Lecture 9/10: Lecture 9/10 Health Care in Ireland Health Care in Ireland: Health Care in Ireland
No society can legitimately call itself civilized if a sick person is denied medical aid because of lack of means
Nye Bevan (1945)
Things have only got better: Things have only got better From 1990 - 2002
418% increase in expenditure on health
Per capita spending up $500 per person per year
Public health expenditure higher than EU average
Number of patients treated up from 658 to 963 thousand
Health service employees up 41,000
Waiting lists cut from 40,000 to 29,000
But does more mean better? Comparative health expenditure: Comparative health expenditure Comparative growth in health expenditure 1992-2004: Comparative growth in health expenditure 1992-2004 Public Private expenditure: Public Private expenditure Health spending in Ireland: Health spending in Ireland Total health spending accounted for 7.1% of GDP in Ireland in 2004, some way below the latest available average of 8.9% across OECD countries.
In terms of health spending per capita, Ireland ranks just above the OECD average, with spending of 2596 USD in 2004 (adjusted for purchasing power parity) compared with an OECD average of about 2550 USD
Dwarfed in comparison with the United States (which spent 6102 USD per capita in 2004), and significantly lower than Luxembourg, Switzerland and Norway (with spending from 4000 to 5000 USD).
.However Irish spending on health is distorted because:
There is no proper health accounting standard for Ireland.
Social spending is included among health spending.
There is no accurate figure for the amount of money spent on private healthcare.
The ‘black hole’ and other spending myths: The ‘black hole’ and other spending myths The OECD now assesses that some 25% of Irish health spending is in fact social spending which should not be included in making comparisons with other states.
Adjusted for this Irish per capita health spending does not yet appear to have attained the EU per capita average
Over the last 20 years, Ireland has been spending on average some 70 per cent of the EU per capita average on health care, having dropped as low as 56% of the average in 1990
From 1970 until 1996 the capital spending programme of successive governments ran at only 66% of the EU average.
This means that recent increased spending is likely to be doing no more than bringing up to scratch facilities that suffered decades of under spending Doctors 2004: Doctors 2004 In 2004, Ireland reported 2.8 physicians per 1 000 population.
This figure is higher than in countries such as the United States, Canada, the United Kingdom and Australia, but falls short of the OECD average of 3.0 and well behind some other European countries such as France, Germany, Spain and Portugal, who all record 3.4 physicians per 1 000 population.
On the other hand, Ireland records a very high density of practising nurses, with 15 nurses per 1 000 population in 2004 (noting though that the comparability with other countries is more limited due to the inclusion of different classes of nurses, mid-wives, etc.).
Hospital beds 2004: Hospital beds 2004 The number of acute care hospital beds in Ireland in 2004 was 2.9 per 1 000 population, below the OECD average of 4.1 beds per 1000 population.
In most OECD countries including Ireland, the number of hospital beds per capita has fallen over recent decades.
Health Status indicators: Health Status indicators Ireland performs poorly on life expectancy at birth for both men and women and is in the bottom one-third of countries.
Ireland also scores poorly on infant mortality, where it is in the bottom one-third of the range.
In contrast, Ireland is among the best performers in terms of the proportion of babies born with low birth weight.
Non Medical factors: Non Medical factors “non-medical factors”, are indicators relating to tobacco consumption, alcohol consumption, road traffic accidents, sulphur oxide emissions and immunisation rates.
Ireland does well on road traffic injuries, is in the middle range in terms of sulphur oxide emissions and the percentage of the adult population smoking daily but scores in the bottom range for alcohol consumption and childhood immunisations.
Health Outcomes: Health Outcomes The indicators employed relate to leading causes of mortality and premature mortality, namely cancer, heart attack, strokes and suicide.
They measure mortality standardised for age for men and for women relating to lung cancer, heart attack and stroke, together with potential years oflife lost through lung cancer for men and for women, female breast cancer and male suicide.
Ireland receives four gold medals (for male and female mortality rates from strokes and for male and female potential years of life lost due to lung cancer),
Ireland scores particularly poorly on male and female mortality from heart attack (the highest rates in the OECD) and for potential years of life lost due to female breast cancer
Overall performance: Could do better: Overall performance: Could do better Primary care strategy: Primary care strategy Primary care has become a central focus of official health strategy as Ireland, seeks to shift the emphasis from expensive hospital-based health care to primary curative and preventative interventions.
General practitioners play the central role in primary care, and one of the most distinctive features of the Irish healthcare system is the pricing of GP services.
For those who have medical card cover – generally because they fall below the specified income threshold – GP visits are free. For the rest of the population, GP visits must be paid for out of pocket on a fee per service basis;
Usually the patient has to bear that full cost (i.e., it is not reimbursed even where they have health insurance).
GPs are free to set the charge to meet their full costs and the majority of GPs provide services to both sets of patients – medical cardholders and non-medical cardholders.
In many other OECD countries, by contrast, primary care is either free or heavily subsidised, by one means or another, for most or all of the population
GP Visiting rates by country: GP Visiting rates by country GP visits and income: GP visits and income In Ireland, visiting rates are about twice as high towards the bottom compared with the top, whereas in most of the other countries that ratio is rather lower, at approximately 1.5.
Where Ireland also stands out, though, is in the very sharp fall in the visiting rate as one goes from the second to the third decile – when the average number of visits drops from 6.6 to 3.6. No other country sees such a sharp decline.
The obvious question to ask is whether this could reflect the impact of medical card entitlement on the cost of a GP visit to patients. In fact the key difference in terms of GP visiting rates in Ireland is simply between those with and without medical cards.
Medical Card Scheme: Medical Card Scheme Only 27.7 per cent of the population is now eligible for medical cards on income grounds, the lowest level since the GMS scheme was introduced in 1972.
Criteria for eligibility are unclear and often discretionary
In 1977 nearly 39 per cent of the population was covered by the scheme. In 2003 individuals on incomes above 138 euro a week and a family of four on an income of over 250 euro failed to qualify for cards.
So low are the income limits for cards that in 2003 a GP visit and a 20 euro chemist bill could cost over 40 per cent of the weekly income of a single person and nearly a quarter of the income of a family of four earning just above the eligibility limits for cards.
A ten-day hospital stay, at a charge of 40 euro per night subject to a 400 euro maximum, could consume over two-thirds of the monthly income of the same individual and 37 per cent of the monthly income of the family of four. Consequently, many individuals and families are going without necessary care Public/Private mix 1: Public/Private mix 1 For many years those towards the top of the income distribution in Ireland have been encouraged to take out “private” health insurance.
In the late 1950s the Voluntary Health Insurance Board (VHI) was established as a monopoly state-backed not-for-profit health insurer to cater for the top 15 per cent or so of the income distribution, who did not (then) have entitlement to public hospital care from the state.
Public/private mix 2: Public/private mix 2 A crucial difference between Ireland and many other countries “private” insurance provided for many years by what was to all intents and purposes an arm of the State.
Much of the “private” care it covers was and is delivered in public hospitals.
Medical consultants retained the right to treat their private patients in public hospitals, and about half of all private hospital care is in fact delivered in those hospitals.
Most patients receiving private care – in a publicor private hospital - have insurance, and the insurer reimburses both medical consultant and hospital.
Most medical consultants are contracted to care for public patients in public hospitals on a salaried basis, while maintaining the scope to treat private patients on a fee-for-service basis.
Slide21: From the 1950s to the late 1970s or early 1980s, this public-private mix supported by “private” health insurance functioned in roughly the way it was designed to do, with a monopoly insurer covering private care for the well-off and in effect “topping up” the public system.
There have been dramatic rises in the percentage of the population buying health insurance. This jumped up from about 20 per cent to 30 per cent in the late 1970s, jumped once again in 1987 to 35 per cent, rose steadily through the 1990s and by now is very close to half the population.
This occurred despite the fact that full entitlement to public hospital care (subject to some charges levied on all those without medical card cover) was extended to the top part of the income distribution
A two tier system emerges: A two tier system emerges Attitudinal surveys ( Watson and Williams 2001, Health Insurance Authority 2003) suggest that concern about waiting times for public hospital care is uppermost in people’s minds, that quality of care has also come to be seen as a significant issue, and that having a private room or other “hotel” aspects are not seen as an important reason for buying private insurance.
Waiting times for public hospitals are widely perceived to be long, both by those with and without insurance.
So what people essentially believe they are buying is the assurance that they can access hospital care when they need it, without undue waiting and with care from a medical consultant of their choice.
Healing the rich at the expense of the poor: Healing the rich at the expense of the poor What is distinctive about the Irish case is that the public hospital system has come to be seen very widely as a two-tier one, offering the better-off more rapid access.
They are in effect subsidised by the taxpayer Subsidisation comes through tax breaks on insurance premia and below-cost charges for private care in public hospitals (Nolan and Wiley 2001).
Even if private care in public hospitals covered its full cost or even generated a surplus to cross-subsidise care of public patients, an equity concern would arise about two-speed access to those hospitals.
The main argument advanced for retention of private care in public hospitals is that this allows the most able medical specialists to be available to care for public patients.
There has been no attempt to assess the scale of the purported benefits to the public system, nor whether the benefits of close interaction with private care are outweighed by the costs.
Slide24: There is a distortionary impact of the incentives for medical consultants and hospital managers associated with the inter-mingling of public and private care.
Most medical consultants employed to treat public patients, and paid a salary for doing so, also have private patients for whom they are paid on a fee-per-service basis.
While consultants are committed to a specified number of hours per week caring for public patients there is no effective monitoring and the incentive they face to concentrate more of their attention on private patients
Public hospital managers also face an incentive to maximise revenue from private patients in any given year, since this is one of the few sources of additional revenue at their disposal
Social inequalities in Irish health: Social inequalities in Irish health ‘Irish people die younger because they tolerate an
inequality between them that breeds ill-health, and they accept a health care system and a view of health care which implicitly places lesser value on the lives of those with lesser means.’
Wren (2003) An Unhealthy State