Still waiting for lower GP fees

Moves are afoot to end the closed list of GPs for public patients – but there’s no guarantee it will curb the high fees that sees many put off visits to their doctor

WHILE THE Irish dental market is in the middle of an almighty shake-up, we have yet to see such moves connected to our GP services. But with the IMF demanding more competition in “sheltered sectors”, can hard-pressed consumers finally look forward to cheaper visits to their local doctor?

Since June 1st, dentists across Ireland have been obliged to publicly display prices for all services they deliver, and this, combined with an increase in dental tourism and the cut-back in care available under the PRSI scheme, means that the market has become a lot more competitive. Where once you could have been expected to pay up to €60 for a consultation, now there are practices delivering this for €30–€40.

If you need to visit your local GP however, you will likely find yourself paying upwards of €45 to do so, with some Dublin-based practices charging a staggering €70 for a 15-minute visit.

So why are prices so high? OECD statistics indicate that GPs here are paid more than in the UK, Germany, France and Sweden, while most – some 80 per cent – are in receipt of a General Medical Scheme (GMS) list and are therefore paid by the Government to treat patients with medical cards. In 2008, for example, doctors received in excess of €500 million, with one Dublin-based GP practice receiving more than €1 million.

However, Kieran Ryan, chief executive of the Irish College of General Practitioners (ICGP), says that GPs are not coining it and he claims that much of the GMS money goes on renting a premises, hiring additional doctors, nurses, secretaries and running costs. Another issue is that in recent times the Government has started to reduce the amounts it pays out for medical card patients. So, for GPs operating in disadvantaged areas, this reduction can have a significant impact on income, as the practice may rely largely on medical card patients. “GPs are expected to maintain the same level of services but the cost base remains the same,” he says.

But some people are unconvinced. After all, if a practice is getting a six-figure sum in guaranteed income, which should more than adequately cover running costs, surely they could afford to charge private patients less? For GP Dr Marcus de Brun, who is not on the GMS scheme, it is particularly grating that he finds himself charging €50 a patient, which is the same – or less – than local doctors who benefit through the scheme. He says that the GMS lists represent the “cash cow” of general practice, because as well as paying significant sums for treating public patients, they also give pension and holiday rights to their owners.

So why doesn’t he get one himself? Well, therein lies the reason the IMF has pinpointed the medical profession as a “sheltered sector” and is looking to introduce more competition. You can’t just request to treat medical card patients; currently GMS contracts are only awarded in specific circumstances such as the resignation of an existing contract holder, or when the HSE identifies a need for a new GMS post.

De Brun learned this the hard way. In 2009, he moved back to Ireland from New Zealand to set up a GP practice. After buying a premises in Rush, Co Dublin, he found out that he would not be able to treat public patients, as doctors in the area already controlled the available GMS lists, so he had to work solely on building up a base of private patients to fund his practice.

He says now he was “foolish to open a private practice and manage solely on private income”, which has become more difficult given the worsening economy. Not only that; when any of his patients qualify for a medical card, they have to “up sticks and move practice” as he can no longer treat them. “It beggars belief,” he says, adding that while he has considered moving back to New Zealand, it would be difficult because he owns the premises.

But, given that the GMS lists are tightly held, if, as the IMF wants, the lists are opened up to all qualified GPs by the third quarter of this year, would this mean an inflow of new practices? With increased competition, would this then push down prices? According to the Department of Health, it is currently preparing legislation which will allow all GPs who wish to obtain contracts to treat public patients under the GMS scheme to do so.

However, there is some scepticism – on both sides of the fence – as to whether or not this will make any material difference to the cost and delivery of GP services.

For the ICGP, the high start-up costs incurred in running a GP practice means that in many areas, it is simply an unviable business. Opening up the GMS list won’t change this.

De Brun is not getting his hopes up that his business will change anytime soon. “It’s very difficult not to be cynical,” he says, and he argues that the “devil will be in the detail” of any legislation, suggesting that it may be proposed that only new medical card patients will be entitled to be treated by any doctor. This would leave the vast majority of patients in the hands of incumbent GPs.

Another way to introduce more competition into the sector might be to have better disclosure. As mentioned, dentists now have to publicly display their prices, and as a recent HEALTHplus survey indicated, the levels of compliance have been very high.

But could a similar practice be adopted for GPs? Last year, a survey by the National Consumer Agency showed that just 50 per cent of GPs display their prices, and it urged GPs to make the practice compulsory. However, doing so is not currently on the agenda of either the Irish Medical Council or the ICGP.

So is there anything you can do? Well, if you are new to an area and looking for a GP, or if you are fed up with paying for what you perceive to be an over-priced service with your own doctor, you can check out the prices ahead of booking by ringing around, or by using a new online service. While price is obviously not the only consideration when it comes to choosing a doctor, in these straitened times it is a priority, particularly for those with families.

Whatclinic.com compiles a database of doctors operating all around Ireland, and includes the prices for many. So, for example, if you are a patient of a doctor charging €70 a visit in Ballsbridge, a quick search on the site will show that you can find an alternative in the area charging just €50. Or by moving further afield to Drimnagh, you could save yourself as much as €25. Outside the capital, prices are largely cheaper, with GPs from just €40 in Co Cavan, but there are still discrepancies. In Kilkenny, for example, prices can range from €45 to more than €60.

In the meantime, there is little expectation that GP services – unlike most aspects of the economy – will be re-priced anytime soon. Despite the decrease in demand for services, with people tending to either put off or postpone visits to their GP as much as they can in the current climate, prices have not shifted. According to Ryan, anecdotal evidence would suggest that visits to GPs have fallen by about 15–30 per cent across the country – but rather than cutting fees to bring patients back, he says that GPs are fearful that even if they cut prices, patients might still stay away.