Primary Care Reimbursement Service Statistical Analysis of Claims and Payments Feidhmeannacht na Seirbhíse Sláinte Health Service Executive Seirbhís Aisíoca Príomhchúraim Primary Care Reimbursement Service Bealach amach 5 an M50 Exit 5 M50 An Bóthar Thuaidh North Road Fionnghlas Finglas Baile Átha Cliath 11 Dublin 11 D11 XKF3 D11 XKF3 Guthán: (01) 864 7100 Ph: (01) 864 7100 Facs: (01) 834 3589 Fax: (01) 834 3589 Ríomhphost: [email protected] Email: [email protected] Láithreán Gréasáin: www.hse.ie Website: www.hse.ie Primary Care Reimbursement Service STATISTICAL ANALYSIS OF CLAIMS AND PAYMENTS 2016 Contents Summary of Statistical Analysis Page TablePage Table Page Table 4 Introduction 38 9 Average Cost per Eligible Person per Scheme 80 19 GMS: Cost of Special Type Consultation Claims by CHO by CHO SCHEMES OVERVIEW 41 10 GMS: Average Pharmacy Cost by CHO, Gender 83 20 GMS: Number of Dispensing Doctors* and Age Group based on the number of and Persons for Whom They Dispense by CHO 6 Schemes – Claim Reimbursement MC holders 86 21 GMS: Number and Cost of Special Items of and Payment Arrangements 47 11 DPS: Statistical Data by CHO Service Reimbursed to GPs 9 Summary Statement of Activity – 2016 50 12 LTI: Statistical Data by CHO 87 22 GMS: Number and Cost of Special Items of 10 Total Payments and Reimbursements – 2016 Service Claims by CHO 12 Number of Agreements with Contractor Groups GENERAL PRACTITIONER SECTION 92 23 GMS: Investment in General Practice 13 Number of Agreements with Contractor Development by CHO Groups by CHO 54 Fees and Allowances under Capitation 14 Number of Eligible Persons – 2016 Agreement as at 31st December 2016 PHARMACY SECTION 15 Number of Eligible Persons by CHO 56 Fees and Allowances under the Fee-Per-Item 16 Average Cost per Eligible Person per Agreement and Fees under the Immunisation 96 Scale of Fees Payable to Participating Pharmacists Scheme 2016 Scheme, Health (Amendment) Act 1996, as at 31st December 2016 17 1 Number of Agreements with Contractor Groups Methadone Treatment Scheme and Heartwatch 97 Payments to Pharmacists: Claims 20 2 GMS: Summary of Statistical Information Programme as at 31st December 2016 Reimbursed 2016 for 2012 – 2016 58 Payments to General Practitioners 2016 98 Payments to Pharmacists: Claims Reimbursed 21 3 LTI/DP Schemes: Summary of Statistical 59 Payments to General Practitioners 2016 2016 by CHO Information for 2012 – 2016 by CHO 101 Number of Items Claimed by Pharmacists 22 4 High Tech Wholesaler and Manufacturer 60 Number of Claims by General Practitioners 102 Number of Items Claimed by Pharmacists Payments 2016 61 Number of Claims by General Practitioners by CHO by CHO 105 24 GMS: Reimbursement Cost of Prescriptions CARDHOLDER SECTION 64 13 GMS: Payments to General Practitioners by CHO 65 14 GMS: Payments to GPs by CHO 108 25 GMS: Payments to Pharmacists for Prescriptions 24 5 GMS Medical Cards: Number of Eligible 68 15 GMS: Average Payment to GPs in Panel by CHO Persons by CHO Ranges by CHO 111 26 GMS: Number of Prescription Forms and Items 25 6 GMS GP Visit Cards: Number of Eligible 71 16 GMS: Number of GPs in Payment Ranges by CHO Persons by CHO by CHO 114 27 GMS: Reimbursement Cost of Stock Order 26 7 GMS Medical Cards: Number of Eligible Persons 74 17 GMS: GP Panel Size by CHO Forms by CHO by CHO, Gender and Age Group 77 18 GMS: Number of Special Type Consultation 117 28 GMS: Number of Stock Order Forms and 32 8 GMS GP Visit Cards: Number of Eligible Persons Claims by CHO Items by CHO by CHO, Gender and Age Group 2 Contents Summary of Statistical Analysis Page Table Page Table Page Table 120 29 GMS: Number of Items per Prescription Form 159 42 GMS: The Top 100 Most Commonly Prescribed 204 Payments to Dentists: Claims Reimbursed 2016 121 30 DPS: Number of Items per Claim Form Products in the Order of their Prescribing by CHO 122 31 LTI: Number of Items per Claim Form Frequency 205 Number of Dental Treatments Claimed 2016 123 32 EEA: Number and Cost of Pharmacists Claims 162 43 GMS: The Top 100 Products by Ingredient Cost 206 Number of Dental Treatments Claimed 2016 by CHO 165 44 DPS: The Top 100 Most Commonly Prescribed by CHO 126 33 GMS: Number of Pharmacists in Dispensing Fee Products in the Order of their Prescribing 207 54 DTSS: Payments to Dentists Ranges by CHO Frequency 210 55 DTSS: Number of Treatments 129 34 DPS: Number of Pharmacists in Dispensing Fee 168 45 DPS: The Top 100 Products by Ingredient Cost 213 56 DTSS: Number of Dentists with DTSS Contracts Ranges by CHO 171 46 LTI: The Top 100 Most Commonly Prescribed by Payment Range 132 35 LTI: Number of Pharmacists in Dispensing Fee Products in the Order of their Prescribing Ranges by CHO Frequency OPTICAL SECTION 174 47 LTI: The Top 100 Products by Ingredient Cost 218 Scale of Fees Payable under the Health DISPENSING DATA SECTION 177 48 HT: The Top 100 Most Commonly Prescribed Service Executive Community Ophthalmic Products in the Order of their Prescribing 136 GMS: Major Therapeutic Classifi cation of Drugs, Services Scheme Frequency Medicines and Appliances 220 Payments to Optometrists/Ophthalmologists: 180 49 HT: The Top 100 Products by Ingredient Cost 137 DPS: Major Therapeutic Classifi cation of Drugs, Claims Reimbursed 2016 183 50 GMS: Distribution of Medicines and Appliances Medicines and Appliances 221 Payments to Optometrists/Ophthalmologists: by Anatomical Therapeutic Chemical 138 LTI: Major Therapeutic Classifi cation of Drugs, Claims Reimbursed 2016 by CHO Classifi cation Medicines and Appliances 222 Number of Treatments by Optometrists/ 188 51 DPS: Distribution of Medicines and Appliances by 139 36 Notes on commonly prescribed categories Ophthalmologists Anatomical Therapeutic Chemical Classifi cation (see tables 37 - 40) where the MMP has 223 Number of Treatments by Optometrists/ 193 52 LTI: Distribution of Medicines and Appliances by issued guidance. Ophthalmologists by CHO Anatomical Therapeutic Chemical Classifi cation 140 37 GMS: Top 20 Medicines and Appliances 226 57 HSE – Community Ophthalmic Services Scheme: 198 53 HT: Distribution of Medicines and Appliances by (ATC level 4) by Highest Expenditure 2016 Number of Treatments and Cost of Claims Anatomical Therapeutic Chemical Classifi cation 145 38 DPS: Top 20 Medicines and Appliances 229 58 HSE – Community Ophthalmic Services Scheme: (ATC level 4) by Highest Expenditure 2016 Number of Optometrists/Ophthalmologists DENTAL SECTION 150 39 LTI: Top 20 Medicines and Appliances by Payment Range (ATC level 4) by Highest Expenditure 2016 202 Scale of Fees Payable under the Dental 154 40 HT: Top 20 Medicines and Appliances Treatment Services Scheme as at 31st (ATC level 4) by Highest Expenditure 2016 December 2016 158 41 GMS: Notes on Some of the More Commonly 203 Payments to Dentists: Claims Reimbursed 2016 Prescribed Products 3 Introduction The HSE’s Primary Care Reimbursement Service a Medical Card or a GP Visit Card compared with 28% I would also like to take this opportunity to thank (PCRS) supports the delivery of a wide range of primary in 2005. While there was a reduction in medical card the staff in the Primary Care Reimbursement Service care services to the general public through over 7,168 eligibility in 2016 of 2.94% compared to 2015, there was involved in the continued delivery of day to day services, primary care contractors across a range of community a 9.09% increase in GP Visit Card eligibility over the for their contribution and commitment to the delivery of health schemes. These schemes form the infrastructure same period. these vital support services to the public and to primary through which the Irish Health System delivers a care contractors throughout the year. signifi cant proportion of Primary Care to the public. During 2016, 3.7 million people were registered for Community Scheme services provided by General HSE PCRS made total payments and reimbursements Practitioners, Pharmacists, Dentists and Optometrists or John Hennessy of €2.7 billion in 2016 under the GMS (Medical Card), Ophthalmologists. National Director Primary Care Drugs Payment, Dental Treatment, Long Term Illness and Community Ophthalmic Schemes. On behalf of the HSE, I would like to thank all of our clients and contractors for their co-operation throughout Eligibility for Medical Cards (including GP Visit Cards) 2016, and we look forward to working with you to has increased by 86% since January 2005. Almost 2.2 continue to improve all of the services that we provide to million people or 45% of the population is covered by the public into the future. 4 OVERVIEW Schemes – Claim Reimbursement and Payment Arrangements During 2016, HSE Primary Care Reimbursement All GMS claims are processed and paid by the Long Term Illness Scheme (LTI) Service reimbursed claims and made payments to Primary Care Reimbursement Service. Since the 1st On approval by the Health Service Executive, persons General Practitioners (GPs), Community Pharmacists, October 2010, an eligible person who is supplied a who suffer from one or more of a schedule of illnesses Dentists and Optometrists/Ophthalmologists totalling drug, medicine or medical or surgical appliance on are entitled to obtain, without charge, irrespective of €2,700m, in respect of medical card and national the prescription of a Registered Medical Practitioner, income, necessary drugs/medicines and/or appliances primary care schemes. Registered Dentist or Registered Nurse Prescriber, under the LTI Scheme. is charged a prescription charge by the Community Claim data is processed and reimbursements are made Pharmacy Contractor, currently €2.50 per item subject Dental Treatment Services Scheme (DTSS) by the Primary Care Reimbursement Service under to a limit of €25 per family per month (effective 1st Under the Dental Treatment Services Scheme GMS the following Schemes: December 2013).