Dr. Ronan Kavanagh

Emigration and arthritis. Some things to consider.

In Arthritis and Rheumatism, rheumatoid arthritis, rheumatology, Uncategorized on January 4, 2012 at 6:50 am

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.

  1. As a patient in the U.S. I can attest to the importance of getting your benefits in writing before you make your decision. Although, even if you do, that may not matter when the policy is renewed. Our private insurance companies can easily change your benefits when they see rising costs. Also, unless you are in a group plan, (such as through an employer) they can deny coverage altogether. So even if you had $900 a month for a somewhat decent policy, they can deny you anyway.Our healthcare system is very broken. Some things are not covered, so y you

    • Continued…..

      I currently have private health insurance through an HMO. My co-pay is 50% of non-generic drugs. $438 u.s. dollars for my portion a month. Now, I can’t afford Enbrel. Remicade is my only other choice, as it is considered an office co-pay, $30 per treatment. If you have further questions, please feel free to ask.

  2. As a rheumatologist in Australia who has had a patient just arrive from the UK expecting to have access to TNF inhibitor therapy, I would suggest patients thinking of moving countries take Dr Kavanagh’s advice. Get as much information as possible documented, bring this documentation to the new rheumatologist, & if at all possible get some link before you leave the country to make the transition as smooth as possible.

    Our Australian guidelines seem much tougher than those in Ireland, but overall, I think they are fair.

    • Thanks Irwin. That’s good advice and great to have a local perspective. Many of our younger patients are emigrating to Australia at present so expect to see some in your practice over the next few years.

  3. When I moved to the UK a couple of years ago I had no problems. I registered with a local GP and they immediately refered me to a rheumatologist. I was able to get access to Humira but I think if I wasn’t on it already I’m not sure if they would have been quick to put me on it. A big bonus for me is that there are now no medication charges in Scotland.

  4. Ronan,

    Thank you for the interesting article… I think there is a thesis in it.

    This is very practical and sound slant on problems people don’t envisage until they have to deal with them. It’s a pity you don’t see more insights like these on HSE websites. I’m going to forward this onto them and see if they would post a link to your blog. Anyway…couple of things I would say.

    As an AS patient on Enbrel, this is a very real issue. If emigration is on the cards, and it may well be, then it is something I need to address. More than passports, and visa’s, this would potentially stop any plans if I couldn’t get it reasonably resolved in advance. At least to the point where I understood I had a confirmed appointment with a recommended rheumatologist and that I know would be already successfully treating similar cases.

    There is an another issue though. If Australia, US, Canada, UK were the only places people emigrated then one could reasonably suggest a booklet of the recommended steps per their country of choice. However, my assumption at this point is that approach to treatment is going to vary on a country by country basis. That’s a lot of variation. One could argue that, at least WITHIN Europe (this is what we signed up to Europe for isn’t it?!?) shouldn’t the home scheme that the migrant is on follow that person to their destination country? Surely that isn’t too difficult to administer.

    Furthermore, what happens when that migtrant, who now has 5 more excellent years of skills to offer back to Ireland and wishes to return so their kids can go to school here..wants to get back on the hi-tech scheme? There does not seem to be an answer to this question? If one was already a member of the hi-tech scheme…does this membership lapse!!! It would seem from your article that a lot of doubt remains about the long term viablity of hi-tech subsidisation in Ireland. There is a possibility of a discrimination case here if you were refused. The current government approach to addressing costly subsidies at present seems to be the “anyone new will not avail of” definition :-)

    I’m not saying that hi-tech drugs are the only answer, but I’m on them for 7 years and it is working…this is not a risk I will take lightly.

    Thank you again for raising the topic, I can see this running and running.

    Garrett

    • There’s a couple of questions there Garrett!

      At present there is good funding for biologic drugs through the HiTech scheme in Ireland. At the moment you can stop and start Hi Tech drugs without problems with reapproval and your ‘membership’ doesn’t lapse. If one were to leave for a few years then the situation could be vastly different. It is impossible to predict where we will be regarding funding for these drugs in 5 years time.

      Regarding information booklets for the subgroup of patients on biologicals who want to negotiate their way in a different country, I think its unlikely to happen. The best way is to enquire on an individual basis (with some help from your rheumatologist) on your situation in the country where you plan to go.

  5. Hi Ronan,

    Great article! I’ve moved around Europe a lot, the most recent move being a few months ago to Switzerland. I’ve a couple of other pieces of advice to add if I may:
    1. Think about the weather where you are moving to if your arthritis flares with different pressures- I had 5 years remission in Greece and 2 yrs misery in the UK (pre biologics but IM steroid heaven!?)
    2. Be very careful about total health insurance availability both in your destination country and if you return to Ireland- it might be worth maintaining your cover in Ireland so you don’t encounter a ‘waiting period’ when you return. In Switzerland you must have private health insurance by law. They can’t refuse you the basic (which is extensice and high quality) but they can refuse anything extra, e.g. Private hospital room, for any condition, as you are catagorised as high risk for any disease once you have arthritis
    3. Find out who the national arthritis patient organisation is- they are a wonderful source of information (and support when far from home). Arthritis Ireland have lots of links with groups in Europe, and both US and Australia have fantastic patient organisations!

    One final note I think New Zealand are very restricted on their licencing of biologics so one to double check for travellers heading there.

    I’m happy to provide further info to anyone who’d like it.
    Again great job on a very important and complex topic!
    Nicola

  6. HI Ronan,
    I have AS. Myself and my husband are temporary residents in Australia on a fixed term 4-year work contract. The best advice I can give to anyone thinking of coming out to Oz is to find a rheumatologist and try to speak to them or one of their specialist nurses directly. It took around 6 months for me to get Humira here. They have specialist clinics that work off a very similar criteria to the UK. They even use the measurement system developed in Bath. (BASDAI) The system is far from straight forward in Oz, but I think I was lucky to get a wonderful nurse who worked with my wonderful nurse in the UK to get all my records and tests sent over and then she followed everything up at every stage of the process. We took a risk, but we figured worse case scenario we would go back if things didn’t work out.

  7. Hi Ronan,
    I have read though the comments and replies above. They have all been very helpful. I have RA and currently on Tocilizumab, the monthly infusion. We are thinking of moving to OZ but have reservations because of my medical history. Until now, I wasn’t sure what treatment was available over there. I thought it was time to lookinto it in more detail and I can see it is a possibility at least. Would there be any assistance with any healthcare payment plans or is this something we would have to pay for? The care and support I have had from my hospital in London has been so good and so it is a worry to find a good doctor/hospital to move to.

    • Nicola,my understanding is that Tocilizumab would be harder to get funding for in Oz. Let me put you in contact with an Australian rheumatologist who has contributed to this discussion before. I’ll get him to reply to your query if I can.

      • Hi Ronan, thank you for coming back so quickly. That will be most helpful. Tocilizumab is a fairly new drug so I would of imagined it would be harder to obtain. Any help or guidance at this stage will be greatly received.

      • See Dr. Irwin Lim’s response Nicola. It should help.

      • Tocilizumab is available in Australia for use in RA. It is government funded apart from a small copayment (about US$35 a month) if you qualify for Medicare (depends on your status/visa so you will have to check this). Your medical condition may make it harder to qualify for residency.

        Next problem is access to rheumatologists. Very much depends on part of Australia. Not much of a problem in big cities like Melbourne & Sydney but bigger problem elasewhere especially in rural areas. When settling in Australia, get a GP asap then get a referral to his/her favourite rheumatologist asap. You will need to pay a fee to see a rheumatologist generally as the bulk of rheumatology service is provided in the private sector.

        Bring as much documentation as possible to help the rheumatologist negotiatiate/fill in forms with the funding authorities. In particular, joint counts, DAS scores, ESR & CRP pre-biologic treatment. Need to know medication history and what was trialed beforehand, need to have documented response to biological DMARD. Correspondence from specialists, imaging reports, laboratory results & a prepared history with as much detail as you can obtain is always helpful. There are set criteria to be met and I have done this once before for a patient from the UK. Lots of forms & ringing around on the part of the rheumatologist.

      • Thats great advice Irwin. Thanks for taking the time to post the information.

  8. Dr Irwin Lim

    Thank you for your advise. I have a lot of planning to do and understand a lot of people will be involved in any transition. I will take your advise on board and speak to my doctors and nurses in London to look into gathering my documents together for the future.

    Thank you again for you kind, helpful advise and your time in coming back to me.

    Nicola

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