One of the realities of Ireland’s fall from economic grace is the large numbers of people emigrating from our shores in search of a better life.
I know this because amongst them are some of my younger patients in my practice, many of whom are afflicted with conditions like rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. Whereas many of them are doing well on treatment, and seem quite up-beat and excited to be considering the idea of a few years away, there are some downsides to consider. This is particularly true for those who are on biologic treatments for their arthritis.
Biologic therapies are a group of modern, hi tech and effective treatments for certain types of arthritis. They are also very expensive. The annual cost in this country for a patient treated with once of these drugs ranges from €15,000 to €20,000.
Although many gripe about the state of the Irish health service, one of the things it does very well is provide funding for these drugs. At present (although likely to change) there are very few restrictions on a Irish rheumatologist’s ability to prescribe biologic therapies for arthritis.
Every Irish citizen is entitled to have the costs of subcutaneous biologics (e.g. Enbrel, humira, Simponi, Cimzia) covered (subject to shortfall) through a fund known as the ‘HiTech scheme’. This is usually subject to maximum shortfall per family of €132 per month and about a third of the Irish population who have a medical card (those over the age of 70yrs and those below a certain income) which entitles them to (almost) free medical care where they have to pay 50c per month per item on their prescription. The centrally funded Hi Tech scheme (which is ring fenced from other health service costs), does not cover the costs of the Intravenous biologic drugs (e.g. Remicade, Roactemra and Orencia). These are usually funded through local hospital budget (much to the chagrin of public hospital administrators). Those with private health insurance have the costs of intravenous drugs and related infusion costs met by their insurer (a bit less than 50% of the Irish population carry health insurance).
For those patients who are considering changing jurisdiction there are always two considerations when it comes to getting continued access to your regular arthritis medication.
1. The first is that a change in country means a change in rheumatologist. Where your new rheumatologist will effectively be the gate keeper to access treatments, your ability to get access to these drugs depends wholly on your new rheumatologist agreeing that biologic therapy is appropriate for you. Whereas consensus for patients with more severe forms of arthritis is unlikely to differ, there are often grey areas where opinions may vary. The decision making process however is more likely to be informed by local funding issues.
2.Funding for biologic therapies is much more restricted in other countries. For example, in Australia, access to biologic therapies for anklosing spondylitis is restricted to patients with a certain grade of severity of AS on Xray whereas in Ireland it is wholly at the discretion of the treating rheumatologist.
3. Even where you have Irish private health insurance, it will usually only cover you for emergency treatment abroad for a certain period.
What is the best advice for those thinking about emigrating who are on treatment?
1. Be aware that you may not automatically entitled to access to biologic treatments abroad. The HiTech scheme in Ireland only covers the cost of drugs of patients living here.
2. If you are thinking about emigrating, discuss it with your rheumatologist before making any firm decision. He/She may be able to recommend a rheumatologist and initiate contact for you.
3. Firmly establish the funding guidelines and restrictions on prescribing of these drugs in your target country and ask your rheumatologist for advice. I have included links to the UK (NICE) guidelines (for Rheumatoid arthritis Ankylosing Spondylitis Psoriatic arthritis , Australian Medicare guidelines (Rheumatoid arthritis , Ankylosing Spondylitis, Psoriatic arthritis) and Canadian guidelines. US regulations are much more complicated. I think it would be fair to say that having health insurance in the US would be imperative and that you would need to establish from the target insurer what their coverage guidelines are. Get it in writing!
If you are a patient in a country other than Ireland who has guidance you’d like to offer to foreign patients thinking of emigrating you your country, please add a comment.