Primary Care Reimbursement Service Statistical …

1 Primary Care Reimbursement ServiceStatistical Analysis of Claims and PaymentsFeidhmeannacht na Seirbh se Sl inteSeirbh s Ais oca Pr omhch raimBealach amach 5 an M50An B thar ThuaidhFionnghlasBaile tha Cliath 11D11 XKF3 Guth n: (01) 864 7100 Facs: (01) 834 3589R omhphost: ithre n Gr as in: Service ExecutivePrimary Care Reimbursement ServiceExit 5 M50 North RoadFinglasDublin 11D11 XKF3Ph: (01) 864 7100 Fax: (01) 834 3589 Email: Care Reimbursement ServiceSTATISTICAL ANALYSIS OF CLAIMS AND PAYMENTS20162 Contents Summary of Statistical Analysis 4 IntroductionSCHEMES OVERVIEW 6 Schemes Claim Reimbursement and Payment Arrangements 9 Summary Statement of Activity 2016 10 Total Payments and Reimbursements 2016 12 Number of Agreements with Contractor Groups 13 Number of Agreements with Contractor Groups by CHO 14 Number of Eligible Persons 2016 15 Number of Eligible Persons by CHO 16 Average Cost per Eligible Person per Scheme 2016 17 1 Number of Agreements with Contractor Groups 20 2 GMS: Summary of Statistical Information for 2012 2016 21 3 LTI/DP Schemes: Summary of Statistical Information for 2012 2016 22 4 High Tech Wholesaler and Manufacturer Payments 2016 CARDHOLDER SECTION 24 5 GMS Medical Cards.

2 Number of Eligible Persons by CHO 25 6 GMS GP Visit Cards: Number of Eligible Persons by CHO 26 7 GMS Medical Cards: Number of Eligible Persons by CHO, Gender and Age Group 32 8 GMS GP Visit Cards: Number of Eligible Persons by CHO, Gender and Age Group 38 9 Average Cost per Eligible Person per Scheme by CHO 41 10 GMS: Average Pharmacy Cost by CHO, Gender and Age Group based on the number of MC holders 47 11 DPS: Statistical Data by CHO 50 12 LTI: Statistical Data by CHOGENERAL PRACTITIONER SECTION 54 Fees and Allowances under Capitation Agreement as at 31st December 2016 56 Fees and Allowances under the Fee-Per-Item Agreement and Fees under the Immunisation Scheme, Health (Amendment) Act 1996, Methadone Treatment Scheme and Heartwatch Programme as at 31st December 2016 58 Payments to General Practitioners 2016 59 Payments to General Practitioners 2016 by CHO 60 Number of Claims by General Practitioners 61 Number of Claims by General Practitioners by CHO 64 13 GMS: Payments to General Practitioners 65 14 GMS: Payments to GPs by CHO 68 15 GMS: Average Payment to GPs in Panel Ranges by CHO 71 16 GMS: Number of GPs in Payment Ranges by CHO 74 17 GMS: GP Panel Size by CHO 77 18 GMS.

3 Number of Special Type Consultation Claims by CHO 80 19 GMS: Cost of Special Type Consultation Claims by CHO 83 20 GMS: Number of Dispensing Doctors* and Persons for Whom They Dispense by CHO 86 21 GMS: Number and Cost of Special Items of Service Reimbursed to GPs 87 22 GMS: Number and Cost of Special Items of Service Claims by CHO 92 23 GMS: Investment in General Practice Development by CHOPHARMACY SECTION96 Scale of Fees Payable to Participating Pharmacists as at 31st December 201697 Payments to Pharmacists: Claims Reimbursed 201698 Payments to Pharmacists: Claims Reimbursed 2016 by CHO101 Number of Items Claimed by Pharmacists 102 Number of Items Claimed by Pharmacists by CHO 105 24 GMS: Reimbursement Cost of Prescriptions by CHO 108 25 GMS: Payments to Pharmacists for Prescriptions by CHO 111 26 GMS: Number of Prescription Forms and Items by CHO 114 27 GMS: Reimbursement Cost of Stock Order Forms by CHO 117 28 GMS: Number of Stock Order Forms and Items by CHOPagePageTableTablePageTable3 Contents Summary of Statistical Analysis 120 29 GMS: Number of Items per Prescription Form 121 30 DPS: Number of Items per Claim Form 122 31 LTI: Number of Items per Claim Form 123 32 EEA: Number and Cost of Pharmacists Claims by CHO 126 33 GMS: Number of Pharmacists in Dispensing Fee Ranges by CHO 129 34 DPS: Number of Pharmacists in Dispensing Fee Ranges by CHO 132 35 LTI: Number of Pharmacists in Dispensing Fee Ranges by CHODISPENSING DATA SECTION 136 GMS.

4 Major Therapeutic Classifi cation of Drugs, Medicines and Appliances 137 DPS: Major Therapeutic Classifi cation of Drugs, Medicines and Appliances 138 LTI: Major Therapeutic Classifi cation of Drugs, Medicines and Appliances 139 36 Notes on commonly prescribed categories (see tables 37 - 40) where the MMP has issued guidance. 140 37 GMS: Top 20 Medicines and Appliances (ATC level 4) by Highest Expenditure 2016 145 38 DPS: Top 20 Medicines and Appliances (ATC level 4) by Highest Expenditure 2016 150 39 LTI: Top 20 Medicines and Appliances (ATC level 4) by Highest Expenditure 2016 154 40 HT: Top 20 Medicines and Appliances (ATC level 4) by Highest Expenditure 2016 158 41 GMS: Notes on Some of the More Commonly Prescribed Products 159 42 GMS: The Top 100 Most Commonly Prescribed Products in the Order of their Prescribing Frequency 162 43 GMS: The Top 100 Products by Ingredient Cost 165 44 DPS: The Top 100 Most Commonly Prescribed Products in the Order of their Prescribing Frequency 168 45 DPS: The Top 100 Products by Ingredient Cost 171 46 LTI.

5 The Top 100 Most Commonly Prescribed Products in the Order of their Prescribing Frequency 174 47 LTI: The Top 100 Products by Ingredient Cost 177 48 HT: The Top 100 Most Commonly Prescribed Products in the Order of their Prescribing Frequency 180 49 HT: The Top 100 Products by Ingredient Cost 183 50 GMS: Distribution of Medicines and Appliances by Anatomical Therapeutic Chemical Classifi cation 188 51 DPS: Distribution of Medicines and Appliances by Anatomical Therapeutic Chemical Classifi cation 193 52 LTI: Distribution of Medicines and Appliances by Anatomical Therapeutic Chemical Classifi cation198 53 HT: Distribution of Medicines and Appliances by Anatomical Therapeutic Chemical Classifi cationDENTAL SECTION 202 Scale of Fees Payable under the Dental Treatment Services Scheme as at 31st December 2016 203 Payments to Dentists: Claims Reimbursed 2016 204 Payments to Dentists: Claims Reimbursed 2016 by CHO 205 Number of Dental Treatments Claimed 2016 206 Number of Dental Treatments Claimed 2016 by CHO 207 54 DTSS: Payments to Dentists 210 55 DTSS: Number of Treatments 213 56 DTSS: Number of Dentists with DTSS Contracts by Payment RangeOPTICAL SECTION 218 Scale of Fees Payable under the Health Service Executive Community Ophthalmic Services Scheme 220 Payments to Optometrists/Ophthalmologists: Claims Reimbursed 2016 221 Payments to Optometrists/Ophthalmologists.

6 Claims Reimbursed 2016 by CHO 222 Number of Treatments by Optometrists/ Ophthalmologists 223 Number of Treatments by Optometrists/ Ophthalmologists by CHO 226 57 HSE Community Ophthalmic Services Scheme: Number of Treatments and Cost of Claims 229 58 HSE Community Ophthalmic Services Scheme: Number of Optometrists/Ophthalmologists by Payment RangePageTablePageTablePageTable4 IntroductionThe HSE s Primary Care Reimbursement Service (PCRS) supports the delivery of a wide range of Primary care services to the general public through over 7,168 Primary care contractors across a range of community health schemes. These schemes form the infrastructure through which the Irish Health System delivers a signifi cant proportion of Primary Care to the PCRS made total payments and reimbursements of billion in 2016 under the GMS (Medical Card), Drugs Payment, Dental Treatment, Long Term Illness and Community Ophthalmic Schemes.

7 Eligibility for Medical Cards (including GP Visit Cards) has increased by 86% since January 2005. Almost million people or 45% of the population is covered by a Medical Card or a GP Visit Card compared with 28% in 2005. While there was a reduction in medical card eligibility in 2016 of compared to 2015, there was a increase in GP Visit Card eligibility over the same 2016, million people were registered for Community Scheme services provided by General Practitioners, Pharmacists, Dentists and Optometrists or Ophthalmologists. On behalf of the HSE, I would like to thank all of our clients and contractors for their co-operation throughout 2016, and we look forward to working with you to continue to improve all of the services that we provide to the public into the future. I would also like to take this opportunity to thank the staff in the Primary Care Reimbursement Service involved in the continued delivery of day to day services, for their contribution and commitment to the delivery of these vital support services to the public and to Primary care contractors throughout the HennessyNational Director Primary CareOVERVIEW6 Schemes Claim Reimbursement and Payment ArrangementsDuring 2016, HSE Primary Care Reimbursement Service reimbursed claims and made payments to General Practitioners (GPs), Community Pharmacists, Dentists and Optometrists/Ophthalmologists totalling 2,700m, in respect of medical card and national Primary care data is processed and reimbursements are made by the Primary Care Reimbursement Service under the following Schemes.

8 General Medical Services (GMS)Persons who are unable without undue hardship to arrange general practitioner medical and surgical services for themselves and their dependants are eligible for the GMS Scheme. Drugs, medicines and appliances approved under the Scheme are provided through Community Pharmacists. In most cases the GP gives a completed prescription form to an eligible person, who takes it to any Pharmacy that has an agreement with the Health Service Executive to dispense drugs, medicines and appliances on presentation of GMS prescription forms. In rural areas a small number of GPs hold contracts to dispense drugs and medications to GMS cardholders who opt to have their medicines dispensed by him/her GMS claims are processed and paid by the Primary Care Reimbursement Service . Since the 1st October 2010, an eligible person who is supplied a drug, medicine or medical or surgical appliance on the prescription of a Registered Medical Practitioner, Registered Dentist or Registered Nurse Prescriber, is charged a prescription charge by the Community Pharmacy Contractor, currently per item subject to a limit of 25 per family per month (effective 1st December 2013).

9 The prescription charge is recouped by the HSE from the Pharmacist. Drugs Payment Scheme (DPS)The Drugs Payment Scheme (DPS) provides for payment to the Pharmacist for the supply of medicines to individuals and families where the threshold of 144, effective from 1st January 2013, has been exceeded in a calendar month. In order to avail of the Drugs Payment Scheme a person or family must register for the Scheme with the HSE PCRS. Drugs, medicines and appliances currently reimbursable under the Scheme are listed on the HSE website. Other items which were reimbursable under the Drug Cost Subsidisation Scheme and Refund of Drugs Scheme continue, in certain circumstances, to be reimbursable under the Drugs Payment Scheme. Long Term Illness Scheme (LTI)On approval by the Health Service Executive, persons who suffer from one or more of a schedule of illnesses are entitled to obtain, without charge, irrespective of income, necessary drugs/medicines and/or appliances under the LTI Treatment Services Scheme (DTSS)Under the Dental Treatment Services Scheme GMS eligible adults have access to a range of treatments and clinical procedures comprised of Routine Treatments and Full Upper and Lower Dentures.

10 Routine Treatments are available for all eligible persons. Dentists may also prescribe a range of medicines, as part of their treatment, to eligible persons. European Economic Area (EEA)Residents from one of the other states of the European Economic Area, with established eligibility, who require emergency general practitioner services while on a temporary visit to the State are entitled to receive from a General Practitioner a GMS prescription form for necessary medication and to have such medication dispensed in a Pharmacy that has entered into an agreement with the Health Service Executive within the State. 7 Schemes Claim Reimbursement and Payment Arrangements continuedHigh Tech Arrangements (HT)Arrangements are in place for the supply and dispensing of High Tech medicines through Community Pharmacists. Such medicines are generally only prescribed or initiated in hospital and would include items such as anti-rejection drugs for transplant patients or medicines used in conjunction with chemotherapy or hormonal therapy.