Taking the public out of healthcare

Government-mooted plans to give tax rebates to private health insurance subscribers, signifying a shift to a private system that is part-financed by the taxpayer, has raised questions over the judiciousness of the proposal.

Compared to most countries’ national health systems, Malta really has it quite good: there is no shortage of medical expertise and the facilities available are of high quality and technologically up-to-date.

Above all, it is free – and sometimes slow – but anyone with a Maltese ID card can turn up at Mater Dei or local health centres and receive top quality healthcare, medicines, X-rays, MRIs and operations, without spending a cent.

St James Hospital chief executive Dr Josie Muscat had told MaltaToday that public funds were being wasted on unnecessary hospital tests – around 7 million blood tests alone are carried out last year, which works out to a rate of over 15 blood tests per capita. He controversially claimed that the large number of patients not opting for private healthcare to “a high level of poverty”.

His claims notwithstanding, it’s the strain on the national coffers which, in the long term, which constantly raises the issue of how to finance public healthcare.

The PN administration had issued a consultation document for a primary healthcare scheme in 2009, but this was shelved after being harshly criticised by family doctors. Under this scheme, GPs and their private practices were to act as a filter for everyday minor health problems and free up resources at Mater Dei general hospital for more serious medical referrals. The National Health Systems Strategy, announced in February, is a direct descendant of the 2009 document.

Speaking to MaltaToday, the president of the Malta College of Family Doctors, Prof. Pierre Mallia, said that in his opinion, the minister at the time gave up too early, missing “a golden opportunity.”

“It is normal to disagree in the initial stages and quite frankly the excuse that the document was leaked was irrelevant as many people knew what was going on. It was not top secret and as far as I know nobody was sworn to silence. Conversely, had members of the working party not been hand-selected but were instead direct representatives of bodies like the Malta College of Family Doctors, Association of Private Family Doctors and so on, things may have gone much more smoothly.

 “It is ironic that a U-turn was made and more power was given to health centres, increasing the burden on doctors there,” Mallia said.

“Governments need to realise that just as Church schools ease the burden on governments, so do private doctors take on many patients daily who otherwise would have to have recourse to government services.”

The healthcare debate was reignited last April by the government’s decision to pay two private hospitals for MRI scanning services, in an attempt to reduce the 4,000-long waiting list at Mater Dei hospital. Health Parliamentary Secretary Chris Fearne had said at the time that the government was looking to encourage similar public-private health partnerships.

The public appears to have started to reassess their health cover.

In 2012, around 20% of the population, or 90,000 individuals, had some type of private health cover. 11,202 subscribed to individual cover while 79,954 were insured under group policies. The numbers can only grow if the tax refund scheme is introduced.

“The scheme would give family doctors more opportunity to follow their patients, if they go private,” according to Dr Anthony Azzopardi, president of the Association for Private and Family Doctors. “As things stand, once a patient is referred to Mater Dei, the private doctor’s role ends.”

As long as public health services remain in place for those who cannot afford health insurance, Azzopardi sees the private sector as taking a burden off the government.

“If private health insurance was more widespread, more private hospitals would open up with consequent competition, both as regards facilities offered and prices charged. More private bed-spaces available would be of help when Medical Tourism is encouraged. By now the government has a very good idea of the price of each bed at Mater Dei as well as of all interventions carried out.”

Azzopardi advises that hospital populations should be stratified in age bands, to find the average cost to the government of every person in each age band.

“The rebate offered should at least approximate the cost savings made according to the patient’s age. Even if the government would uncharacteristically decide to be over-generous this would be socially just even if simply because more bed spaces would be available to those who cannot afford to go private.

“Unfortunately, when it comes to tax rebates,” Azzopardi notes, “the government tends to be rather mean and miserly.”

Both associations said they had not been contacted by, nor participated in, any discussions with the government.

The issue of Malta’s current model of public healthcare’s long-term sustainability has been the elephant in the room for several legislatures now.

Those proposing and those who stand to gain from the scheme will be swift to pooh-pooh fears that it is the beginning of the end of free health services, but realistically it would be myopic to suggest anything else.

Opposition MP Claudio Grech has warned that the scheme must be meticulously planned to ensure the optimum use of taxpayers’ money. Failure to do so, he says, would be to risk abuse by unscrupulous insurers, offering “ineffective and inappropriate” health cover. Grech advised that before implementing such a scheme “it is necessary to ensure that insurance policies offer a baseline level of universal coverage in a way that patients are not short-changed due to the small print in the policy.

“It is unthinkable to use taxpayer money to sponsor health insurances which are ineffective and inappropriate for a patient’s requirements. The introduction of such concepts should not be driven by exclusively financial arguments but should be primarily based on fairness, equity and access to care while ensuring that public health services will remain a free choice of health service at the point of care.”

On their part, local insurers have cautiously welcomed the proposal, but agree that more details are needed before they would be able to take a stance on the issue. Certainly, tax rebates are expected to lead to a greater demand for health insurance and more private hospital use, which would be good news for insurers. Insurers who spoke to MaltaToday agreed that the proposals could benefit both insurers and private hospitals by encouraging more people to take up private insurance.

Whatever scheme is adopted, there must be safeguards against beginning the slippery slope towards national healthcare following the pre-Obamacare US model, where no free public health services are offered. Medical treatment (and by extension, medical insurance) would become a seller’s market, as a result.

Requests for further information sent by this paper to the minister remained unanswered.

Until then, questions remain regarding what kind of cover would be needed by the average citizen, whether the tax refund will equate to the premium paid or whether the amount refundable is to be capped, whether beneficiaries of company-funded policies will still be entitled to tax breaks and how the currently uninsured will be affected.