Hospital consultants should be paid the same way for treating public and private patients, health economist Prof Dale Tussing told a weekend conference in Tallaght Hospital.
It seemed to him that public waiting lists were longer than private waiting lists because of the way consultants were paid.
"Specialists are paid by salary for public patients and by fee for private patients," said Prof Tussing, professor of economics at Syracuse University, New York.
"A bias in the direction of treating private patients is exactly what one would predict on the basis of the remuneration mix."
Compulsory health insurance was one way of changing this. This implied that hospitals would be funded from payments made to them by insurance companies. However, State subsidies to hospitals would have to continue for at least a time.
Some hospitals would find it hard to adjust to a new system and would not survive without help. Some localities would lose out if the location of hospitals was left to the market and others might be unable to afford modern technology or to pay staff properly. For these reasons some State subsidies might have to continue indefinitely.
There was an urgent need to modernise GP services, Prof Tussing said. The GP service at present "is not a modern service".
"Nearly half of GPs are in solo practice. Two thirds don't employ nurses."
High referral rates to specialists often reflected the isolation and uncertainty of GPs, he said. A modernised GP service could take pressure off the hospital sector, both in-patient and out-patient.
One objective should be to reduce GP referrals to specialists for investigation and treatment. Modernising the GP service was a more urgent priority than making the service free to all.
Prof Tussing also argued that a fall in the number of beds "is not necessarily a bad thing". Modern diagnostic techniques and changes in medical practice had greatly reduced the need for observation beds and long stays in hospitals.
He advocated the provision of more "post-acute convalescent beds" to reduce the average length of stay in acute beds and thereby possibly reduce waiting lists.
Compulsory health insurance should be introduced "to end our grossly unfair 'two-tier' system", the chairman of the Adelaide Hospital Society, Mr Richard Greene, told the conference. People's health needs and not their wealth should determine their access to the health services, he said.
"It is striking that it is only in the insurance-based systems of Europe that the capacity exists to treat not only all patients in, say, Germany, but also to be able to offer treatment for those on our waiting lists."
Mr Greene asked what confidence the people could have in "more rhetoric" in a new health strategy "if it is not accompanied by major reform of our failed health structures".
The Adelaide Hospital Society advocated that such reforms should include, along with compulsory health insurance, replacing the 10 health boards with four health authorities "with strong, directly elected citizens' voices"; a free GP service for the entire population and a "voluntary citizen-based board" for every hospital.
People felt "a sense of desperation" about the health service, said Dr Maureen Gaffney, chairwoman of the National Economic and Social Forum. "There's a growing consensus that nothing less than a fundamental reform of our health system is required."
Social partnership had successfully addressed the economic crisis of the 1980s and could also address the health crisis. It was very interesting, she said, that national agreements "have paid so little attention to the health issue until the Programme for Prosperity and Fairness".
"Private patient care is delivered promptly and generally by consultants in person," Irish Times journalist Maev-Ann Wren said. "Public patient care comes tardily and is frequently delivered by doctors in training."
Ways of reforming the two-tier system included a single waiting list for public and private patients, a ban on private practice in public hospitals, a public system so good that everyone would opt for public care and paying consultants the same way for all patients, public and private.
pomorain@irish-times.ie