Serious concern has been expressed about the cost of the medical card and drug payments scheme by the Brennan Commission value-for-money report into the health system.
The report says that the cost of the General Medical Services (GMS) had increased "at an alarming rate" , with the cost of the medical card scheme rising two-and-a-half times between 1997 and 2002.
The commission, chaired by Prof Niamh Brennan, calls for accountability issues to be addressed, including the function of GP's within both the GMS and the publicly funded drugs and medicines schemes.
The report labels the medical card scheme as "one of the biggest challenges and financial risks to the health service nationally".
It expresses concern at the ongoing failure to have changes to the scheme costed, or to have its operations monitored and expenditures verified.
The commission also says there is little or no evaluation of attendance patterns, prescribing rates or hospital referrals amongst GP's.
The choices facing the Government in this area are "stark", says the commission, which proposes that the Government negotiate budget limits for the scheme.
It also proposes that mechanisms are devised whereby agreed outcomes will be delivered for agreed outputs.
Suggested outcomes include a reduction in inpatient admissions and the treatment of a greater number of accident and emergency cases through the primary medical service.
In a specific recommendation, the commission says that each GP be given a practice budget to cover his or her medical card patients.
Should an individual doctor requires funding over the agreed budget, the doctor will have to outline to the health board C.E.O. the clinical factors which give rise to the overspending.
Based on an evaluation of annual reports made by each GP to a health board C.E.O., overpayments made in a previous year should be "netted off" by the board against that GP's practice budget for the following year, the report says.
The commission also wants the Department of Health to take "immediate steps" to agree with representatives of doctors the "necessary changes " to the GP's contract of service so that its recommendation are implemented.