Oncology Drugs Management System

Systemic anti-cancer drug treatment is currently funded through three separate funding streams in the Irish public healthcare system:

  1. The community drug schemes of the Primary Care Reimbursement Services (PCRS) (including the high tech arrangements, the GMS and DPS) for drugs self-administered by patients at home.
  2. Hospital base budgets for drugs administered in hospitals.
  3. The Oncology Drug Management System (ODMS) for specific high-cost drugs administered in hospitals.

Historically, drugs administered in hospital settings, including systemic parenteral chemotherapy, were funded from within a hospital’s overall budget.  The NCCP introduced the Oncology Drug Management System in July of 2012 to oversee and manage the funding of specified hospital-administered systemic anti-cancer drug treatments to public hospitals. The Primary Care Reimbursement Service (PCRS) facilitate the operation of this system. The system also addresses the growth in costs associated with new drugs and new indications of hospital administered systemic anti-cancer drug treatment and allows for the introduction of a “money follows the patient” funding model.

More Information:

Approved drugs

Reimbursement process

Patient eligibility for oncology drugs web application

Approved Drugs

The drugs included in the ODMS have been recommended by the NCCP Technology Review Committee and approved for funding by the HSE Drugs Group for specified indications [i]. The scheme allows direct reimbursement to the hospitals, through the PCRS, based on administration of specified anti-cancer drug treatments to individual patients for the approved indications.

New systemic anti-cancer drug treatments are added to the system on an ongoing basis when approved for funding. 

The list of approved drugs for this programme is available here.

Protocols for approved drugs can be found in the protocols section.

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Reimbursement for new drugs from the Oncology Drug Management System (ODMS):

This scheme entitles hospitals to recoup, in full, the costs of the specified systemic anti-cancer drug treatments administered to patients approved for funding for agreed indications by the HSE Drugs Group. The scheme does not cover new drugs which displace drugs currently in hospital use; funding for such drugs comes from within the existing hospital base budget.

Hospitals are advised in writing by the NCCP when new oncology drugs are approved by the HSE drugs committee. This approval indicates the funding stream for each newly approved drug and provides the link to the associated protocol on the NCCP website - NCCP Chemotherapy Protocols.

Hospitals are required to register as an ‘Oncology Centre’ with the PCRS prior to submitting reimbursement claims. The application form (which is available from oncologydrugs@cancercontrol.ie)  is completed by the hospital CEO/GM or delegate and returned to the PCRS.  Once the Hospital is registered, details of approved system users must be submitted to the PCRS. A comprehensive user manual is available to registered users by contacting the NCCP at oncologydrugs@cancercontrol.ie.

Hospitals order, administer and pay for the specified drugs in line with usual hospital practices.

The hospital can then submit reimbursement claims as required. The criteria for these claims are as follows:

  • Claims may only be submitted for eligible patients (see patient eligibility below)
  • Claims may only be submitted for indications approved for funding. (these may be found in the associated protocol at NCCP Chemotherapy Protocols)   
  • Claims for reimbursement may only be submitted following administration of the drug dose to an eligible patient for the approved indication. Claims should be made for the dose given where the remainder of the vial is used for another dose. Full vial costs should only be claimed where the remainder of the vial cannot be used for another dose. Wastage should be minimised where possible.
  • The dispensed date, as completed on the reimbursement claim, must reflect the  administration date of the drug to the patient i.e. each patient dose must be registered separately for reimbursement and should not be registered in advance of administration or by amalgamating doses.
  • Reimbursement claims may be registered on the system up to a maximum of one month after the date of administration. Late reimbursement claims may not be reimbursed.
  • Errors in reimbursement claims should be corrected immediately. 

Audit:

Audits of claims are undertaken periodically by the NCCP.

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Patient eligibility for claiming reimbursement from the Oncology Drug Management System (ODMS)

 


Determination of eligibility for public health care services in Ireland is the responsibility of the treating hospital.

Claims must only be made for:

-         Eligible patients.

-         Indications which are approved for funding.

- The dose administered unless there is wastage incurred.

Entitlement to health services is primarily based on residency and means (income source), rather than on a person’s payment of tax or pay-related social insurance (PRSI)[ii].

Any person, regardless of nationality, who is accepted by the Health Service Executive (HSE) as being ordinarily resident in Ireland[iii] is entitled to receive the same level of health care as Irish citizens.  People have either full eligibility (Category 1; medical card holders) or limited eligibility (Category 2) for health services[ii].

A person’s source of income is also a determinant of eligibility. Any EU member citizen who is resident in Ireland but maintains their income links (salary or social security) with their home country remains the funding responsibility of their home country.

Patients who are ineligible for public health services in Ireland are liable for the full economic cost of treatment. This may be self funded or funded by a private insurance company.

European Health Insurance Card (EHIC):

Cancer care is considered specialised care and as such funding is not covered under the European Health Insurance Card (EHIC).

Patients who have EHIC cards however are entitled to ‘necessary’ treatment but not specialised treatment.

Treatment Abroad Scheme:

Where a resident of another EU country presents for cancer treatment in Ireland, the treating hospital may contact that person’s country of residence to seek approval for reimbursement from that member state.

In these cases, reimbursement should be claimed by the hospital in line with other ‘Treatment Abroad’ application.

Patients treated in Ireland under the Treatment Abroad Scheme are excluded from reimbursement claims from the ODMS as the costs of the drugs should be included in the cost of care.

European Cross Border Directive:

The Cross Border Directive (CBD) allows for EU residents to access health services in EU member states other than their own.

The Cross Border Directive allows for Irish residents to avail of healthcare in other EU member states that they would be entitled to within the public health system in Ireland, which is not contrary to Irish legislation. The costs must be born by the individual and he/she then seeks reimbursement for the cost of the healthcare upon return to Ireland.

Irish patients availing of the CBD will only be reimbursed for drug treatments, including cancer treatments, which are funded in Ireland at the time of treatment.  

Patients from other countries availing of the CBD are liable for the full economic cost of treatment in Ireland, to be paid at the time of treatment, which will then be reimbursed if eligible in their home country. Neither the treating hospital in Ireland nor the patient is eligible for reimbursement under the Oncology Drug Management System.

Find out more about the Cross Border Directive

Eligibility for Claiming reimbursement under ODMS:

A hospital can claim reimbursement under the ODMS scheme only for those patients who are eligible for health care services in Ireland.

Claims under ODMS can be made using one of the following as a patient identifier: a GMS, PPSN [iii] number or LTI card. All patients eligible for treatment will be eligible for one of these numbers/cards.

Treatment costs for ineligible patients will not be reimbursed from the ODMS.

Further information on eligibility for public health services can be accessed on the website of the Department of Health. For individual cases you can contact euregulations@hse.ie

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References


[i] DOH. Health (Pricing and Supply of Medical Goods) Act. 2013.

[ii] http://www.citizensinformation.ie/en/health/entitlement_to_health_services/entitlement_to_public_health_services.html

[iii] A person is normally regarded as "ordinarily resident" in Ireland if he/she satisfies the HSE that it is his/her intention to remain in Ireland for a minimum period of one year. To establish that a person is ordinarily resident the HSE may require (i) proof of property purchase or rental, including evidence that the property in question is the person’s principal residence, (ii) evidence of transfer of funds, bank accounts, pensions etc, (iii) a residence permit or visa, (iv) a work permit or visa, statements from employers etc.

[iv] http://www.citizensinformation.ie/en/health/entitlement_to_health_services/entitlement_to_public_health_services.html

[v] DIRECTIVE 2011/24/EU OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 9 March 2011

[vi] The Oncology Drugs Management System has recently been recognized by the Department of Social Protection for the collection of patients’ PPSN. Details are provided on the Department’s website at http://www.welfare.ie/EN/Topics/PPSN/Pages/rou.aspx.

[vii] The eligibility section was drafted in conjunction with the HSE EU Regulations Office

 

You can download a  PDF document of the information above. Please note that the PDF does not contain the list of approved drugs as this information is updated regularly.

 

The information contained on this page was developed by the NCCP with advice from the HSE EU Regulations Office.

V2. June 25th 2014. Approved by NCCP / HSE EU Regulations Office. Last updated 06/12/17.

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