Seanad Éireann debate -
Wednesday, 11 Nov 1998

Vol. 157 No. 1

Adjournment Matters. - Health Insurance for Psychological Services.

Mrs. Ridge

The Latin saying mens sana in corpore sano refers to a sound mind in a sound body and it is that matter I seek to address. Many people with physical symptoms have undiagnosed psychiatric illnesses. Stress is a causative and exacerbating factor in illnesses as diverse as arthritis, hypertension, cardiac problems, infertility, etc. However, one can have a medical consultation for the Nutron diet and it is tax deductible but a consultation with a psychologist or counselling therapist must be paid for in full by the patient.

It is unfair that holders of private medical insurance, whether with BUPA or the VHI, if referred to a psychologist for a consultation must pay the full cost of such services. The psychological services in Ireland are fully professional and the practitioners generally have a university training to masters level. I do not refer to psychics or people with limited counselling training, but to those with third level qualifications.

Some health boards provide a service with resident psychologists, therapists and counsellors for medical card holders. However, those not holding medical cards may not avail of the psychological services without paying in full. I do not decry the fact that such people are outside the medical card scheme, rather the unfairness of the arrangements.

A doctor will often prescribe medication for a patient. However, if an issue of mental health or stress is involved the patient may be referred to a psychiatrist. In many cases the services of a psychologist would be equally valuable and in some cases even more so. Society and people have become so busy that nobody is available to listen anymore. The religious tradition of confession seems to be dying out and, for all its shortcomings, it provided many people with an outlet to express their difficulties to a receptive source.

If one is referred to a psychiatrist by their doctor medical insurance will cover the consultation but if one is referred to a psychologist one is not covered. I am aware that there is a good counselling and psychological service available to those suffering from cancer related illnesses and it is to be applauded.

With regard to BUPA health insurance in particular, full cover for psychological services was introduced for its customers in the UK. Much has been made of the great service BUPA offers to its Irish customers but I do not understand why there is a discrimination between the Irish and the British subscribers.

I have taken trouble to research this matter and there is a body of research evidence which shows that a proper psychological service results in reduced medical costs. It would seem not only fair but desirable if it reduces costs to change the arrangements for medical insurance subscribers. Our European neighbours Austria, Belgium, Switzerland, Finland, Italy, the UK and the Netherlands provide that holders of insurance can avail of psychological services, in some cases on an in-patient basis but in many cases on an outpatient basis. However, no such allowance is made for people in Ireland.

It does not appear that all citizens are being treated equally in this matter. It cannot be right to separate mind and body in a healing process, particularly when highly qualified professional services are available. All citizens should have access to such services. For once it is the people who have some means who are being excluded rather than those who have none. I applaud the health boards for their services. I ask the Minister of State to take my request on board. It would be a positive step for mental health. The private health insurers must be taken to task on this matter.

Minister of State at the Department of Health and Children (Mr. Fahey)

I thank Senator Ridge for raising this issue. By way of introduction, it should be explained that our private health insurance system had its origins in the need to provide protection against the cost of hospitalisation for those who were outside the entitlement to public hospital services. Private health insurance has developed in this way up to the present time and now covers in excess of 40 per cent of the total population.

It is important to understand that, in an insurance context, Senator Ridge's motion gives rise to a complex and important range of considerations. It involves issues relating to commercial freedom, financial capacity, customer preference, competition and appropriate legislative intervention.

There are, of course, significant and obvious implications to the State intervening into the decisions of commercial undertakings as regards what services they can and should cover in a competitive market. No doubt we would all agree that there would need to be appropriate and compelling public policy reasons for the State to impinge upon the behaviour of individual private commercial bodies or, indeed, an entire market.

Looking at the broad picture of the legislation and regulation of health insurance business, the corollary to proceeding on the lines of Senator Ridge's motion would require the regulations governing minimum benefit to be extended to cover the services of psychologists. For the information of Members of the House it should be explained that these regulations require that each health insurance contract must not provide benefits below a prescribed level, referred to as minimum benefit.

The key rationale for the existence of minimum benefit is to support community rating by requiring insurers to undertake a broad spread of risk in order to reduce the scope for designing products aimed primarily or exclusively at the young and healthy.

The success of community rating is dependent on inter-generational solidarity. If insurers are in a position to offer health insurance contracts aimed at low risk groups with lower levels of, or less extensive, cover than is generally available, the degree of inter-generational solidarity within the present health insurance market could be undermined. In the absence of minimum benefit requirements, it would be open to insurers to design plans specifically to attract younger low risk people.

At this point, it should be clarified that it is not open to the Minister, Deputy Cowen, under the legislation governing the Voluntary Health Insurance Board to direct it to cover particular classes of service. The Minister believes this is as it should be, and as the board wishes to have it, by reference to the board's freedom to make its own strategic and commercial judgments about its operations.

The Department is currently engaged in the preparation of a White Paper on private health insurance which has involved receipt of submissions from and discussions with a large variety of interests. The Psychological Society of Ireland was among the bodies which presented views in connection with the preparation of the White Paper.

A number of submissions received on the White Paper called for the enhancement of the minimum benefit requirements under health insurance contracts. The case was put, in some instances, that interventions of particular kinds, encouraged by the availability of benefits, would actually prove cost effective for insurers in that they would reduce the incidence, duration or frequency and, consequently, the associated high cost, of hospital in-patient stays.

The Minister has noted these assertions and he is aware that the insured public will always welcome the addition of benefits provided these are not contingent upon increased premiums. He considers this to be essentially a product development issue and it falls to the promoting interests to convince the insurers of the force and merits of their case.

Such a dynamic is part of what characterises a free and competitive market. As has been explained already, the primary rationale for minimum benefit is the support and protection of community rating by limiting the scope for the development of health insurance contracts which are targeted at the young to the exclusion of the elderly.

There is a question as to whether it would be disproportionate and an undue interference in the commercial freedom of insurers, to include further services under the minimum benefit arrangements.

There are, of course, other providers of health services who would see themselves as having a case, just as legitimate and well-based as psychologists, for inclusion under minimum benefit. Against this, there is the position of insurers to be considered, not simply in the sense of their commercial freedom but also as regards their financial capacity to have liability for additional services, which did not form part of the traditional minimum cover, thrust upon them by dint of regulation. In addition to the practical matters of financing new benefits, insurers, having regard to customer feedback, need to have scope to move towards addressing what would be most favourably regarded by their customers in the way of enhanced benefits.

The advisory group on risk equalisation. which reported to the Minister in April this year, advocated the removal of ancillary health services from the ambit of the existing health insurance regulatory framework. This is among the matters being considered by the Department in the context of the preparation of the White Paper.

It is hoped that what I have said on the Minister's behalf will provide an insight into the difficult and important considerations which lie behind Senator Ridge's motion. The submission of the Psychological Society of Ireland on private health insurance and psychological services will be given the fullest consideration in the context of the preparation of the White Paper. The aim is to complete work on this in the current year and, subject to Government approval, to publish it shortly thereafter.

Mrs. Ridge

I thank the Minister of State for his reply.