The HSE wants health insurance companies to be restricted from paying medical consultants employed by the State for treating private patients in circumstances where this is not permitted under their contracts.
In a report to the Department of Health, the HSE argues that such a move would introduce a new regulatory mechanism which would "dis-incentivise" consultants from breaches of their public employment contractual commitments.
The HSE report urges the Government to assign powers to the health insurance sector regulator, the Health Insurance Authority, to require that insurers only reimburse consultants employed by public hospitals for the treatment of subscribers where contractually they are allowed to do so.
A contract introduced in 2008 set out rules on the level of private practice that consultants employed in public hospitals can carry out and imposes restrictions in some cases on where fee-paying patients can be seen.
Internal email
However, in autumn 2015, HSE chief Tony O'Brien told then minister for health Leo Varadkar in an internal email that the application of rules restricting the level of private practice which senior doctors can carry out in public hospitals had become a "farce".
Earlier this month, an investigation carried out by RTÉ uncovered instances of a number of consultants engaging in more extensive private practice than permitted under their contract.
In a statement on Friday, Minister for Health Simon Harris said he had asked the HSE to ensure that more robust measures were in place in 2018 to make sure all consultants comply with their contractual obligations. Mr Harris said he was very keen that "all options" would be examined.
The Minister told the Dáil this week it was clear that existing arrangements were not sufficiently robust to deliver compliance in all circumstances.
“As a result, some consultants are able to engage in private practice activity at levels that significantly exceed the permitted levels, or else they may engage in significant levels of off-site private practice, although their contract does not provide for this.”
In its report to the department, the HSE warns that a range of official policies in place to encourage the generation of private income by hospitals to fund the delivery of services “appear to conflict with the need to ensure compliance” with the contract.
The HSE report also indicates hospitals have been reluctant to establish new consultant positions which only allow for the treatment of public patients – known technically as type A consultant positions – as this would limit access to income generated by fee-paying patients.
Each year, public hospitals are set a target by the HSE for the generation of private income. In 2016, public hospitals were urged to collect over €633 million for accommodating fee-paying patients.
Private patients
The HSE report maintains that in order for hospitals to secure sufficient accommodation income from private patients to meet expenditure requirements, “consultants are both required and incentivised to treat and charge a particular volume of private patients without reference to contractual limits”.
The HSE proposes thatthe department work with it, the Health Insurance Authority and health insurers to separate the payment of accommodation charges from consultants’ private contractual relationship with patients.
“One way to achieve this would be for the health insurer to receive some form of certification that the accommodation of the patient was medically necessary, perhaps by way of regular independent audit, and provision for remittance of payment from the hospital to the insurer if some period of accommodation was found to be unnecessary.”
