives of health service in Ireland as set out in the White Paper to develop an efficient and effective single-tier health service which promotes equitable access to high quality care on the basis of need. The National Disability Authority notes that the White Paper confirms that Social Care services will be outside the Universal Health Insurance system and continue to be funded by the tax system. However, people with disabilities need to access the wider health system and some people with disabilities need ongoing and frequent access to primary or specialist health services, as they are a group which is at higher risk of ill-health than the general population. 1 So the interface between the wider health system, the elements to be funded by Universal Health Insurance, the health elements to be funded by general taxation, and the care system will be particularly critical to ensure that people with disabilities continue to have access to the quantum of service they need and in a seamless manner. The National Disability Authority also notes the intention to establish a separate independent Expert Commission to examine the issues around the basket of services to be provided under Universal Health Insurance and within the overall health system. The Minister will announce details of the Commission in the near future. The National Disability Authority welcomes the intention that views on the basket of services will be sought by the Commission when it commences its consultation process. People with disabilities should be considered as a key 1 The National Disability Survey 2006 showed that 12% of people with disabilities described their health as bad or very bad, and a further 38% as fair. This compares with 2% of the general population with bad or very bad health, and 11% with fair health (QNHS health module 2010). Three quarters of people with disabilities in 2006 were on regular medication. National Disability Authority Page 1

2 strand of this consultation process. The National Disability Authority would be happy to help the Department in relation to consulting with people with disabilities, and have previously facilitated engagement through focus group sessions for the relevant areas of your department working on disability policy. The Department of Health is aware that a Disability Impact Assessment is a mandatory requirement for all substantive proposals to Cabinet. It would be important that any proposals for Universal Health Insurance are assessed in line with the guidance to establish any implications for persons with disabilities and the actions to address same. This submission benefits from the inputs of a wide variety of disability stakeholders who participated in workshop that the National Disability Authority held on the Universal Health Insurance White Paper on the 22 nd of May. In making this submission, the National Disability Authority s advice has focused primarily on the disability-related issues in particular areas contained in the White Paper. Proposed organisation and delivery of the Universal Health Insurance model Safeguards Access to cover The National Disability Authority welcomes the intention that the new Universal Health Insurance policy should ensure that people with disabilities have equal access to cover as the general population. The National Disability Authority notes the Government s policy objective is to further develop the risk equalisation scheme so that it continues to be as effective as possible in terms of providing the necessary support to community rating while at the same time the scheme remains robust, transparent and promotes fair and open competition 2. It is important to maintain and ensure, in any further development of the Universal Health Insurance, that: people with disabilities have access to cover at a reasonable cost insurers cannot refuse to accept people with disabilities as customers 2 Department of Health,(April 2014) The Path to Universal Healthcare- White paper on Universal Health Insurance, 30 National Disability Authority Page 2

3 customers with disabilities do not face barriers, because of pre-existing medical or disabling conditions, to getting insurance or to switching insurance provider community rating is designed to ensure that customers with disabilities do not face premiums that are loaded in relation to their disability Geographic location of health services The National Disability Authority acknowledges that the Government is committed to the transformation of public hospitals into independent, not for profit Hospital Trusts....in the immediate term, the Hospital Groups will harness the benefits of increased independence and greater control at local level, while over time they will make the transition to fully competing Hospital Trusts in the context of a universal insurance-based health system 3. The National Disability Authority advises that there are a number of safeguards that would need to be considered in relation to the establishment of largely independent regional hospital clusters, which includes safeguarding against: potential higher rates of readmission to hospitals, given that hospitals will be competing and incentivised to treat patients quickly and ultimately discharge quickly with the potential of higher rates of readmissions into the hospital system and/or post-discharge complications the continuing rise of the cost of compulsory health insurance, given that the opening of the existing private health insurance market to competition has not kept premiums down people with disabilities incurring additional costs, such as transport, because they need to access certain specialisms, which may only be available nationally in a given location inadequate provision and or level of service being provided for within the basic package or basket of services especially for those with chronic illness or who acquire a disability such as acquired brain injury and may need more intense level of hospital treatment and rehabilitation at a particular point in time the State having to find more money year on year to fund the payment of compulsory health insurance, given that it is estimated that the State will fully fund 40% of people and subsidise payments of another 30% and fund disability and social care services from the exchequer and fund particular services (yet to be decided) which may be classified as 3 Department of Health,(April 2014) op.cit, 27 National Disability Authority Page 3

4 specialist health services. It is unclear how this could be sustained and would result in either raising more taxes or reduce spending in other areas and the potential impact that might have on people dependant on other services funded by the Exchequer Integration between health services outside of Universal Health Insurance and those in standard package Access to care It is important that the new Universal Health Insurance policy will ensure that people with disabilities can access the therapies they require to enable them achieve maximum recovery and maximum independence. Services, such as, physiotherapy and occupational therapy play a key role in enabling people with disabilities achieve maximum independence and rehabilitation. For people with mental health difficulties, psychology, counselling and similar talk therapies can support people to recover. The cost of such therapies can lead to significant out-of-pocket costs which can be a disincentive to treatment and rehabilitation, which can lead to ultimately higher costs to the health system. The National Disability Authority advises that these kinds of therapies should be included within the scope of the basic package or basket of the proposed health insurance system. Supports to access health services Some people with disabilities and long-term illnesses require supports to access mainstream health services, for example in the form of Personal Assistant services, sign language interpreters, dementia support personnel or advocates. Whether such supports will be provided as part of the basic Universal Health Insurance package will need to be considered. If such supports to access mainstream health services are not going to be covered by the basic Universal Health Insurance basket then means to provide them through seamless coordination of the Universal Health Insurance and non- Universal Health Insurance systems will need to be developed. Complex care and access to teams Access to a team of specialists from a number of disciplines constitutes best practice for supporting people with complex disabilities and for many chronic conditions. Such team-based approaches can be challenging to organise, and the situation may be further complicated if individual elements of a team come from the Universal Health Insurance -funded and non- Universal Health Insurance elements of the proposed model, or if individual practitioners are contracted by different insurers. Consideration needs to be given as to how such multidisciplinary team-working or cross-specialism teams could be impacted by the National Disability Authority Page 4

5 introduction of Universal Health Insurance, and to design the system in a way that addresses this issue.. Health and rehabilitation Many people who acquire a disability, for example through a brain or spinal injury or stroke, will require an extended period of rehabilitation in the community after an initial period of hospitalisation. At present coordination between hospital and community based rehabilitation is often poor and community-based rehabilitation is in many cases under-developed. Universal Health Insurance may further fragment the provision of rehabilitation services (depending on what is in the basic basket and what remains outside). Consideration will therefore need to be given to how the introduction of Universal Health Insurance might impact on rehabilitation, and what can promote best rehabilitation outcomes. Some aspects of rehabilitation, for example vocational rehabilitation, which are likely to be outside the Universal Health Insurance basket, should according to best practice, be integrated with hospital based rehabilitation. The means to ensure seamless delivery of service from the point of view of the person receiving services needs to be factored into service design. Apportioning costs between Universal Health Insurance and non- Universal Health Insurance elements of health system Some people with disabilities and chronic conditions will need to frequently access elements of the health and social care system which are Universal Health Insurance and non- Universal Health Insurance funded. Therefore, conflicts between insurers limiting their exposure to expensive claims in the Universal Health Insurance -funded system, and frontline health and social care staff limiting tax-payer exposure in the non- Universal Health Insurance funded system pose a risk to all service users but pose a particularly high risk to those who require frequent, ongoing, expensive support which requires input from both the Universal Health Insurance and non- Universal Health Insurance funded parts of the system. Similarly, there is significant potential for tension between the Universal Health Insurance and non- Universal Health Insurance system for people with who need to move from one part of the system to another, such as: A person requiring a move out of hospital to a step down facility in the community A person being supported in community requiring a hospital procedure It is essential that the system is structured in a way that ensures that individuals receive optimal supports or interventions, and that their treatment and National Disability Authority Page 5

6 treatment pathway should not suffer because of disagreements between the Universal Health Insurance and non- Universal Health Insurance systems on the parameters of their responsibilities. Such disagreements will disproportionately impact on those with ongoing and complex health care needs, and those with disabilities. It is particularly important that the interface between what is acute care (funded by Universal Health Insurance) and what is rehabilitative care does not become a zone where people with disabilities are caught between health insurers and the state each trying to pass responsibility for a stage in the care path to the other. Chronic illness As part of the quality framework within Universal Health Insurance chronic illness should be actively case-managed with a focus on better healthcare outcomes for people. Priorities for phasing in the delivery of Universal Health Insurance Primary or community care settings The National Disability Authority acknowledges the importance of the commitment to treat people, as far as possible, in primary or community settings outlined in Future Health. Such an approach would in the long run reduce the overall costs in the health system because one would not be relying on hospital treatment. Similarly, improvements in areas, such as, preventive care and management of chronic illness would reduce the need for hospitalisation and access to other areas, such as Child and Adolescent Mental Health services are critical too. Previous research has shown that about a quarter of all those who do not have medical cards cannot afford to go to their local doctor. This can result, in some cases, that when they do seek medical help, the illness may have developed to a point that they then have to be hospitalised. So removing financial barriers of the free GP service could result in cost savings in the long run as well as good health outcomes. It is important therefore that adequate and appropriate resources are committed to establishing the primary or community care settings and to optimising structures that will best support the delivery of primary and community care. The establishment of a Patient Safety Agency The National Disability Authority welcomes the proposal for the establishment of a Patient Safety Agency. The Authority advises that it is important that people with disabilities are represented within such structures given the high level of people with disabilities with health issues (see footnote 1). National Disability Authority Page 6

7 Development of detailed policy to support integration The National Disability Authority notes that it is intended that.. this policy will set out clear systemic, organisational, clinical, informational, financial and normative processes to deliver integration... (and)... is committed to the effective integration of UHI services and child protection services delivered by the Child and Family Agency 4. In addition, the National Disability Authority advises that the development of a detailed policy to support integration between health, disability and social care is also critical and should be an integrated part of the proposed development of the detailed policy to support integration. The National Disability Authority would also advise that, as part of this process, due consideration should be given to how there could be potential alignment, for the benefit of a person with a disability who requires both health and support services, of the money follows the patient within Universal Health Insurance system and individualised funding as outlined in the Value for Money and Policy Review. Supplementary insurance The purchase of supplementary insurance will be dependant and influences by what ultimately will be determined as the basic package or basket of services. The National Disability Authority is conscious that the basic package needs to be adequate for the needs of people with disabilities who may have additional requirements over and above that of the general population. The basic package, for example, might contain 10 sessions per year of physiotherapy and that may be more than adequate for the general population but inadequate for a person with a disability because of the nature of the health condition. It is important that if the system is based on need then that is addressed within the basic package and not deemed as supplementary. It is equally important, that in the continuing provision of a Universal Health System, that in order to maintain the cost of the basic package, that other necessary therapies for people with disabilities or provisions, like a private room, for a person with cystic fibrosis who needs such a facility when hospitalised, does not get pushed out of the basic package into a supplementary insurance. Similarly, a person with certain neurological conditions should have access to the specialist, of whom there may only be one nationally, as opposed to the basic package limiting it to a local neurological consultant in a specified hospital, because the insurer has a contract with a particular health provider in a given location. 4 Department of Health,(April 2014) op.cit, 70 National Disability Authority Page 7

8 Values framework The National Disability Authority acknowledges the importance of the values contained within the Values Framework and in particular those related to patient safety are critical. However, the values as stated appear to be more systems focussed and it would be important to also have person-focused values. Such values would include: patient centred quality including patient health outcomes equity access to appropriate levels of service medium and long term value for money It is also essential to ensure that the economic incentives to the different players (insurance companies, GPs, hospitals, health service staff) in the new system support the stated values rather than providing counter-incentives to function differently. Policy and operational aspects of the subsidy system Subsidy system Extra costs incurred by people with disabilities In calculating income to determine Universal Health Insurance subsidies for individuals, it will be important to have regard to the fact that people with disabilities often have a range of additional costs which most meet from their incomes. These extra costs vary from person to person but they typically include: costs associated with transport needs medicines support (such as privately funded home help or therapy services) equipment It would be important that the Universal Health Insurance subsidy system is analysed from the point of view of the people with disabilities and mechanisms to net off higher costs incurred by people with disabilities. It would be important to consider that the family member with earned income may be incurring costs associated with another family member with a disability. National Disability Authority Page 8

9 Income thresholds The income thresholds for the subsidy system, if not properly designed, could become a barrier for people taking up work or taking on increased hours. The income threshold for the current Medical Card system can, in some instances, discourage people with disabilities taking up work or taking on increased hours. Also, for those who currently have neither a Medical Card nor private health insurance paying a Universal Health Insurance premium will be a new cost of taking up employment. This cost when combined with others costs associated with disability may prove a very significant disincentive to work for this group of people with disabilities. Those on low to middle incomes The latest data show that 44% of people have private health insurance, while about 40% have a medical card, leaving some 16% of the population who have neither a medical card nor who currently pay insurance. This is likely to include people with disabilities who because of their disability work reduce hours, or are in lower-skilled employment. This group may be significantly affected by any additional out-of-pocket costs they may incur on the introduction of Universal Health Insurance. Employment disincentives The National Disability Authority has been tasked with facilitating the development of a Comprehensive Employment Strategy by Government for people with disabilities, working with Government Departments. A key issue which has been raised is the strong disincentive to work which currently exists due to the potential loss of the medical card. Additional costs of paying Universal Health Insurance premiums could provide an added disincentive to employment for people with disabilities. Entitlements under various schemes, for example, medical cards, GP visit cards, Long term illness scheme Analysis needs to be done as to whether outcomes, (both individual health outcomes and system efficiency outcomes), would best be achieved by allowing some people with disabilities and long term conditions, who will frequently need access to a range of health services, to be fully exempt from the means test (similar to the allocation of medical cards on the basis of hardship at the moment) and automatically granted the full subsidy. However, given the variability in health needs for people with the same condition, consideration would need to be given as to whether diagnostic category or National Disability Authority Page 9

10 health need would be the most efficient way to determine the cohort of people who should be exempted. Eligibility systems based on diagnostic categories tend to have a number of flaws, such as: Excluding those who don t have a clear diagnosis Excluding those with rare conditions Lacking sensitivity to the great variance in levels of need in people with the same diagnosis An eligibility system based on health needs can address the issues cited above but may be more complex and expensive to establish and administer. Therefore, a system which looks at exempting some people with disabilities and long-term illnesses from paying Universal Health Insurance premiums will need to strike a balance between assessing people s actual level of need and administrative efficiency. Until the contents of the basic Universal Health Insurance basket of services is known, it is difficult to comment on how the replacement of the Medical Card with a full subsidy access to a basic plan under Universal Health Insurance will impact on people with disabilities Once the contents of the basic package are determined, an analysis of the difference between what is covered by the basic package and has been covered by the Medical Card will need to be conducted. Details of revised funding arrangements for items not covered by the basic package (but previously covered by the Medical Card) will need to be developed to ensure that people with disabilities and long-term illnesses do not lose access to supports which are critical to keeping them healthy and independent. It may also be the case that providing some entitlements presently covered by the Medical Card (such as wheelchairs and aids and appliances) to all for free under the non- Universal Health Insurance funded health care system may be a more efficient way of meeting the needs of some people with disabilities than by giving them automatic entitlement to a full Universal Health Insurance subsidy. Given the importance of access to health services to people with disabilities and chronic conditions consulting with and communicating to people with disabilities around changes to any of the above schemes will be very important. National Disability Authority Page 10

11 Regulation of healthcare providers and purchasers Regulation mechanisms to ensure good governance The National Disability Authority notes that in the proposed new structures underpinning Universal Health Insurance there are a range of agencies, stakeholders and Government departments involved - HIA, HiQA, Patient Safety Agency, Central Bank, Department of Health etc and each with specific remits, roles and in some instances regulatory monitoring functions. There is a need for oversight of the whole system and an annual reporting mechanism of how Universal Health System is working. Such reports should also highlight any deficiencies and ort inadequacies in the system, particularly from the point of view of the adequacy, appropriateness of services provided, especially for people with disabilities, and the cost of same. Every aspect of the Universal Health Insurance regulatory framework will be dependent on timely, reliable and high quality information being provided. It is critical to have the necessary legal framework in place for this happen but also the IT infrastructure that enables the different systems communicate with each other in a seamless fashion. It would also be important, from the consumer perspective, that people have a clear transparent redress system defined within the regulatory framework. The National Disability Authority advises that health insurance companies be required to ensure their information and customer services are designed to be fully accessible to people with disabilities, with requirements similar to those set out for public bodies in Part 3 of the Disability Act To enable people navigate the different offerings of different insurers, it is important that information is clear, comprehensive and expressed in plain English. Information should be available in different formats on websites that conform to WCAG2 standards; in large print, in audio format or Braille as required. Staff may need training and support to ensure that they can provide an efficient and courteous service to everybody, particularly people with disabilities. There are some key on-line resources available, free of charge, from the National Disability Authority that offer useful guidance in that respect including an accessibility toolkit, on-line disability awareness training and our practical guidelines for accessible buildings. National Disability Authority Page 11

12 The new Universal Health Insurance legislation should require insurers to make their services accessible to people with disabilities. Consideration should also be given to the particular needs some people with disabilities will have in understanding packages that may be offered by insurers. In this regards a person may need an advocate to help them or other forms of support and agencies like the Citizens Information Board could play an important role. Financing of the Universal Health Insurance and the overall health system Regulatory and administration costs of the system Set up costs Given the scale of the regulatory and administrative infrastructure required to implement a Universal Health Insurance system, it seems likely that there will be significant investment in the short term, which may reduce costs over the medium to long term. However, given the short term financial pressures on the health system, it would be useful to the public discussion on Universal Health Insurance, if the short term costs or investments were calculated and made public and a clear indication given as to whether these costs were to be met from the existing health budget. Funding Universal Health Insurance and non- Universal Health Insurance elements of the Health system The issues around the integration of the delivery Universal Health Insurance funded and non- Universal Health Insurance funded elements of the health system are discussed elsewhere in this submission. In terms of funding, a concern would be that Universal Health Insurance premiums would drive investment in the Universal Health Insurance covered part of the health system but that other areas such as public health and primary care which are critical to good health outcomes may not receive the investment required if they are not covered by Universal Health Insurance. Part of the discussion and analysis on Universal Health Insurance will require more detail on how the whole of the health system will be funded over the next number of years. Excess payments, co-payments and people with disabilities A standard feature of health insurance markets is that people can reduce their premium payments if they choose to take on the risk of paying an excess National Disability Authority Page 12

13 payment should they need to access a health service. Alternatively, a mandatory system of out of pocket co-payments for all at the point of service use can be both a way of raising revenue and deterring unnecessary use of the health system. However, for many people with disabilities and chronic conditions, who require frequent access to the health system, the option of reducing their premium payments will not be a choice. Similarly, mandatory co-payment will structurally discriminate against them. The issue of compensating people with disabilities and chronic conditions for the increased exposure to excess payments / co-payments has been acknowledged and addressed in the Dutch Universal Health Insurance system. Mechanisms to ensure that excess payments / co-payments don t structurally discriminate against certain groups, including people disabilities and chronic conditions, will need to be considered if such payments are to be a feature of how the Universal Health Insurance system will be funded. Cost-control mechanisms It is difficult to comment on the cost control mechanisms based on the level of details provided in the White Paper. However, it would be important that the setting of maximum prices for healthcare providers and capping of insurer claims, etc., is balanced against the need to provide adequate care to people, who because of their disability or chronic conditions might require expensive interventions or medicines. It would be important that more detail on how decisions on such competing demands will be determined and should be published to allow for debate on the issue. As the population ages, as people with life-long disabilities live longer, and as the number of people who survive catastrophic injuries increases, there will be inevitable upward demographic pressures on health spending. It is important that the system of Universal Health Insurance to be implemented is sustainable in the face of such pressures, so that people with disabilities or chronic conditions will not be faced with diminished access to health care for the future, or with unsustainable premiums that pressurise them to leaving the workforce. Concluding remarks The National Disability Authority would be happy to provide more detailed advice on any of the issues raised in this submission and would be willing to provide any additional information and support as required. National Disability Authority Page 13

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