Brennan Report - Department of Health and Children

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Report of the Commission on Financial Management and Control Systems in the Health Servicecardholder consults the GP. In some cases the GP may have little or no contact with aregistered patient, while in other cases the GP may have frequent consultations with a medicalcardholder. Capitation fees per patient range from ¤ 36 per patient per annum to ¤ 670 perpatient per annum, as shown below:●●Annual capitation fee for pre-existing (largely means-tested) cardholders: from ¤ 36 to¤ 171 (range depends on patient’s age, sex and distance from doctor’s surgery).Annual capitation fee for newly-eligible (non-means tested) over 70s category: ¤ 462 or¤ 670 (the higher rate is payable in respect of persons resident in nursing homes).The standard GP capitation fee only covers GP services provided between 9am and 5pm,Monday to Friday. Although applying standard office hours to a service that requires (onoccasion) a 24 hour a day, 7 day a week service seems to be a mismatch between servicedelivery and service demands, under their contract, GPs are entitled to additional payments forservices provided outside this period, such as:● Surgery: ¤ 35.● Home visits: ¤ 35 to ¤ 70 (depending on the distance to patient’s home).GPs also get extra payments for certain additional services provided. These include:● Suturing of cuts and lacerations/ECG tests and their interpretation: ¤ 22.● Influenza vaccination: ¤ 30.● Hepatitis B vaccination: ¤ 108.The medical card scheme represents a major challenge and financial risk to the health servicenationally. There are three broad but clearly interrelated areas of concern:● As seen in Chapter 2, there have been serious failures in costing changes, monitoringoperations and verifying expenditures.● There is little or no evaluation of attendance patterns, prescribing rates, hospital referralsetc. amongst GPs within the medical card scheme.● The increase in the costs associated with the medical card scheme is very high –the cost in 2002 (over ¤ 900 million, including the supplementary estimate) is some twoand a half times greater than the 1997 figure.In relation to the Medical Card Scheme, the choices faced by Government, on behalf of the taxpayingpublic, are stark. It can either:● accept that this system cannot be controlled and continue to meet the annual funding deficits ofsuch an open ended scheme;or● it can negotiate budget limits for the scheme and devise mechanisms whereby agreed outputs, inline with the Government’s own Health Strategy, will be delivered for agreed budgets (e.g. in relationto reduction of inpatient admissions, treatment of more hospital Accident and Emergency casesthrough the primary medical service, etc).We believe it is in the public interest to increase the controls in this system.78
Chapter 6 Accountability – General Medical Services and Community Drug SchemesRecommendations in respect of the General Medical ServiceR6.1 The health board CEO should, in consultation with the General Practitioner (GP), draw up, consistent withnational guidelines established by the Executive, a Practice Budget for each GP covering his/her patientsregistered as medical cardholders.R6.2 The Practice Budget at R6.1 above should be broken down between:(i) Medical treatments; and(ii) Drug prescriptions.R6.3 The Practice Budget at R6.1 above should be based on treatment costs having regard to:(i) The demographic profile of each GP’s medical card patients;(ii) Attendance, treatment and prescribing patterns;(iii) Attendance of patients at Accident and Emergency clinics; and(iv) Referral patterns to general hospitals.R6.4 In the event that a GP requires funding above the budget agreed at the start of the year, it should be necessaryfor him/her to submit a request for same to his/her health board CEO citing the clinical factors which have givenrise to the overspend.R6.5 Health boards should monitor individual versus normative patterns of referral of patients to hospitals. (This canbe facilitated by appropriate identification of patients by source within the hospital coding systemsrecommended at R5.21.)ImplementationR6.6 The Secretary General of the Department of Health and Children should take immediate steps to agree withGPs’ representatives the necessary changes to GPs’ Contract for Service to give effect to recommendations R6.1to R6.5 above.R6.7 The Secretary General of the Department of Health and Children should take immediate steps to devise astandard template for annual Practice Plans.List of Registered Medical CardholdersOne problem identified in Chapter 2 (see Table 2.11) was inaccurate lists of medicalcardholders for each GP with cases of duplicate registrations, where cardholders are registeredwith more than one GP, and the presence of large numbers of inactive cardholders, some ofwhom may have died. GPs continue to receive a capitation fee in respect of these registeredcardholders.Health boards are responsible for preparing centralised records of medical cardholders, withdetails of their addresses, which are then used to allocate medical cardholders to individual GPs.This list forms the basis for payment of the capitation fees by the GMS (Payments) Board.Nonetheless, it seems likely that the doctor, who will know many of his/her patientspersonally, would, in some cases, be aware that a patient has died and that the capitation fee paidin respect of such a patient was erroneously paid.We are of the opinion that health boards should introduce new procedures to audit theirmedical cardholder lists on a systematic basis (including comparing them against other healthboard lists to check for duplications) to reduce the incidence of errors. We also believe thatindividual GPs should have responsibility for checking and verifying the accuracy of these lists.Where the health board discovers an overpayment to a GP, this overpayment should be79
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Commission onFinancial Managementan
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TABLE OF CONTENTSEXECUTIVE SUMMARY
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6.4 COMMUNITY DRUG SCHEMES 80Medica
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Executive SummaryEXECUTIVE SUMMARYT
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Executive SummaryWe do not underest
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Executive Summary"demand-led" schem
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Terms of ReferenceTERMS OF REFERENC
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GlossaryEstimates for Public Servic
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Chapter 1 Introduction and Backgrou
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Chapter 1 Introduction and Backgrou
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Chapter 2 Overview and Issues2.2 OR
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Chapter 2 Overview and IssuesAppend
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Chapter 2 Overview and IssuesFigure
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Chapter 2 Overview and Issuesother
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Page 127 and 128: Appendix 1Appendix 1COMMISSION MEMB
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Appendix 2SIPTU*South Eastern Healt
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Appendix 3Name of AgencyBord na Rad
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Appendix 3Name of AgencyIrish Blood
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Appendix 3Name of AgencyWomen’s H
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Appendix 4Department of Health and
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Appendix 4collated and assessed by
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Appendix 4The most detailed element
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Appendix 4Ratifying and Submitting
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Appendix 4changes to the Service Pl
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Appendix 4advised of their existenc
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Appendix 4Approvals Required in lin
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Appendix 5Appendix 5DIAGNOSIS RELAT
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Appendix 5Figure: Ax.1 Casemix Adju
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Appendix 6Appendix 6AUDIT OF STRUCT
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Appendix 7(vii)(viii)(ix)participat
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Appendix 8Appendix 8 - Integrated M
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ADDENDUMNumber Recommendation IT Ti
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Number Recommendation IT TimeframeR
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Brennan Report - Department of Health and Children

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