Minister Reilly to lift restrictions on GPs who can treat medical card holders
On 14 September, Minister James Reilly announced that he had got Cabinet approval to lift restrictions on GPs treating patients with medical cards. So will this make it easier for people to access GPs and drive down high costs of GP visits?
Quite simply we don’t know yet and the detail of the legislation will determine that but lets look at its origins – the EU/IMF Programme for National Recovery where it says ‘all restrictions on appropriately trained GPs who wish to hold General Medical Scheme (GMS) contracts will be abolished’. This sentence on page 33 is contained in the section on professional services which acknowledges that the costs of many professional services have come down but highlights a few specific areas – legal, insurance and GP’s – where costs have not come down. The Competition Authority have also called for such a measure to increase competitiveness in this sector.
Their aim is to drive down the costs of GP care through more open competition between GPs, which in turn should make GPs more accessible. However, the rules of the market do not always apply to health/GP care and particularly in this context where the vast majority of GPs incomes come from their medical card patients, ie the majority of their income does not come from the private free market but from annually guaranteed public money.
We do not know exactly how much of GPs income comes from their medical card patients because GP’s are self employed contractors. There are about 2,600 of them practicing in the country (although no one could give me a definitive number) and 80% of these have GMS patients and were paid about €477 million last year for treating them. They are paid through capitation which works out on average at €240 per person per year but it varies enormously depending on age, distance from GP etc. GP’s also get paid for vaccines, baby checks etc.. but much of what they earn is direct income as it goes to pay for nurses, premises, equipment. Estimates of average GP incomes are hard to get but average income is guesstimated at €120,000 a year..
To get ‘free’ GP care, if you are a medical card holder, once you get your card, you get a list of GPs in your area and you can choose which one you want and then you have to get the GP to accept you. You hear about people being unable to get on a GP list as they are closed although both GPs and HSE say today that this is no longer the case except in Kildare.
And there are increased numbers of unemployed and lower incomes, more people are eligible for medical cards so there is a greater demand to get on a GMS list. In June there were 1,680,534 people covered by medical cards – an additional 121,757 since June 2010. When you include GP visit cards, over 39% of population is now covered to go to their GP without paying.
The main obstacle currently in place is for newly qualified GP’s to get a GMS list – either have to apply to the HSE for a list that comes up when someone has retired, which is advertised or join a practice, so it’s a long and insecure route in.. And GMS lists are a majority of most GP’s income so they are crucial.
The press release from the Minister says the HSE ‘can enter into a contract with any suitable qualified GP’ not just those on the list so this might take some of the uncertainty away for newly qualified GPs.
And getting on the ladder of a GP career is particularly a female issue. There is a general feminisation of medical care – currently 40% of GPs are women but 80% of those in training are female .
So is there any chance this move will drive down costs for private patients? This is still unclear. We know from international and national experience that the ‘market’ in health care can lead to over investigation and over referral to hospital care.
Also providers, in this instance GPs, may migrate to richer, more profitable areas as happens now so there’s a real problem in that rural areas and certain urban deprived areas which are under provided. So there is a risk that increased competition or less regulation would make that worse not better.
THis issue could be dealt with in legislation but it never has been up to now. The contract currently in place was agreed in 1989 and health care has changed a lot since then. Minister Reilly has spoken publicly about introducing a new GP contract, about incentivising GPs to treat chronic diseases etc but speaking to an IMO rep he says they have not begun discussions with the minister on this although he is now six months in place.
Finally the programme for government promises free GP care for all by 2016 and the first to get a bite of this will be those on the long term illness scheme – who are due to get free GP care within the first year of government. A spokesman for the government said these plans are on track – although GP’s say they have not heard a word about this. Presumably this requires extra payment to GP’s – interesting to see where this comes from, I will watch with interest…