Extending eligibility for general practitioner care in Ireland: Cost implications

Connolly, Sheelah; Keegan, Conor; O'Malley, Seamus; Regan, Mark Research Report Extending eligibility for general practitioner care in Ireland: Cost implications Research Series, No. 156 Provided in Cooperation with: The Economic and Social Research Institute (ESRI), Dublin Suggested Citation: Connolly, Sheelah; Keegan, Conor; O'Malley, Seamus; Regan, Mark (2023) : Extending eligibility for general practitioner care in Ireland: Cost implications, Research Series, No. 156, The Economic and Social Research Institute (ESRI), Dublin, https://doi.org/10.26504/rs156 This Version is available at: https://hdl.handle.net/10419/298300 Standard-Nutzungsbedingungen: Die Dokumente auf EconStor dürfen zu eigenen wissenschaftlichen Zwecken und zum Privatgebrauch gespeichert und kopiert werden. Sie dürfen die Dokumente nicht für öffentliche oder kommerzielle Zwecke vervielfältigen, öffentlich ausstellen, öffentlich zugänglich machen, vertreiben oder anderweitig nutzen. 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If the documents have been made available under an Open Content Licence (especially Creative Commons Licences), you may exercise further usage rights as specified in the indicated licence. https://creativecommons.org/licenses/by/4.0/ EXTENDING ELIGIBILITY FOR GENERAL PRACTITIONER CARE IN IRELAND: COST IMPLICATIONS SHEELAH CONNOLLY, CONOR KEEGAN, SEAMUS O’MALLEY AND MARK REGAN RESEARCH SERIES NUMBER 156 JANUARY 2023 E V I D E N C E F O R P O L I C Y EXTENDING ELIGIBILITY FOR GENERAL PRACTITIONER CARE IN IRELAND: COST IMPLICATIONS SHEELAH CONNOLLY CONOR KEEGAN SEAMUS O’MALLEY MARK REGAN January 2023 RESEARCH SERIES NUMBER 156 Available to download from www.esri.ie Ó The Economic and Social Research Institute Whitaker Square, Sir John Rogerson’s Quay, Dublin 2 https://doi.org/10.26504/rs156 This Open Access work is licensed under a Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. ABOUT THE ESRI The mission of the Economic and Social Research InsStute (ESRI) is to advance evidence-based policymaking that supports economic sustainability and social progress in Ireland. ESRI researchers apply the highest standards of academic excellence to challenges facing policymakers, focusing on 12 areas of criScal importance to 21st-century Ireland. The InsStute was founded in 1960 by a group of senior civil servants led by Dr T.K. Whitaker, who idenSfied the need for independent and in-depth research analysis to provide a robust evidence base for policymaking in Ireland. Since then, the InsStute has remained commiYed to independent research and its work is free of any expressed ideology or poliScal posiSon. The InsStute publishes all research reaching the appropriate academic standard, irrespecSve of its findings or who funds the research. The quality of its research output is guaranteed by a rigorous peer-review process. ESRI researchers are experts in their fields and are commiYed to producing work that meets the highest academic standards and pracSces. The work of the InsStute is disseminated widely in books, journal arScles and reports. ESRI publicaSons are available to download, free of charge, from its website. AddiSonally, ESRI staff communicate research findings at regular conferences and seminars. The ESRI is a company limited by guarantee, answerable to its members and governed by a council comprising 14 members who represent a cross-secSon of ESRI members from academia, civil services, state agencies, businesses and civil society. The InsStute receives an annual grant-in-aid from the Department of Public Expenditure and Reform to support the scienSfic and public-interest elements of the InsStute’s acSviSes; the grant accounted for an average of 30 per cent of the InsStute’s income over the lifeSme of the last research strategy. The remaining funding comes from research programmes supported by government departments and agencies, public bodies and compeSSve research programmes. Further informaSon is available at www.esri.ie THE AUTHORS Sheelah Connolly is a senior research officer at the ESRI and an adjunct associate professor at Trinity College Dublin (TCD). Conor Keegan was a senior research officer at the ESRI, and Seamus O’Malley was a research assistant at the ESRI at the Sme of compleSng this research. Mark Regan is a research analyst at the ESRI and an adjunct staff member at TCD. ACKNOWLEDGEMENTS Financial support for this research was provided by the Department of Health. The authors would like to thank the members of the Department of Health/ESRI Research Programme on Healthcare Reform Steering Group for their input and direcSon in compleSng this analysis. In parScular, the authors would like to thank Deirdre Coy and Tiago McCarthy from the Department of Health for their valuable insights. The authors also acknowledge the contribuSon of Anne Nolan of the ESRI. Valuable comments on the text and suggesSons for revision were provided by three anonymous reviewers. We thank all those who provided contribuSons while acknowledging that the authors bear sole responsibility for the analysis and interpretaSons presented. This report has been accepted for publica3on by the Ins3tute, which does not itself take ins3tu3onal policy posi3ons. All ESRI Research Series reports are peerreviewed prior to publica3on. The author(s) are solely responsible for the content and the views expressed. CONTENTS LIST OF TABLES .................................................................................................................................... VI LIST OF FIGURES ................................................................................................................................. VII LIST OF BOXES .................................................................................................................................... VII ABBREVIATIONS ................................................................................................................................ VIII EXECUTIVE SUMMARY ........................................................................................................................ IX 0.1 Introduction ..................................................................................................................... ix 0.2 Methods ........................................................................................................................... ix 0.3 Findings ............................................................................................................................. x 0.4 Discussion ........................................................................................................................ xi CHAPTER 1 INTRODUCTION ............................................................................................................... 1 CHAPTER 2 FINANCING GP CARE AND THE ROLE OF USER CHARGES: A REVIEW OF THE LITERATURE .......................................................................................................................................... 3 2.1 Introduction ..................................................................................................................... 3 2.2 Financing GP care ............................................................................................................. 3 2.3 Cost-sharing for GP services ............................................................................................ 4 2.4 Extending eligibility and reducing cost-sharing ............................................................... 7 2.5 Summary .......................................................................................................................... 8 CHAPTER 3 GENERAL PRACTICE IN IRELAND ..................................................................................... 9 3.1 Introduction ..................................................................................................................... 9 3.2 Eligibility ........................................................................................................................... 9 3.3 Demand ......................................................................................................................... 10 3.4 Supply ............................................................................................................................ 11 3.5 Summary ........................................................................................................................ 12 CHAPTER 4 METHODS ...................................................................................................................... 13 4.1 Overview of approach .................................................................................................... 13 4.2 Population projections ................................................................................................... 16 4.3 Extending eligibility ........................................................................................................ 17 4.4 Take-up of eligibility ....................................................................................................... 19 4.5 Demand for GP visits ...................................................................................................... 20 4.6 Costing free GP care ....................................................................................................... 22 4.7 Scenarios ........................................................................................................................ 26 4.8 Extension: Two free GP visits ......................................................................................... 27 4.9 Sensitivity analysis ......................................................................................................... 28 Contents | v 4.10 Cost estimates for existing cardholders and non-cardholders ...................................... 28 CHAPTER 5 FINDINGS ...................................................................................................................... 29 5.1 Introduction ................................................................................................................... 29 5.2 Current non-cardholders ............................................................................................... 29 5.3 Extending eligibility: demand implications .................................................................... 30 5.3.1 Extending eligibility by age group 30 5.3.2 Extending eligibility by income group 32 5.4 Extending eligibility: cost implications ........................................................................... 35 5.4.1 Extending eligibility by age group 35 5.4.2 Extending eligibility by income group 35 5.5 Sensitivity analysis ......................................................................................................... 36 5.6 Extending eligibility: two free GP visits .......................................................................... 37 5.7 Cost for existing cardholders ......................................................................................... 38 5.8 Cost for non-cardholders ............................................................................................... 40 CHAPTER 6 DISCUSSION .................................................................................................................. 42 6.1 Summary of findings ...................................................................................................... 42 6.2 Limitations ..................................................................................................................... 44 6.3 Policy implications ......................................................................................................... 45 6.3.1 Extending eligibility 45 6.3.2 Paying GPs 47 6.3.3 Achieving universal health care 48 REFERENCES ....................................................................................................................................... 50 TABLES 0.1 Projection scenario assumptions ........................................................................................... x 4.1 Cardholder groups included in the analysis ........................................................................ 14 4.2 Summary of main assumptions for population scenarios ................................................... 17 4.3 Extension of eligibility for free GP care based on age group .............................................. 18 4.4 Number of GP visits per annum by age group, sex and card status ................................... 22 4.5 Increase in demand for GP visits on receipt of a medical card or GP visit card .................. 22 4.6 Capitation rates by age and sex, 2019 ................................................................................ 23 4.7 Proportion of various fees and allowances used in the analysis to estimate the cost of extending eligibility for free GP care to the total population ............................................. 25 4.8 Projection scenario assumptions ........................................................................................ 27 5.1 Number of new cardholders if eligibility is extended on the basis of age, 2023–2026 ...... 30 5.2 Projected number of GP visits (million): no extension to eligibility and age-based extension to eligibility, 2023–2026, central scenario .......................................................................... 31 5.3 Projected number of GP visits (million) by card status using the age-based approach to extending eligibility, 2022–2026, central scenario ............................................................. 31 5.4 Current income limits for a GP visit card and required income limits to cover an additional one-third of population each year ...................................................................................... 32 5.5 Projected number of GP visits (million); no extension to eligibility and income-based extension to eligibility, 2023–2026, central scenario ......................................................... 34 5.6 Projected number of GP visits by card status using the income-based approach to extending eligibility, 2022–2026, central scenario .............................................................................. 34 5.7 Projected cost to the State of extending eligibility for free GP care (new cardholders), agebased approach, €(million), 2023–2026 ............................................................................. 35 5.8 Projected cost to the State for extending eligibility for free GP care (new cardholders), income-based approach, €(million), 2023–2026 ................................................................ 36 5.9 Sensitivity analysis: percentage effect on 2026 cost of changing one assumption (%), central scenario ............................................................................................................................... 37 5.10 Projected cost to the State of providing two free GP visits (new cardholders), €(million), 2026 ............................................................................................................................................ 37 5.11 Projected cost to the State for GP services for existing cardholders, €(million), 2023–2026 ............................................................................................................................................ 38 FIGURES 4.1 Hippocrates Model framework, new cardholders .............................................................. 16 5.1 Percentage of the population without a medical card or GP visit card, 2019 .................... 30 5.2 Percentage of previous non-cardholders that would become eligible in each year if eligibility is extended on the basis of income .................................................................................... 33 5.3 Projected cost to the State for existing cardholders and new cardholders using the age-based approach to extending eligibility (€million), 2026, central scenario ................................... 39 5.4 Projected number of people eligible for free GP care: current eligibility and age-based extension to eligibility (million), 2022–2035, central scenario ........................................... 40 5.5 Projected out-of-pocket expenditure on GP services by non-cardholders (€ million), 2019– 2026, central scenario ......................................................................................................... 41 BOXES 4.1 Switch modelling of medical and GP visit cards .................................................................. 19 4.2 The Healthy Ireland Survey and GP utilisation .................................................................... 21 2 | Extending eligibility for general practitioner care in Ireland The aim of the research in this report is to esSmate the cost of extending eligibility for free GP services at the point of use to the whole populaSon (i.e. if everyone becomes eligible for a GP visit card). The analysis esSmates the cost implicaSons for the State of alternaSve approaches to extending eligibility (based on age and income) and the costs for exisSng cardholders as well for non-cardholders. Next, Chapter 2 will idenSfy and discuss some consideraSons in relaSon to extending eligibility for GP services in Ireland, with reference to the naSonal and internaSonal literature on the subject. Aser that, Chapter 3 will provide an overview of general pracSce in Ireland, and Chapter 4 the data sources and methods of the analysis. Chapter 5 will present the findings. Finally, Chapter 6 will summarise these findings, idenSfy the limitaSons of the analysis, and discuss the implicaSons to policy. CHAPTER 2 Financing GP care and the role of user charges: A review of the literature 2.1 INTRODUCTION Different countries adopt different approaches to financing GP care, including the extent to which such services are paid out of pocket by service-users. In this chapter, alternaSve approaches to financing GP care (including the role of user charges) and their implicaSons for care are examined. The chapter also idenSfies and discusses countries that have, in recent years, sought to increase eligibility or reduce user charges for GP services. 2.2 FINANCING GP CARE InternaSonally, a number of different methods are used to reimburse GPs including fee-for-service, capitaSon payments, salary and pay for performance. A large range of studies have examined the advantages and limitaSons of the different approaches (Gosden et al., 2000; Jegers et al., 2002; KrisSansen and Mooney, 1993; SlaYery et al., 2013; Steinbrook, 2009). Under fee-for-service payment, providers receive a fee for each item of service provided. As payments are Sed directly to the number of services provided, providers may have a financial incenSve to increase acSvity (KrisSansen and Mooney, 1993) with a resulSng increase in potenSally inappropriate care and costs. Fee-for-service payment mechanisms may also discourage providers from delegaSng to other (more appropriate) providers (Saltman and Figueras, 1997) and generally provide liYle incenSve to improve quality of care (Steinbrook, 2009). Under a system of capitaSon, health-care providers are generally paid a fixed fee for each paSent registered on their list. The payment is usually weighted by paSent characterisScs, including age and sex, and someSmes deprivaSon, which influence the need for health care (Brick et al., 2010). As addiSonal acSvity under a capitaSon system represents a cost to the provider, providers paid under capitaSon may prioriSse long-term prevenSve health care. However, capitaSon payments may encourage pracSSoners to hold larger-sized paSent lists in order to maximise income, which may result in a higher workload and shorter consultaSons (Gosden et al., 2000). Also, it may encourage ‘cream-skimming’ as providers seek out lowrisk paSents (ScoY, 2000) and quicker referral to secondary care. Salaried health-care providers receive a fixed salary, typically to work a set number of hours per week (Wren et al., 2015). Similar to capitaSon payments, salary 4 | Extending eligibility for general practitioner care in Ireland reimbursement may encourage health-care providers to opt for less complex cases in order to reduce their workload (Saltman and Figueras, 1997). It may also encourage providers to pass on more difficult or Sme-consuming cases to others. A Cochrane review that evaluated the impact of the different payment methods for primary-care doctors found that fee-for-service resulted in more primary-care contacts, visits to specialists and diagnosSc and curaSve services, but fewer hospital referrals and repeat prescripSons compared with capitaSon (Gosden et al., 2000). Recognising the potenSal impact of different payment schemes, a number of countries have experimented with mixed or blended methods, including a capitaSon or salary component as well as a fee-for-service or block payments for the provision of certain services or the achievement of a specific objecSve (Brick et al., 2010). In the UK, for example, while the majority of funding for GPs comes from capitaSon payments based on the age and sex composiSon of registered paSents, addiSonal needs, list turnover, pracSce market forces, rurality and the number of paSents in nursing and residenSal homes (Rhys et al., 2010), addiSonal income can be earned through the Quality and Outcomes Framework (QOF). Introduced in 2004, the QOF is a voluntary extra-payment structure intended to link payments to quality of care (Roland and Guthrie, 2016), with 72 indicators across four domains (clinical, organisaSon, paSent experience and addiSonal services). In Australia, GPs are paid under a fee-for-service model with the public insurer (Medicare) determining fees. GPs can either accept the Medicare determined payment as full compensaSon or can charge an addiSonal out-of-pocket fee. Similar to the UK, performance incenSves (including the PracSce IncenSve Program, PIP) has been introduced to encourage beYer quality of care and to decrease the undesired effects of fee-for-service (Taylor et al., 2016). The available evidence on blended payment schemes is mixed (Eijkenaar et al., 2013; Van Herck et al., 2010), with liYle evidence of a ‘magic bullet’ to deal with the perverse incenSves arising from different payment schemes (Van Herck et al., 2010). In some OrganisaSon for Economic Co-operaSon and Development (OECD) countries, in recent years, there has been a move towards more innovaSve ways to pay health-care providers. These include bundled payments for episodes of care for chronic condiSons, which aim to improve quality and reduce costs, and populaSonbased payments in which groups of health-care providers receive payment on the basis of the populaSon covered (OECD, 2016). 2.3 COST-SHARING FOR GP SERVICES In many countries, health-service-users also contribute to the cost of such services. PaSent cost-sharing refers to any direct payment made by health-service-users to Financing GP care and the role of user charges | 5 providers. The most common type of cost-sharing for GP services are co-payments, where the paSent pays a flat amount for each service received. While different countries adopt different approaches to cost-sharing for GP services, in most European countries (with Ireland being an excepSon) there is a tendency to lower cost-sharing for primary-care services as much as possible, parScularly for GP visits (Kringos et al., 2013). In the UK, Germany and Canada, for example, most GP visits are provided without charge at the point of use (Allin et al., 2020; Blumel and Busse, 2020), although there may be charges for some services (e.g., sick cerSficates and travel prescribing) and for some groups of people (e.g., non-residents). In other countries, the extent of cost-sharing tends to be relaSvely low and is osen subject to payment caps. For example, in the French health-care system, the typical fee for a primary-care visit with a registered physician is in the region of €7.50 (Tikkanen et al., 2020). There are a range of safety nets in place with caps on copayments at €50 per year for physician visits (Durand-Zaleski, 2020) and exempSons for various groups including low-income households. In addiSon, some people choose to purchase private health insurance (PHI) which covers some copayments. In Australia, the federal government sets fees for GP and specialty visits; it pays 100 per cent of the GP fee and 85 per cent of the specialist fee. PaSents pay the remaining 15 per cent of specialist fees, as well as any surcharges. GPs and specialists can choose to charge above the set fees, although there is a maximum paSent out-of-pocket fee per service. In 2016–2017, about 86 per cent of GP visits were provided without an addiSonal charge to paSents (Glover and Woods, 2020). In Norway, a co-payment of NOK 155–334 (€16–34) is payable for a primary-care visit, with a maximum out-of-pocket contribuSon for health-care expenses each year (amounSng to NOK 2,258 [approximately €233] in 2017; Sperre Saunes, 2020). Generally, the reason for cost-sharing is to reduce demand for health-care services. The extent to which this happens in pracSce depends on the price elasScity of demand, defined as the responsiveness of the quanSty demanded to a change in price. If cost-sharing is levied on services for which demand is largely price-inelasSc (i.e. not responsive to changes in price), it shiss the burden of financing from the public sector to the user. On the other hand, if cost-sharing is used on services for which demand is price-elasSc (i.e. responsive to changes in price), co-payments may reduce the demand for such services (Kiil and Houlberg, 2014). Another reason for cost-sharing is to raise revenue. Much of the early evidence on the impact of cost-sharing came from the RAND Health Insurance Experiment (HIE) in the United States (Keeler, 1992). The study 6 | Extending eligibility for general practitioner care in Ireland ran from 1974 to 1977 and included 5,809 people who were randomly assigned into insurance plans that either had no cost-sharing or that had 25 per cent, 50 per cent or 95 per cent cost-sharing (with a maximum annual family out-of-pocket payment of $1,000). Overall, the experiment found that cost-sharing reduced the use of all types of health-care services. The average price elasScity was calculated to be −0.20 across the different types of health-care services included in the experiment (Manning et al., 1987). Further analysis within the RAND HIE showed that cost-sharing reduced the demand for effecSve and ineffecSve treatments to the same extent (Shapiro et al., 1986) and reduced the demand for health-care services more for low-income groups – in parScular low-income children (Lohr et al., 1986). The impact of costsharing on health was ambiguous: cost-sharing was found to be associated with poorer blood-pressure control, corrected vision and oral health, but it did not appear to have an impact on other aspects of health (Keeler, 1992). Since the RAND HIE, a number of other studies have examined the impact of costsharing on health-care service usage. Van de Voorde et al. (2001), for example, examined the effects of co-payments on the demand for physician services in Belgium in the period 1986–1995. They found out-of-pocket price elasSciSes for the general populaSon from −0.39 to −0.28 for GP home visits, −0.16 to −0.12 for GP office visits and −0.10 for specialist visits. These esSmates were generally lower for older and disabled people. Considering the Australian case, McRae and Butler (2014) esSmated a price elasScity of demand of −0.19 for GP services over an eightyear period. Reviewing the evidence across a range of health-care services and countries, Kiil and Houlberg (2014) found that for all types of health-care services except hospitalisaSons, the majority of reviewed studies found a negaSve effect of copayments; the esSmated price elasSciSes were all negaSve and less than 1. They note that the health effect of cost-sharing has only been assessed empirically in a limited number of studies, of which half did not find any significant effects in the short term. The impact of cost-sharing on health is likely to depend on whether cost-sharing affects the use of ‘appropriate’ or ‘inappropriate’ health-care services. However, the inability of paSents to discriminate between appropriate and inappropriate health-care services may be limited, with evidence that people reduce essenSal as well as non-essenSal health services (Tamblyn et al., 2001; Rice and Matsuoka, 2004). There is evidence that vulnerable groups reduce their use of health-care services relaSvely more than the remaining populaSon as a result of co-payments (Kiil and Houlberg, 2014). Financing GP care and the role of user charges | 7 A growing body of literature examines how a reducSon in cost-sharing for GP services in Ireland might affect uSlisaSon. Nolan (2008), for example, invesSgated the impact of gaining (and losing) a medical card on number of GP visits among those aged 16 years and older and found that for those gaining a medical card there was an increase in the annual number of GP visits by between 27 and 39 per cent. Ma and Nolan (2017), addressing a similar quesSon for those aged 50 years and over, found that gaining a medical or GP visit card was associated with an addiSonal 1.3 GP visits per annum, equaSng to an approximate increase of 43 per cent in the number of annual visits. For children, Nolan and Layte (2017) found that gaining a medical or GP visit card resulted in an addiSonal 0.8 visits per annum for those aged nine months (25 per cent increase) and an addiSonal 0.5 visits per annum for those aged nine years (63 per cent increase). The findings in these studies are based on naSonally representaSve samples of people who gained a medical or GP visit card over a parScular Sme period. However, it is possible that some of the increase in uSlisaSon observed is related to factors other than gaining a card. For example, a person could gain a card because they became ill and they (or their parent) could no longer work. Consequently, a lower family income made them eligible for a card (Nolan and Layte, 2017). The increase in GP uSlisaSon could therefore be partly due to greater need. Consequently, the esSmate of increased uSlisaSon is likely to be an upper bound on the true effect of gaining a card on GP uSlisaSon (Nolan and Layte, 2017). A small number of studies have examined the impact of the introducSon of free GP visits for the under-sixes in Ireland (in 2015) on the number of GP visits for this group. O’Callaghan et al. (2018) found that the annual number of visits among the under-sixes increased by 29 per cent for daySme services and 26 per cent for outof-hours services following the introducSon of free GP care for this group. McDonnell et al. (2022) found that the change led to an increase in aYendance at daySme GP services of between 20 and 21 per cent and at out-of-hours services of between 21 and 29 per cent. Kirby and Murphy (2022) examined the effect of providing free GP care at the point of use for 16–17-year-olds and found that it would increase the average number of GP visits by 38 per cent per annum. 2.4 EXTENDING ELIGIBILITY AND REDUCING COST-SHARING As detailed in the previous secSon, most European countries tend to keep user charges for GP services as low as possible. In some countries, where user charges for such services have tended to be higher, aYempts have been made in recent years to reduce such payments. Together with Ireland and Latvia, Cyprus was previously idenSfied as having relaSvely high co-payments for primary-care services in a European context (Kringos et al., 2013). Prior to 2013, approximately 85 per cent of the populaSon was covered by the publicly financed health-care system. Beneficiaries were divided into two groups, with low user charges for the 8 | Extending eligibility for general practitioner care in Ireland largest group and higher user charges for a small group of beneficiaries (Theodorou et al., 2012). Between 2013 and 2019, in response to the financial crisis, enStlement to services decreased and user charges increased; there was a subsequent increase in catastrophic out-of-pocket expenditure (KontemenioSs and Theodorou, 2020). A major reform was iniSated in 2019 to extend coverage to the whole populaSon and to reduce user charges. While user charges remained for some services, GP services were exempt (KontemenioSs and Theodorou, 2020). To date, there is relaSvely liYle evidence on the impact of these changes; however, they are expected to reduce unmet need and financial hardship and to enable Cyprus to make progress towards universal health care (OECD and European Observatory on Health Systems and Policies, 2019). While potenSally of less relevance to the Irish context, a number of lowand middle-income countries have extended eligibility or reduced cost-sharing for various health-care services in recent years. In Africa, for example, several countries have removed cost-sharing in public health-care faciliSes with subsequent increases in uSlisaSon (Ridde and Diarra, 2009; Nabyonga et al., 2005). In 2001, the government of Uganda abolished user fees at public health-care centres and hospitals. Subsequently, Nabyonga-Orem et al. (2011) examined the impact of the removal of such charges on the frequency of reported illness and health-care uSlisaSon. They found that there was an increase in illness reporSng since user charges were removed, especially among poorer groups. USlisaSon of health-care services in the period immediately aser the aboliSon of user charges increased, parScularly by the poorest group. They also found that there was an increase in the use of lower levels of care with subsequent reducSons in the use of hospital services. 2.5 SUMMARY Different payment methods are used to pay GPs; however (with Ireland being an excepSon), most European countries aYempt to keep cost-sharing for such services relaSvely low. In recent years, a number of countries (especially lowand middleincome countries) have reduced or removed cost-sharing for GP services. CHAPTER 3 General practice in Ireland 3.1 INTRODUCTION This chapter will provide an overview of general pracSce in Ireland, focusing in parScular on eligibility for GP services, as well as the demand and supply for such services. 3.2 ELIGIBILITY As noted in Chapter 1, there are two main categories of enStlement to publicly funded health-care services in Ireland. Those with a medical card (Category I) are enStled to a range of public health-care services, free at the point of use; those without a medical card (Category II) are enStled to subsidised public-hospital services and prescripSon medicines but pay the full cost of GP and other primaryand community-care services. In 2005, the GP visit card was introduced, which enStles the holder to free GP visits. There is some limited enStlement for primary-care services for those without a medical card. For example, all residents are enStled to limited maternityand infant-care services free at the point of use, while a range of screening and vaccinaSon services are also provided without charge for eligible groups (Connolly et al., 2022). Eligibility for a medical card or a GP visit card is assessed primarily based on an income means test, with the threshold for GP visit cards set at about 65 per cent higher than for the medical card. The thresholds differ by family status, age, and number and age of dependent children in the family (Connolly et al., 2022). Income limits are higher for families with an adult over the age of 70, relaSve to those under the age of 70. Recent analysis found that approximately 31 per cent of individuals eligible for a medical card do not take it up (Keane et al., 2021), with a lack of informaSon about eligibility status and social sSgma contribuSng to the failure to do so. In some cases, individuals who are otherwise ineligible for a full medical card or GP visit card may be granted a card on a ‘discreSonary’ basis if they have parScular health needs that would cause them undue hardship. While, tradiSonally, income was the primary determinant of eligibility for a medical card or GP visit card, in 2015, a GP visit card was extended to all children younger than six and to people aged 70 and over. In 2020, approximately 32 per cent of the 10 | Extending eligibility for general practitioner care in Ireland populaSon had a medical card and 11 per cent had a GP visit card (Department of Health, 2021); the remainder of the populaSon (57 per cent) largely pay out of pocket for GP and other primary-care services. Alongside the public health-care system, Ireland has a voluntary PHI market. In the main, PHI in Ireland is used to finance hospital-based services, though some policies also provide some cover for GP and other primary-care services. 3.3 DEMAND General pracSces are osen individuals’ first point of contact with the health-care system in Ireland. They provide a variety of diagnosSc services and medical treatments and act as gatekeepers for a range of secondary-care services (Nolan, 2007). No single administraSve dataset records the number of visits to general pracSce in Ireland; however, using survey data, Walsh et al. (2021) esSmated that there were 18.8 million GP visits in Ireland in 2019. This number is potenSally an underesSmate of GP acSvity because, while it includes out-of-hours visits, it does not include GP visits for those residing in communal establishments (Walsh et al., 2021). Collins and Homeniuk (2021) esSmated that there were 21.4 million GP consultaSons in 2020; while that number includes GP visits to nursing homes, it is based on a survey of GP pracSces with a 32 per cent response rate and may not be representaSve of the general populaSon. GP visiSng rates differ by age, sex and cardholder status. In general, visiSng rates tend to increase with age; however, relaSvely high rates are observed in children aged younger than five years (Wren et al., 2017). Between the ages of approximately 12 and 45, visiSng rates for female paSents tend to be higher than for male paSents, likely reflecSng visits associated with the management of gynaecological and reproducSve issues. And, even though cardholders make up a smaller proporSon of the populaSon than non-cardholders (43 per cent relaSve to 57 per cent in 2020), they account for a higher proporSon of GP visits (61 per cent in 2019; Walsh et al., 2021). While it is likely that this is largely explained by the fact that those with cards tend to be older and more socio-economically disadvantaged than those without cards, the price differenSal for those with and without cards (e.g., free for cardholders and approximately €54 for non-cardholders) could also explain some of the difference. There is some evidence to suggest that user charges for GP services for those without a medical card or GP visit card may contribute to unmet health-care needs. O’Reilly et al. (2007), for example, examined the role of cost in deterring people from visiSng a doctor in Ireland and Northern Ireland (where services are free at the point of delivery). They found that in Ireland, 19 per cent of paSents had a General practice in Ireland | 11 medical problem in the previous year but had not consulted the doctor because of cost. This compared to less than 2 per cent of paSents in Northern Ireland. Among paying paSents, it was the poorest and those with the worst health who were most affected. Similar to other health-care services, demand for GP services is expected to increase significantly in the coming years. For example, incorporaSng esSmates of populaSon growth and ageing, assumpSons around healthy ageing and addressing current unmet need for GP services, Wren et al. (2017) projected that demand for GP visits would increase by between 20 and 27 per cent between 2015 and 2030. 3.4 SUPPLY Most GPs in Ireland are self-employed private pracSSoners, although some GPs are employed by a GP pracSce. The majority of GPs treat both private paSents (nonmedical/non–GP visit cardholders) and public paSents (medical cardholders and GP visit cardholders). Cardholders are required to register with a parScular GP. For private paSents, GP pracSces are largely reimbursed on a fee-for-service basis from individual paSents, with the fee determined by individual pracSces. For public paSents, GPs are reimbursed via the General Medical Services (GMS) scheme. Under the scheme, GPs receive an annual capitaSon payment (i.e., a set amount for each person registered with the GP, adjusted for age and sex) for each medical cardholder and GP visit cardholder on their list, as well as fees for out-of-hours and special items of service provided to medical cardholders and GP visit cardholders (Walsh et al., 2021). A range of allowances are also available to GPs holding a GMS contract. These cover pracSce supports (such as employing a pracSce nurse or a pracSce secretary), rural pracSce supports, annual leave, study leave, sick leave and maternity/ paternity/ adopSve leave. GPs (including both those holding a GMS contract and those without a GMS contract) are also paid fees for services delivered under specific schemes, including the Primary Childhood ImmunisaSon Scheme, the NaSonal Cancer Screening Service (e.g., cervical screening), the Maternity and Infant Care Scheme and the Chronic Disease Management Programme. In 2019, there was a new GP agreement between the Department of Health, the Health Service ExecuSve (HSE) and the Irish Medical OrganisaSon (IMO) regarding the development of GP services (Department of Health et al., 2019). It included plans for addiSonal payments to GPs over a phased basis to support three main strands: 18 | Extending eligibility for general practitioner care in Ireland 4.3.1 Extending eligibility based on age group In 2015, eligibility for a GP visit card was extended to children younger than six and people aged 70 and over. One of the key measures in Budget 2022 was the proposed extension of free GP care to those aged six and seven. In this analysis, it is assumed that eligibility for free GP services will be introduced in 2023 for those aged six and seven, in 2024 for those aged 50–69, in 2025 for those aged 8–17 and, finally, in 2026 for those aged 18–49 (Table 4.3). Consequently, by 2026, everyone would be eligible for GP care that is free at the point of use. TABLE 4.3 EXTENSION OF ELIGIBILITY FOR FREE GP CARE BASED ON AGE GROUP Year Age-group eligibility 2023 6–7 2024 50–69 2025 8–17 2026 18–49 Source: Authors’ assump-ons developed in conjunc-on with the Department of Health. 4.3.2 Extending eligibility based on income Here it is assumed that an enStlement to free GP care will be extended (between 2024 and 2026) based on income, with lower-income groups the first to become eligible. Current income thresholds will be extended in 2024, 2025 and 2026 so that approximately one-third of exisSng non-cardholders will become eligible in each year. By 2026, everyone would be eligible for GP care free at the point of use. EsSmates of income limits and the proporSon of the populaSon that would become eligible for free GP care under the various income limits were derived from the SWITCH Model (SimulaSng Welfare and Income Tax Childcare and Health; Box 4.1). SWITCH uses the 2019 Survey on Income and Living CondiSons (SILC), reweighted to accurately represent the 2019 populaSon and then uprated to 2022 income levels. The analysis is based on a 2022 populaSon and policy system, i.e., the tax and welfare policies in place in 2022. Therefore, it assumes that all monetary and demographic variables (e.g., populaSon and wages) are staSc across the Sme period of analysis (2022–2026). Methods | 19 BOX 4.1 SWITCH MODELLING OF MEDICAL AND GP VISIT CARDS The SWITCH Model is a tax-benefit micro-simulation model which has been developed to simulate Irish households’ tax liabilities and social-welfare entitlement (Keane et al., 2022). The model is based on data drawn from the 2019 SILC. The SILC covers a wide range of issues with a focus on income and living conditions. The survey is carried out annually and includes approximately 4,000 households, or 10,000 individuals, each year (Keane et al., 2022). Using information on a person’s current reported income, the SWITCH Model can estimate eligibility for an income-based medical card or GP visit card (Keane et al., 2021). The modelling of eligibility for a medical card or GP visit card, based on income, closely follows the means test set by the HSE. Assessable income is calculated from all relevant sources. For example, employee income, selfemployed income, capital income and secondary properties for both the applicant and their spouse (if applicable); simulated liabilities of income tax, PRSI (Pay Related Social Insurance) and USC (Universal Social Charge) are deducted. Social-welfare income is also included in the assessment of means, including child benefit and the working family payment. In cases where an applicant’s income is solely derived from a social-welfare income source, they are automatically entitled to a medical card. SWITCH also allows for deductions such as housing costs, childcare costs and allowances for dependent children as per HSE guidelines. The assessment of means occurs at the family level, as defined by the HSE. The assessable income is then compared to the relevant income limit, which varies by age and living status (living alone or with family). Aside from income-based entitlement to cards, the model also includes age-based eligibility, such as, for GP visit cards, those aged 70 and over and those under six. There is a hierarchical structure to the modelling whereby individuals who are simultaneously eligible for a medical card and a GP visit card are modelled as receiving a medical card. (Such a scenario arises only for under-sixes or over-70s who could be entitled to an age-based GP visit card and an income-based medical card.) The SWITCH Model has been used to formally calculate take-up rates of medical cards (Keane et al., 2021) and has also highlighted a lower take-up of means-tested GP visit cards vis-à-vis means-tested medical cards (Callan et al., 2016). Given this empirical evidence, simulations of card eligibility can be adjusted to incorporate non-take-up. For example, with a take-up rate of 100 per cent, all individuals simulated as eligible for a card apply for and are granted the card. With a take-up rate of 70 per cent, a random 30 per cent of individuals eligible for a card do not receive the card. 4.4 TAKE-UP OF ELIGIBILITY Not everybody who is eligible for a medical card or GP visit card avails of that eligibility. Recent analysis esSmated that 31 per cent of individuals eligible for a medical card do not take up a card (Keane et al., 2021), with a lack of informaSon about eligibility status and social sSgma contribuSng to the non-take-up. Earlier analysis found even lower uptake for the income-based GP visit card (Callan et al., 2016). 20 | Extending eligibility for general practitioner care in Ireland However, uptake for age-related GP visit cards appears higher than uptake for income-based cards, with analysis from the SILC showing 85 per cent of those aged younger than six in receipt of a GP visit card (Figure 5.1). The very detailed applicaSon form and potenSal uncertainty about eligibility under the incomebased approach may explain the difference in uptake between income-based and age-based cards. However, the reasons for non-take-up are not well understood, and, as such, non-take-up is modelled as a random process. Based on uptake rates idenSfied above, in this analysis, an uptake rate of 85 per cent is assumed in the age-based approach to extending eligibility, while an uptake rate of 70 per cent is assumed in the income-based approach. The cost implicaSons of a 100 per cent uptake will also be examined. 4.5 DEMAND FOR GP VISITS To idenSfy the number of GP visits that could be expected for new cardholders if GP care that is free at the point of use was introduced for all, esSmates of addiSonal demand were applied to current age-specific GP visiSng rates (for those aged 6–70 years) for the new cardholder populaSon. Current age-specific visiSng rates for the cardholder and non-cardholder group were esSmated from the Healthy Ireland survey using wave 4 and 5 data for adults and wave 5 data for children (Box 4.2). Table 4.4 shows the esSmated average number of GP visits by age group, sex and card status. EsSmates of visiSng rates were applied to the 2019 populaSon to esSmate visiSng volumes in 2019. The proporSon of the populaSon without a medical card or GP visit card was esSmated from the 2019 SILC for Ireland. Methods | 21 BOX 4.2 THE HEALTHY IRELAND SURVEY AND GP UTILISATION The Healthy Ireland survey is an annual face-to-face survey. Interviews are conducted with a representative sample of the population aged 15 and older living in Ireland (Ipsos MRBI, 2018). The sample size is approximately 7,500 people per wave. To date, six waves of the survey have been completed in the following years: 2015, 2016, 2017, 2018, 2019 and 2021. Waves 4 and 5 (relating to 2018 and 2019) included the following question in relation to GP utilisation: ‘When was the last time you consulted a GP or family doctor on your own behalf? (This includes home visits and phone consultations but excludes nurse-only consultations.)’ The following response options were provided: • Less than 12 months ago; • More than 12 months ago; • Never consulted; • Don’t know; • Refused. Those who reported that they had consulted a GP or family doctor less than 12 months ago were asked the following question: ‘How often in the past four weeks did you consult a GP on your own behalf, excluding nurse-only consultations?’ For the first time, wave 5 of the survey included questions relating to children of the survey respondent. Each respondent was asked whether they had children, the age of each child, whether each child attended a GP in the past 12 months and the number of visits in the previous four weeks. The weighted mean number of GP visits per annum by sex and age bands (16–17, 18–29, 30–39, 40– 44, 45–49, 50–54, 55–59, 60–64, 65–69) for those aged 16 and over for both cardholders and noncardholders was estimated by multiplying the number of visits in the previous four weeks by 13. These age groups were chosen so that there was a sufficient degree of disaggregation of age groups to incorporate different age breakdowns used in the analysis. (The age-based approach to extending eligibility uses the age categories 6–7, 8–17, 18–49, 50–69, while capitation payment rates (on which the costing analysis is based) uses the following categories: 6–15, 16–44, 45–64, 65–69.) A similar approach was adopted to estimate GP visiting rates for children for the following age bands: <6, 6–7 and 8–15. No data was collected on the sex or cardholder status of the child. For children aged six and over, it was assumed that they had the same eligibility status as the respondent parent or guardian. As it was not possible to identify those aged younger than six without a GP visit card in this analysis, a constant visiting rate across cardholders and non-cardholders was assumed. 22 | Extending eligibility for general practitioner care in Ireland TABLE 4.4 NUMBER OF GP VISITS PER ANNUM BY AGE GROUP, SEX AND CARD STATUS Age group Male with card Male with no card Female with card Female with no card <6 4.8 4.8 4.8 4.8 6–7 2.7 2.6 2.7 2.6 8–15 2.5 1.9 2.5 1.9 16–17 5.2 1.2 6.3 2.7 18–29 4.1 1.4 5.2 2.9 30–39 4.5 1.5 5.8 3.7 40–44 6.3 1.5 7.6 3.1 45–49 5.1 1.3 6.5 3.3 50–54 6.8 1.9 6.2 2.8 55–59 7.2 3.1 7.4 3.3 60–64 8.1 2.8 7.0 4.0 65–69 7.0 4.6 7.4 4.7 70+ 6.7 3.5 7.1 5.2 Source: Authors’ es-ma-on based on Healthy Ireland Waves 4 (2018) and 5 (2019) for adults (16+) and wave 5 for children (<16) Note: Card includes both medical cards and GP visit cards. There is no data on the card status of those under six so it is assumed that everyone has the same number of visits. Some cau-on is required in interpre-ng these es-mates as, for some categories, the number of respondents is rela-vely small. Previous research for Ireland esSmated the expected increase in demand associated with receipt of a full medical card or GP visit card (Table 4.5). As detailed in SecSon 2.3, these esSmates are likely to be an upper bound on the expected increase in the number of GP visits that would be expected were non-cardholders to become eligible for free GP care. These esSmates of addiSonal demand were applied to age-specific GP visiSng rates (for those aged 6–70 years) for the new cardholder populaSon to idenSfy the number of GP visits that would be expected for new cardholders if free GP care were introduced. TABLE 4.5 INCREASE IN DEMAND FOR GP VISITS ON RECEIPT OF A MEDICAL CARD OR GP VISIT CARD Age group Additional number of visits per annum (% increase in visits) Source 6–15 0.5 (63%) Nolan and Layte, 2017 16–54 0.9–1.3 (27–39%) Nolan, 2008 55–70 1.3 (43%) Ma and Nolan, 2017 4.6 COSTING FREE GP CARE While GPs are paid through a variety of mechanisms and schemes, the main approach to cosSng an extension of eligibility for GP care in this analysis is based on the current-capitaSon-rate approach. This approach assumes that GPs receive the ageand sex-specific capitaSon rate for exisSng cardholders in 2019 for each Methods | 23 previous non-cardholder (Table 4.6), plus the mean of some other fees payable to GPs (Table 4.7). The use of current capitaSon rates means that GPs would receive a level of remuneraSon for the care of new cardholders equivalent to the amount received for exisSng cardholders. In general, new cardholders would have beYer health status than the exisSng cardholder group and might be expected to have lower visiSng rates, even if the price of such visits falls to zero. When free GP care was extended to all children younger than six in 2015, the agreed capitaSon rate (which was subsequently applied to exisSng cardholders as well as to new cardholders) increased from between €42.39 and €74.59 (depending on the age of the child) up to €125. These increased payments were in return for an enhanced service which included free visits for prevenSve checks and annual reviews of children with asthma (Department of Health, 2015a). In line with this precedent, this analysis will examine the use of current capitaSon rates, 75 per cent of current capitaSon rates and 135 per cent of current capitaSon rates as potenSal rates for new cardholders. The lower capitaSon rates (75 per cent) reflect the expected lower uSlisaSon of GP services amongst new cardholders, while the higher capitaSon rates capture increased GP acSvity associated with enhanced service provision. The 2019 capitaSon rates are adjusted in line with the rate increases negoSated for those aged 6 and over in 2020 (2.74 per cent), 2021 (10.22 per cent) and 2022 (9.24 per cent) (Department of Health et al., 2019). TABLE 4.6 CAPITATION RATES BY AGE AND SEX, 2019 Age group Male Female <6 €125 €125 6–15 €51.96 €52.56 16–44 €66.33 €108.47 45–64 €132.49 €145.58 65–69 €139.57 €155.70 70+ (community) €326.02 €326.02 Source: HSE, 2019. Note: The rates included here relate to ‘Services rendered by the service provider under the agreement of 2019’. See HSE (2020) for further detail. Capita-on rates for nursing-home residents were not used in this analysis as there is no administra-ve data on the number of GP visits for nursinghome residents. In this analysis the cost of extending eligibility for GP care was only analysed for those aged 6–69 as other age groups are already eligible for GP care. 24 | Extending eligibility for general practitioner care in Ireland In addiSon to capitaSon payments, GPs receive a range of allowances and fees; Table 4.7 shows the type of fees and allowances that were paid to GPs in 2019. It is not clear to what extent fees and allowances would increase were eligibility for free GP care to be extended to the total populaSon. In this analysis, and in consultaSon with officials at the Department of Health, fees and allowances were divided into four categories and dealt with separately: 1. It is anticipated that some fees and allowances would not increase if eligibility for free GP care were extended to the total population. These included payments for services already universally available (including the Maternity and Infant Care Scheme and the National Screening Service). 2. Similar to capitation payments, some fees and allowances are expected to increase pro rata with the number of individuals who avail of free GP care, as is currently the case when an individual is enrolled in the GMS system. These include out-of-hours services and superannuation payments. 3. Some fees (in particular those associated with chronic disease management) are payable based on the diagnosis and management of particular conditions. Increasing eligibility to free GP care will result in an increase in GP visits and potentially an increase in the diagnosis of such conditions. While the extent of the increase in diagnosis is unknown, in this analysis it is assumed that expenditure in these categories would increase by between 8 and 16 per cent if eligibility to free GP care was extended to the total population. 4. A range of allowances are payable with the rate paid related to panel size (the number of GMS patients registered with a particular GP/GP practice). For some allowances, the amount payable is constant and maximised for panels of 100 GMS patients or more. For others, the amount payable increases gradually with panel size. It is not known how an increase in eligibility will impact the distribution of patients across GP practices with different panel sizes. In addition, it is not known if some GPs who currently do not participate in the GMS scheme will start if eligibility for free GP care is extended to all. In this analysis, it is assumed that expenditure in these categories would increase by between 50 and 60 per cent if eligibility to free GP care was extended to the total population. The extent of the increase in the various fees and allowances associated with an increase in eligibility for GP care is unknown and will likely be determined, at least in part, through negoSaSon between GPs (and their representaSve organisaSons) and the Department of Health and the HSE. In addiSon, it is likely that new categories of payment may be developed over Sme, reflecSng new tasks and acSviSes of GPs. Consequently, the expected percentage increases in fees and allowances used in this analysis should be interpreted with a degree of cauSon and do not necessarily reflect what should or could happen to fees and allowances if eligibility is to be extended. Methods | 25 Using the percentage increases idenSfied in Table 4.7, the ‘average’ fees and allowances payable to GPs was esSmated to be €84 per annum per paSent in the central esSmate and €90 in the high esSmate. TABLE 4.7 PROPORTION OF VARIOUS FEES AND ALLOWANCES USED IN THE ANALYSIS TO ESTIMATE THE COST OF EXTENDING ELIGIBILITY FOR FREE GP CARE TO THE TOTAL POPULATION Central estimate High estimate Fees Special claims/services 100% (pro rata) 100% (pro rata) Out-of-hours 100% (pro rata) 100% (pro rata) Dispensing 0% 0% Items of service contract 100% (pro rata) 100% (pro rata) Asylum-seekers 0% 0% Vaccinations 8% 16% Asthma registration 8% 16% Asthma capitation 8% 16% Contribution for GP height measure and self-zeroing scale 8% 16% Diabetes capitation 8% 16% Diabetes registration 8% 16% Allowances Secretarial/nursing 50% 60% Annual leave 50% 60% Rostering/out-of-hours 50% 60% Medical indemnity insurance 50% 60% Rural practice 0% 0% Study leave 50% 60% Maternity leave/paternity leave 50% 60% Locum and practice expenses 50% 60% Other Benefits to retired district medical officers 0% 0% Former district medical officers 0% 0% Superannuation fund 100% 100% National Screening Services 0% 0% Opioid substitution treatment scheme 0% 0% Primary childhood immunisation scheme 0% 0% Heartwatch 0% 0% Maternity and Infant Care Scheme 0% 0% Health (Amendment) Act 1996 0% 0% Source: The list of fees and allowances was derived from the 2019 Primary Care Reimbursement Service (PCRS) annual report (HSE, 2020) and is based on authors’ assump-ons. Note: The percentages used in this analysis are for illustra-ve purposes and do not indicate what could or should happen with fees and allowances if eligibility for GP care free at the point of use is extended. 26 | Extending eligibility for general practitioner care in Ireland 4.7 SCENARIOS For the main analysis, the approach follows that taken in Wren et al. (2017) and many other health-care projecSon exercises (Blanco-Moreno et al., 2013; Charlesworth and Johnson, 2018; de la Maisonneuve and MarSns Oliveira, 2015) of grouping demand and cost drivers into a range of projecSon scenarios. Given the uncertainty inherent in any projecSon exercise, this provides a basis for developing a projecSon range charSng the likely course of future expenditures. The analysis models a set of low, central and high projecSon scenarios (Table 4.8). Each scenario varies drivers in relaSon to projected demand and cost of GP care. Under the central scenario, the populaSon is projected to increase in line with the central populaSon-growth scenario (Table 4.2). Take-up of eligibility is assumed to be 85 per cent under the age-based model and 70 per cent under the income-based model. Under this scenario, the extension of GP eligibility is costed by taking current capitaSon rates (for exisSng cardholders) in 2019, adjusSng these to reflect negoSated rate increases to 2022 (Department of Health et al., 2019) and using this as a basis for capitated payments between 2023 and 2026. Under the low projecSon scenario, the populaSon is projected to increase in line with the low populaSon-growth scenario (Table 4.2). Similar to the central scenario, take-up of eligibility is assumed to be 85 per cent under the age-based model and 70 per cent under the income-based model. Expanded GP eligibility is costed by assuming 75 per cent of current capitaSon rates in 2019, adjusSng these to reflect negoSated rate increases to 2022 (Department of Health et al., 2019) and using this as a basis for capitated payments between 2023 and 2026. Under the high projecSon scenario, the populaSon is projected to increase in line with the high populaSon-growth scenario (Table 4.2). Under this scenario, a 100per-cent take-up of eligibility is assumed under both the age-based and incomebased models. Expanded GP eligibility is costed by assuming 135 per cent of the current capitaSon rates in 2019 and adjusSng these to reflect negoSated rate increases to 2022 (Department of Health et al., 2019). A 2.5 per cent per annum increase to the capitated rates is then applied between 2023 and 2026, reflecSng assumed government-sector nominal average wage growth based on the ESRI COSMO Model’s macroeconomic Upside scenario (Walsh et al., 2021). Methods | 27 TABLE 4.8 PROJECTION SCENARIO ASSUMPTIONS Low pressure Central High pressure Demand assumptions Population growth and ageing Low Central High Uptake of eligibility 85% (age) 70% (income) 85% (age) 70% (income) 100% Cost assumptions Capitation rates 75% of current Current 135% of current Fees/allowances Central Central High Cost No change 2023– 2026 No change 2023–2026 COSMO Upside: projected governmentsector wage growth (2.5% p.a. 2023–2026) Note: Authors’ assump-ons. 4.8 EXTENSION: TWO FREE GP VISITS In the main analysis, it is assumed that all GP visits would be provided free of charge at the point of use; an extension to the analysis includes cosSng two free GP visits for all new cardholders. Rather than using the capitaSon-based approach to cosSng, these two free visits will be costed using a ‘unit cost’ approach. It is assumed that GPs would receive payment for these two visits even if the actual number of visits was fewer than two. Under this approach, a unit cost of a publicly financed GP visit was esSmated using data on capitaSon and other payments to GPs for exisSng cardholders. CapitaSon payments and fees or allowances paid to GPs in 2019 were divided by the esSmated number of GP visits for cardholders to idenSfy the unit cost of a visit (esSmated at €41 per visit). The same fees and allowances used in the capitaSon approach (Table 4.6) to cosSng were also used here. Data on payments to GPs were obtained from the 2019 PCRS annual report (HSE, 2020), while data on the number of GP visits were esSmated by mulSplying the ageand sex-specific number of GP visits for cardholders (esSmated from the Healthy Ireland survey) by the ageand sexspecific number of cardholders. A constant unit cost across all age groups is assumed as there is liYle data to inform how unit costs might differ across age groups. However, it is possible that the cost of a GP visit could differ by age group if, for example, older people were more likely to have mulSple morbidiSes and therefore require a longer visit. ProjecSon scenarios idenSfied in Table 4.7 are also applied under this approach, with GP payments set at current esSmated unit cost, 75 per cent of the current 34 | Extending eligibility for general practitioner care in Ireland TABLE 5.5 PROJECTED NUMBER OF GP VISITS (MILLION); NO EXTENSION TO ELIGIBILITY AND INCOMEBASED EXTENSION TO ELIGIBILITY, 2023–2026, CENTRAL SCENARIO No extension to eligibility Income-based extension to eligibility 2023 19.8 19.8 2024 20.0 20.6 2025 20.2 21.4 2026 20.4 22.3 Source: Authors’ analysis using the Hippocrates Model. Note: The numbers in the table reflect the central scenario detailed in Table 4.7, with a card uptake rate of 70 per cent. Table 5.6 shows the projected number of GP visits in 2022–2026 for those who were exisSng cardholders, new cardholders and non-cardholders if eligibility is extended on an income basis. The projected number of GP visits for new cardholders increases over Sme, while the projected number for non-cardholders (those who are not eligible for a GP visit card or who choose not to avail of a GP visit card) decreases as the number of people eligible for a card increases. The observed increase in the number of visits among exisSng cardholders relates to an increase in the number of older people (with associated higher rates of visiSng) over Sme. Overall, there is an approximate 14 per cent increase in the projected number of GP visits between 2022 and 2026, reflecSng an increase in the number of people eligible for free GP visits (and, hence, an increase in demand) as well as an increase in, and ageing of, the populaSon. TABLE 5.6 PROJECTED NUMBER OF GP VISITS (MILLION) BY CARD STATUS USING THE INCOME-BASED APPROACH TO EXTENDING ELIGIBILITY, 2022–2026, CENTRAL SCENARIO Existing cardholders New cardholders Non-cardholders Total 2022 12.4 0 7.2 19.6 2023 12.5 0 7.3 19.8 2024 12.7 2.1 5.8 20.6 2025 12.8 4.3 4.3 21.4 2026 13.0 6.8 2.5 22.3 Source: Authors’ analysis using the Hippocrates Model. Note: The numbers in the table reflect the central scenario detailed in Table 4.7 with a card uptake rate of 70 per cent. Findings | 35 5.4 EXTENDING ELIGIBILITY: COST IMPLICATIONS 5.4.1 Extending eligibility by age group The central aim of the analysis in this report is to esSmate the cost to the State of extending eligibility for free GP care to current non-cardholders. Under the agebased extension of eligibility, it is assumed that eligibility for a GP visit card will be extended to those aged six and seven in 2023 and to the remaining age groups in subsequent years so that by 2026 all individuals would be enStled to a GP visit card. Table 5.7 shows the projected cost in 2023–2026 for new cardholders based on the scenarios detailed in Table 4.7 using the age-based approach to extending eligibility. In 2026, the expected cost to the State of extending eligibility for free GP visits to everyone ranges from €462 million in the low-pressure scenario to €881 million in the high-pressure scenario. TABLE 5.7 PROJECTED COST TO THE STATE OF EXTENDING ELIGIBILITY FOR FREE GP CARE (NEW CARDHOLDERS), AGE-BASED APPROACH, €(MILLION), 2023–2026 Low Central High 2023 8.7 9.7 13.9 2024 154.3 182.7 282.6 2025 210.3 245.8 386.3 2026 462.0 541.1 881.3 Source: Authors’ analysis using the Hippocrates Model. Note: The assump-ons underlying the scenarios are detailed in Table 4.7. 5.4.2 Extending eligibility by income group Table 5.8 shows the projected cost in 2023–2026 for new cardholders using the income-based approach to extending eligibility. In 2026, the expected cost to the State of extending eligibility for free GP visits to everyone ranges from €381 million in the low-pressure scenario to €881 million in the high-pressure scenario. The lower cost associated with the income-based approach to extending eligibility relaSve to the age-based approach reflects the assumed lower uptake rate associated with the income-based extension to eligibility (in the low and central scenarios). 36 | Extending eligibility for general practitioner care in Ireland TABLE 5.8 PROJECTED COST TO THE STATE FOR EXTENDING ELIGIBILITY FOR FREE GP CARE (NEW CARDHOLDERS), INCOME-BASED APPROACH, €(MILLION), 2023–2026 Low Central High 2023 – – – 2024 119.0 138.8 259.4 2025 240.7 281.3 541.1 2026 380.5 445.6 881.3 Source: Authors’ analysis using the Hippocrates Model. Note: The assump-ons underlying the scenarios are detailed in Table 4.7. 5.5 SENSITIVITY ANALYSIS Table 5.9 shows the impact on projected cost in 2026 (based on the age-based extension to eligibility) of changing one of the assumpSons detailed in the central scenario in Table 4.7. Changing the assumpSon on populaSon growth has relaSvely liYle impact on projected cost. For example, under a low populaSon scenario (relaSve to a central populaSon scenario), projected cost in 2026 would be 1 per cent lower, while under a high populaSon scenario, projected cost would be 2 per cent higher. Projected cost in 2026 is sensiSve to take-up rates and the payment rates to GPs. For example, a take-up rate of 70 per cent rather than 85 per cent would reduce projected cost by approximately 18 per cent, while increasing the take-up rate from 85 to 100 per cent would increase projected cost by almost 18 per cent. Reducing the payment rate to GPs from current capitaSon rates to 75 per cent of current capitaSon rates would decrease projected cost between 10 and 17 per cent, while increasing payment rates to 135 per cent of current rates would increase cost between 27 and 31 per cent (depending on the assumpSon used in relaSon to fees and allowances). Cost would increase by 10 per cent were prices (payments to GPs) to increase by 2.5 per cent per annum between 2023 and 2026 relaSve to a situaSon of no price increase over this Sme period. Findings | 37 TABLE 5.9 SENSITIVITY ANALYSIS: PERCENTAGE EFFECT ON 2026 COST OF CHANGING ONE ASSUMPTION (%), CENTRAL SCENARIO Age-based capitation Projected 2026 cost based on central scenario €541.1 million Assumptions Population Low −1% High 2% Take-up rates 70% −18% 100% 18% Price series COSMO Upside 10% Capitation/fees and allowances 75% current; central −17% 75% current; high −10% Current; high 4% Current + 35%; central 27% Current + 35%; high 31% Source: Authors’ analysis using the Hippocrates Model. Note: The assump-ons underlying the central scenario are detailed in Table 4.7. 5.6 EXTENDING ELIGIBILITY: TWO FREE GP VISITS The preceding analysis assumed that all current non-cardholders would become eligible for a GP visit card which would enStle them to (unlimited) free GP care. As an alternaSve, Table 5.10 shows the projected cost to the State in 2026 of providing all current non-cardholders with eligibility for two free GP visits per annum. In this instance, the projected cost would range from €193 million in the low-pressure scenario to €349 million in the high-pressure scenario. TABLE 5.10 PROJECTED COST TO THE STATE OF PROVIDING TWO FREE GP VISITS (NEW CARDHOLDERS), €(MILLION), 2026 Low Central High 2026 192.6 231.6 348.9 Source: Authors’ analysis using the Hippocrates Model. Note: The assump-ons underlying the scenarios are detailed in Table 4.7. The analysis is based on the unit-cost approach detailed in Sec-on 4.8. Extension of eligibility is assumed to occur in one year (2026). It is also assumed that GPs receive payment for these two visits even if an individual has fewer than two visits. 38 | Extending eligibility for general practitioner care in Ireland 5.7 COST FOR EXISTING CARDHOLDERS Based on the methods outlined in SecSon 4.10, Table 5.11 shows the projected cost to the State in 2023–2026 for exisSng cardholders. Some payments to GPs (e.g., benefits to reSred and former district medical officers and payments related to the Maternity and Infant Care Scheme) are not directly related to the provision of care for cardholders and are not included in these esSmates. Consequently, overall payments to GPs through the GMS system in this period will be greater than those included in this report. Expenditure on exisSng cardholders is projected to be approximately €779 million in 2026 using current capitaSon rates. If capitaSon rates increase for new cardholders, it is assumed that this increase would also apply to exisSng cardholders. Were this the case, projected expenditure for 2026 for exisSng cardholders would be approximately €1,058 million. TABLE 5.11 PROJECTED COST TO THE STATE FOR GP SERVICES FOR EXISTING CARDHOLDERS, €(MILLION), 2023–2026 Central High 2023 744.3 924.6 2024 755.6 966.7 2025 767.5 1,011.4 2026 779.1 1,057.6 Source: Authors’ analysis using the Hippocrates Model. Note: The assump-ons underlying the scenarios are detailed in Table 4.7. The low-pressure scenario was not included because it includes an assump-on of capita-on rates at 75 per cent of current capita-on rates, which, while relevant for new cardholders, would not be relevant for exis-ng cardholders. Figure 5.3 shows the projected cost to the State in 2026 for free GP care for exisSng and new cardholders using the age-based approach to extending eligibility (based on the central scenario in Table 4.7). For some age groups (<6 and 70+), there is no addiSonal cost as these groups already have eligibility for free GP care. However, for others (in parScular the middle age groups), there will be a significant increase as a relaSvely large proporSon of these age groups do not currently have an enStlement to free GP care. Findings | 39 FIGURE 5.3 PROJECTED COST TO THE STATE FOR EXISTING CARDHOLDERS AND NEW CARDHOLDERS USING THE AGE-BASED APPROACH TO EXTENDING ELIGIBILITY (€ MILLION), 2026, CENTRAL SCENARIO Source: Authors’ analysis using the Hippocrates Model. Notes: This figure is based on the central scenario as detailed in Table 4.7. Some payments to GPs (e.g., benefits to re-red and former district medical officers and payments related to the Maternity and Infant Care Scheme) are not directly related to the provision of care for cardholders and are not included in these es-mates. Therefore, these payment to GPs do not reflect payments to GPs via the PCRS. This analysis projects the cost to the State of extending eligibility to free GP care to the total populaSon to 2026. Over the longer term, the projected cost to the State of financing GP care will be heavily influenced by negoSaSons between the Department of Health, the HSE and the IMO on the rate of payment to GPs for cardholders. These rates tend not to increase in a linear fashion and can themselves be influenced by factors such as relaSve bargaining power, future health-care policy and the wider economic and fiscal environment. Consequently, esSmaSng these payments over the longer term incorporates significant uncertainty and is not undertaken as part of this analysis. However, Figure 5.4 shows the number of people who would be eligible for a card under exisSng eligibility schemes and the number who would become eligible for a card if eligibility were to be extended on the basis of age (so that everyone would have an enStlement by 2026), assuming an 85 per cent uptake rate, out to the year 2035. It shows that even if eligibility is not extended to the total populaSon (and other factors, including the rate of discreSonary cards, etc., are held constant), the number of people who would be eligible for a card would increase from approximately 2.2 to 2.6 million between 2022 and 2035 (a 20 per cent increase) due to an increasing number of people aged 70 and over in the populaSon. 0.0 50.0 100.0 150.0 200.0 250.0 300.0 350.0 <6 6─7 8─15 16─17 18─29 30─39 40─44 45─49 50─54 55─59 60─64 65─69 70 + € Millions Always card New card 40 | Extending eligibility for general practitioner care in Ireland FIGURE 5.4 PROJECTED NUMBER OF PEOPLE ELIGIBLE FOR FREE GP CARE; CURRENT ELIGIBILITY AND AGEBASED EXTENSION TO ELIGIBILITY (MILLION), 2022–2035, CENTRAL SCENARIO Source: Authors’ analysis using the Hippocrates Model. Note: The figure is based on the central scenario as detailed in Table 4.7. 5.8 COST FOR NON-CARDHOLDERS Figure 5.1 showed that some people do not avail of a GP visit card despite being eligible for one. Consequently, in this analysis it was assumed that some people will conSnue to pay out of pocket for GP services even if free GP care for all is introduced. Figure 5.5 shows projected out-of-pocket expenditure by individuals between 2019 and 2026, assuming no change to eligibility, an age-based extension to eligibility and an income-based extension to eligibility. It shows that out-of-pocket expenditure would decrease rapidly from 2023 as eligibility for free GP care increases. In 2026, out-of-pocket expenditure is lower in the age-based extension relaSve to the income-based extension to enStlement reflecSng the assumed higher uptake with the age-based approach. If eligibility for free GP care is introduced, out-of-pocket expenditure on GP services is projected to decrease from approximately €467 million in 2026 to between €95 million (age basis) and €161 million (income basis). 0 1 2 3 4 5 6 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 Number of people (million) Existing cardholders New cardholders Findings | 41 FIGURE 5.5 PROJECTED OUT-OF-POCKET EXPENDITURE ON GP SERVICES BY NON-CARDHOLDERS (€ MILLION), 2019–2026, CENTRAL SCENARIO Source: Authors’ analysis based on the Hippocrates Model. Notes: Figure is based on an assump-on of central popula-on growth and a 2.5 per cent increase per annum in the unit cost. 0 50 100 150 200 250 300 350 400 450 500 2019 2020 2021 2022 2023 2024 2025 2026 Expenditure (€ million) No eligibility change age-based eligibility income-based eligibility CHAPTER 6 Discussion 6.1 SUMMARY OF FINDINGS The Sláintecare Report recommended an extension of eligibility to GP care in Ireland. The aim of the analysis in this report was to esSmate the cost to the State of such an extension of eligibility. In this analysis, it was assumed that by 2026 everybody would have eligibility for free GP care by applying for and receiving a GP visit card. However, it was also assumed that not everybody would avail of this enStlement. In 2019, approximately 56 per cent of the populaSon did not have a medical card or GP visit card and, consequently, paid out of pocket for GP services. Extending eligibility for GP care that is free at the point of use would increase the demand for GP visits because the price of such visits would fall to zero. In the age-based approach to extending eligibility, it was esSmated that in 2026 there would be an addiSonal 2.3 million GP visits (represenSng a 12 per cent increase) relaSve to a situaSon of no change in eligibility. The projected cost to the State in 2026 of extending eligibility to free GP care to the total populaSon ranged from €462 million to €881 million using the age-based approach and €381 million to €881 million using the income-based approach. The large range is explained by differing assumpSons on a number of factors including populaSon growth and ageing, take-up rates, payment rates to GPs and economywide cost pressures. For example, for the age-based approach, the lower esSmate assumes low populaSon growth and ageing, an uptake rate of 85 per cent, capitaSon rates which are 75 per cent of current capitaSon rates and no economywide increases in wages between 2023 and 2026. AlternaSvely, the higher esSmate assumes high populaSon growth and ageing, a 100 per cent uptake rate, capitaSon rates that are 135 per cent of current rates and an annual 2.5 per cent increase in economy-wide wages between 2023 and 2026. The lower cost associated with the income-based approach is due to an assumpSon of a lower uptake rate under this approach. The projected cost esSmates were sensiSve to take-up rates and payment rates. For example, under the central scenario in the age-based approach to extending eligibility, reducing take-up of free GP care from 85 per cent to 70 per cent would reduce the projected cost to the State for new cardholders in 2026 by almost 18 per cent, while increasing it to 100 per cent would increase the cost to the State by 18 per cent. Reducing the payment rate to GPs from current capitaSon rates to 75 per cent of current capitaSon rates would decrease projected cost between 10 and Discussion | 43 17 per cent, while increasing payment rates to 135 per cent of current rates would increase cost between 27 and 31 per cent (depending on the assumpSon in relaSon to fees and allowances). The projected cost to the State in 2026 for new noncardholders was relaSvely insensiSve to assumpSons on populaSon growth. The cost to the State of extending eligibility for free GP care from this analysis should be considered in the wider context of rising health-care expenditure in Ireland in recent years. EsSmates from the Central StaSsScs Office show that total (public and privately financed) expenditure on health increased from approximately €19 billion in 2015 to €23.7 billion in 2019 (Central StaSsScs Office, 2021). This further increased to €26.5 billion in 2020, reflecSng addiSonal expenditure associated with the COVID-19 pandemic (Central StaSsScs Office, 2021). More recently, publicly financed health-care expenditure in the region of €21 billion was announced in Budget 2023. Previous research using the Hippocrates Model has shown that current expenditure and projected increases in expenditure on general pracSce are low relaSve to other sectors including community pharmaceuScals, long-term residenSal care and hospital-based care (Keegan et al., 2020; Walsh et al., 2021). For example, in 2019, expenditure on general pracSce was esSmated to be in the region of €1 billion (of which approximately 55 per cent was publicly financed). This compares to expenditure of €2.3 billion on community pharmaceuScals and €2 billion on longterm residenSal care (Walsh et al., 2021). While increasing eligibility for GP visits free at the point of use would increase publicly financed expenditure on GP services (reflecSng increasing visiSng rates associated with a reducSon in the price of GP visits), much of the addiSonal publicly financed expenditure is offset by a reducSon in private expenditure by previous non-cardholders. Previous research esSmated that providing GP care that is free at the point of use in 2018 would increase public health-care expenditure by between 2.4 and 2.7 per cent (Connolly et al., 2022). The increase in total health-care expenditure (including both public and privately financed expenditure) was esSmated to be between 0.5 and 0.6 per cent as GP visits paid for out of pocket at the point of use would be publicly financed if eligibility for GP services were extended. Recent increases in payments to GPs (as detailed in the 2019 agreement between the Department of Health, the HSE and the IMO) mean that the impact of extending eligibility on total and public health-care expenditure is likely to be greater than that esSmated for by Connolly et al. (2022) for 2018. However, it is likely that, as a proporSon of overall health-care expenditure, the addiSonal costs detailed in this analysis would be relaSvely low. REFERENCES Allin, S., G. Marchildon and A. 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