Patrick Malone
Key Point:
The General Medical Service Scheme (GMS) provides Medical Cards (MCs) and General Practitioner Visit Cards (GPVCs) on the basis of an income means-test. Full MC holders receive free access to GP services and pharmaceuticals, while GPVCs entitle access to GP services only. In 2018, just over 2 million GMS medical cards were in circulation, 76% of which were MCs and the remaining 24% being GPVCs: an increase of over 800,000 GMS medical cards since 2006. While the total number of MCs in circulation decreased gradually in recent years, there has been a dramatic rise in GPVCs: increasing by almost 375,000 during the years 2013-2018. The greatest shares of MCs are held by the young aged 0-24 years (31%) and the elderly aged over 75 years (14.4%). Total expenditure has decreased gradually from €1.6 billion in 2008 to €1.5 billion in 2017. Within this expenditure, GP Fees/Allowances increased significantly by €76 million since 2008, while GMS Pharmacist costs fell by about €155 million between the years 2008-2017.
General Medical Service Scheme: eligibility and income thresholds
The assessment of eligibility for an MC or GPVC is based on the income of the applicant and that of their spouse or partner (if any). Table 1 shows the income thresholds established for all age groups[1]. Currently the MC income threshold for single persons under the age of 66 living alone must not exceed €184 per week and €266.50 for a married couple. The income threshold for GPVC stands at €276.00 for single persons living alone and €400.00 for a married couple. Income thresholds for MC and GPVC increases with the age of the applicant: for persons over 66 years the income threshold for MC is €201.50 and €302.00 for GPVC. For older people aged 70 years and over, the income threshold for a MC currently stands at €500 per week for single persons living alone and not more than €700 for entitlement to a GPVC. In the case of a cohabiting or married couple, their weekly income must be below €900 for entitlement to a MC and not exceed €1,400 for a GPVC. Additional allowances also apply for dependants of applicants.
Table 1: Eligibility Criteria for access to Medical Cards
Source: HSE (2015)
Table 2 shows the number, and Figure 1, the proportion, of GMS MCs and GPVCs in circulation during the years 2006 to 2018. In 2006, almost 1.3 million people held a GMS MC (29% MC and 1% GPVC). During the Great Recession and its aftermath, demand for GMS MCs increased steadily: peaking in 2015 with almost 50% of the Irish population with GMS MCs (1.7 million MCs and 430,000 GPVCs). In recent years, there has been a fall in the number of MCs in circulation from 1.8 million in 2013 (40% of the population) to almost 1.6 million in 2018 (32% of the population). However, the total number of GMS MC’s in operation (both MC’s and GPVCs) has increased gradually between the years 2013 and 2018: rising from 1.9 million to 2 million in 2018. This increase has been due to the rising number of GPVCs in operation: increasing from less than 52,000 in 2006 to over 500,000 in 2018.
Table 2: Numbers of the Irish population with medical cards by type 2006-2018
Source: Data for 2006-2017: Primary Care Reimbursement Service (PCRS) Statistical Analysis of Claims and Payments Annual Reports (2006-2017); Data for 2018: Department of Health (2018)
Figure 1: Percentage of the Irish population with GMS Medical Cards 2006-2018
Source: Data for 2006-2017: PCRS Statistical Analysis of Claims and Payments Annual Reports (2006-2017); Data for 2018: Department of Health (2018)
Figure 2 shows the breakdown of GMS MC holders by age cohort. In 2017, the 0-11 age cohort held the largest number of MCs, accounting for 16% of the total number of MCs. Other age cohorts holding a large proportion of the total MCs included: the 12-24 years (15%), over 75 years (14%); 65-74 years (13%) 35-44 (11%) and 44-54 years (11%) age cohorts. The lowest share of MCs was held by the 55-64 years (10%) age cohort.
Figure 2 Proportion of GMS MCs in each age cohort 2017 [2]
Source: PCRS Statistical Analysis of Claims and Payments Annual Report (2017)
Trends in GMS Expenditure 2008-2017
Table 3 shows the breakdown of GMS expenditure. Between the years 2008-2017, GMS expenditure increased steadily from €1.6 billion to a peak of almost €1.8 billion during the depth of the recession in 2012. In more recent years, there has been a gradual decrease in GMS expenditure, to €1.5 billion in 2017 (a decrease of €230 million on 2012). The main areas of GMS expenditure include GP Fees/Allowances and GMS Pharmacist Costs.
Payments to GPs include fees and allowances. Between the years 2008-2017, the total costs of GP Fees and Allowances have increased significantly by €76.4 million (+16%). In 2017, the total expenditure spent on GP fees was €551 million. The capitation fee accounts for the largest share of the total fees payable to GPs, which totalled €276.5 million in 2017. This is a fee received by GPs for each patient who attends their practice with a GMS MC or GPVC. In addition to the capitation fee, GPs also receive fees for a range of other services such as:
- ‘Out of Hours’ costs for non-routine consultations when a GMS patient is seen by their GP or another GP acting on his/her behalf from 5pm in the evening to 9am on the following morning (Monday to Friday) and all hours on Saturdays, Sundays and Bank Holidays;
- Dispensing medicine
- Special fees payable for a range of additional services (i.e. excisions, suturing, vaccinations, catheterization family planning etc.);
- Asthma Registration and Capitation;
- Diabetes Registration and Capitation;
In 2017, the total expenditure for GP Allowances was €152.7 million. These allowances are payable to GP’s to support their practice. Examples of practice support payments include:
- Secretarial/Nursing Staff
- Annual Leave
- Sick Leave
- Maternity/Paternity Leave
- Locum and Practice Expenses
- Rural Practice
- Rostering/Out-of-Hours
In terms of GMS Pharmacist costs, a MC holder with a GMS prescription can choose to have their prescription dispensed in any of the pharmacies who have entered agreements with the Health Service Executive for the provision of services. The payments made to pharmacists include the ingredient cost of medicine, dispensing fees and VAT where applicable. The total expenditure related to GMS Pharmacist costs increased by €143 million between the years 2008-2012. However, in more recent years total pharmacy expenditure has fallen steadily by almost €232.4 million: decreasing from €1.3 billion in 2012 to just under €990 million in 2017.
Table 3: GP and Pharmacist Costs 2008-2017 [3]
Source: PCRS Statistical Analysis of Claims and Payments Annual Report (2017: 55,100)
[1] Figures for 2018 are not currently available.
[2] Note: allowances are made in respect to expenses incurred for rent or mortgage payments, childcare costs and travel to work. Certain groups are also exempt from means testing to qualify for a medical card (i.e. a person with EU entitlement, person with retention entitlement under government schemes such as people in receipt of social welfare payments for a specified period of time.
[3] Figures for 2018 are not currently available.
References
Department of Health (2018) Health in Ireland: Key Trends [Online] Available at: https://health.gov.ie/publications-research/statistics/
Health Service Executive (2015) Medical Card and GP Visit Card: National Assessment Guidelines [Online] Available at: https://www2.hse.ie/file-library/medical-cards/medical-cards-national-assessment-guidelines.pdf
Primary Care Reimbursement Service (2006) Primary Care Reimbursement Service: Statistical Analysis of Claims and Payments 2006. [Online] Available at: https://www.sspcrs.ie/portal/annual-reporting/report/annual
Primary Care Reimbursement Service (2007) Primary Care Reimbursement Service: Statistical Analysis of Claims and Payments 2007. [Online] Available at: https://www.sspcrs.ie/portal/annual-reporting/report/annual
Primary Care Reimbursement Service (2008) Primary Care Reimbursement Service: Statistical Analysis of Claims and Payments 2008. [Online] Available at: https://www.sspcrs.ie/portal/annual-reporting/report/annual
Primary Care Reimbursement Service (2009) Primary Care Reimbursement Service: Statistical Analysis of Claims and Payments 2009. [Online] Available at: https://www.sspcrs.ie/portal/annual-reporting/report/annual
Primary Care Reimbursement Service (2010) Primary Care Reimbursement Service: Statistical Analysis of Claims and Payments 2010. [Online] Available at: https://www.sspcrs.ie/portal/annual-reporting/report/annual
Primary Care Reimbursement Service (2011) Primary Care Reimbursement Service: Statistical Analysis of Claims and Payments 2011. [Online] Available at: https://www.sspcrs.ie/portal/annual-reporting/report/annual
Primary Care Reimbursement Service (2012) Primary Care Reimbursement Service: Statistical Analysis of Claims and Payments 2012. [Online] Available at: https://www.sspcrs.ie/portal/annual-reporting/report/annual
Primary Care Reimbursement Service (2013) Primary Care Reimbursement Service: Statistical Analysis of Claims and Payments 2013. [Online] Available at: https://www.sspcrs.ie/portal/annual-reporting/report/annual
Primary Care Reimbursement Service (2014) Primary Care Reimbursement Service: Statistical Analysis of Claims and Payments 2014. [Online] Available at: https://www.sspcrs.ie/portal/annual-reporting/report/annual
Primary Care Reimbursement Service (2015) Primary Care Reimbursement Service: Statistical Analysis of Claims and Payments 2015. [Online] Available at: https://www.sspcrs.ie/portal/annual-reporting/report/annual
Primary Care Reimbursement Service (2016) Primary Care Reimbursement Service: Statistical Analysis of Claims and Payments 2016. [Online] Available at: https://www.sspcrs.ie/portal/annual-reporting/report/annual
Primary Care Reimbursement Service (2017) Primary Care Reimbursement Service: Statistical Analysis of Claims and Payments 2017. [Online] Available at: https://www.sspcrs.ie/portal/annual-reporting/report/annual