Cancer doctor warns of two-tier health system emerging due to insurance
Michael McCarthy: 'I suspect that at some stage in the next year there will be somebody like Vicky Phelan who will take it up very publicly.' Picture: Ray Ryan
Does the patient have insurance?
If you watch American medical dramas, you know when the answer is ‘no’ only an emotional showdown between medics and managers can help that patient.
Now, however, people in Ireland without health insurance, about half of the population, are unable to access cutting-edge cancer treatment available to people with insurance, a top Irish oncologist has warned.
The difference is leading to difficult conversations around the country with HSE oncologists having to ask patients if they have insurance or not to gain access to the latest cancer drugs.
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Michael McCarthy, medical oncologist at University Hospital Galway, said: “It’s just in the last year that this gap has opened up.”
He works only in the public system.
Up to 2023, he said the only difference between public and private hospitals options was “maybe the speed of access for certain procedures.” This was reassuring with Health Insurance Authority data for 2023 showing 45% of people aged over 18 have health insurance here, meaning 55% rely on the HSE.
Treatment and survival rates for most cancers have improved significantly in the last 20 years, but that comes at a cost. In order for any patient to receive a new drug, it must first be approved by the European Medicines Agency.
Then, pharmaceutical companies approach health bodies in each EU country separately and request assessment. In Ireland this can take about two years, although reforms are set to reduce this, as it is currently about a year in comparable European countries.
Up to last year, almost all private patients also waited for a National Centre for Pharmacoeconomics assessment and other steps. “It seems to me that the HSE is making steady steps to improve their process — the new disparity isn’t because the HSE has gone backwards,” Dr McCarthy said.
“It’s because all the main insurance companies as of this time last year publicly committed to making all oncology drugs available to private patients and private hospitals from the point that the EMA approve it.”
This followed a public advocacy campaign by oncologists working in the private sector for their patients.
Dr McCarthy explained:
This is already playing out in his clinics.
“I’ve had to refer maybe four or five patients (who have insurance) in the last few months to private consultants in private hospitals to get access to these drugs,” he said. “And they are getting the access.”
He also has patients who do not have insurance, so despite some being suitable for newer drugs, they cannot access them yet.
“People are very different in how they react individually to situations, a lot of people just accept it,” he said. “But I suspect that at some stage in the next year there will be somebody like Vicky Phelan who will take it up very publicly. I’m a bit surprised that hasn’t happened so far, but I see it happening at some point.”
The approval process is set to shorten here following recommendations in a report by consultancy firm Mazars last year. As secretary with the Irish Society of Medical Oncology, he contributed to a written submission to the implementation working group for that report on this issue.
He noted “the HSE are doing many of the right things to try and close the gap” but is unsure whether it is enough.
One change will see transparency to what stage a drug is at in the process, so doctors can decide whether a patient can wait for this drug. At the moment, he said, “We are saying I have no idea when it’s available — in many cases the patient could die before it’s made available.”
Scrutiny of the health budget is needed, he acknowledged, saying the HSE has to make “tricky” decisions around spending. “These drugs are ridiculously expensive,” he said.
Immunotherapy helps the immune system to work better to fight cancer cells.
A specialist in head, neck and gynecological cancers, he said the EMA approve drugs which offer clear benefits. Internationally, governments have outsourced research and development of new drugs to private pharmaceutical companies, which gives states less leverage in negotiations.
Among the potential solutions, he argues, are changes in how negotiations work. Oncologists should be more involved particularly in choosing which drugs to prioritize.
He would like to see Ireland pooling bids for new drugs more often with other countries, saying up to 40% of new drugs are not even offered to the HSE by pharma companies due to our small population.
“The disparity in public - private access to standard of care cancer treatments is going to grow larger quickly in the years ahead,” he estimated.
“This is because the rate of development and EMA approval of new cancer treatments is increasing. And public patients will have delayed access to about 60% of these therapies while private patients in principle will have immediate access to 100% of these drugs.”
A pooled bid in January, for example, gave children with metachromatic leukodystrophy (MLD) access to a very expensive drug, Libmeldy, through the Beneluxa Initiative.
In addition to treatment expanding, he pointed to our ageing population which will mean the incidence of cancer rising and more people needing help.
The Irish Cancer Society has already received queries from cancer patients concerned about access to drugs.
Steve Dempsey, Director of Advocacy, said cancer care is time-sensitive.
“The current situation is ad-hoc and arduous for cancer patients, not to mention stressful. Their anguish can then be further compounded by a lack of transparency and information surrounding the reimbursement process,” he said.
“Many rely on the efforts of their physicians and private suppliers to close the gap – this is causing inequity within the treatment pathway.”
When there can also be delays in diagnosis or at general practice level, he said delays in accessing drugs create “an additional challenge”.
He warned: “Too many patients are missing out on medicines that are routinely available in other countries, including Northern Ireland. Currently, the reimbursement system and the lengthy approval timelines do not put the patient at the centre of the process.”
The society welcomes, he said, the government plans for reform.
A report from the Mazars implementation working group “will soon be finalised and submitted to the Minister for Health”, a Department of Health spokeswoman said.
Some 34 new roles are being funded for drug reimbursement as part of reforms, Stephen Donnelly recently told an Irish Pharmaceutical Healthcare Association conference.
From 2021 to 2023, the HSE approved 148 new drugs including 61 for cancer with almost €100m of dedicated funding. This year, €30m is expected to be available for new drugs, with €20m directly provided.
The HSE is seeking to make €10m in savings elsewhere and the department spokeswoman said: “Once achieved, these savings can be considered for reinvestment in new drugs.”
Just weeks ago, the Parliamentary Budget Office said due to limitations in the HSE’s financial system it is not possible to accurately say how much is invested in cancer treatment here.
They also said: “Even greater levels of investment may likely be required to expand services and improve outcomes and the quality of life of those affected by cancer.”
- Irish Cancer Society Support Line: 1800 200 700 or supportline@irishcancer.ie
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