A CRACKDOWN on the cost of prescriptions and a squeeze on medical cards are firmly on the agenda for next month's Budget.
Major changes to make it harder to get a medical card, and to cut waste in the prescription drugs bill, are being examined by the Coalition.
The Government has set its sights on tackling the overall number of medical cards, cutting down the bill for prescriptions on the GMS scheme, and reducing the pay bill in the health sector.
Altering the criteria to qualify for medical cards is politically explosive – but back on the table due to the spiralling cost of providing the cover.
More than half the population is now covered by medical cards and Government figures say this is "not sustainable and can't be afforded any more".
"It was never meant to be for half the population. It's totally out of control," said a senior government politician.
After the massive budget overrun this year, the Coalition is under pressure to put a more credible health budget in place for 2013.
The Coalition is also looking at the spending on prescriptions for those who have medical cards, with a view to cutting the money wasted on unused drugs.
Government figures still believe patients on medical cards are getting prescriptions from doctors they don't need and which are lying unused in bathroom medical cabinets.
Parts of the doomsday list of cuts which Health Minister James Reilly deliberately leaked this time last year now appear to be back on the table.
He had a one-to-one meeting with Public Spending Minister Brendan Howlin last Wednesday to discuss the options.
Dr Reilly threatened last year to raise the 50c prescription charge to €2 and also flagged a €50 charge for a medical card.
But this year, with health spending under even more pressure, it's the eligibility criteria for medical cards that is attracting most attention.
The non-core parts of the pay bill in the health sector are also under examination, including:
• €150m on agency workers.
• €200m in overtime.
• €700m in premium pay.
The Department of Health, the HSE and Department of Public Spending are trying to find the savings in the health budget through "measures that are concentrated, implementable and durable".
Describing it as a "big hill and a huge challenge", Dr Reilly yesterday defended his management of health finances as this year's HSE deficit heads towards €400m.
But he said: "I'm quite confident we're going to come in an awful lot better than €400m (this year).
"There has been huge progress against the backdrop of extraordinary cuts in the healthcare budget. My principal stand now is this: I don't want to be cutting services, but I must cut the cost of services and that has to be addressed."
However, the health budget is going to be reduced by another €900m next year and government sources say Dr Reilly is obviously finding it hard to cut back in such a sensitive area.
"Look at the hassle he got from the €8m out of the home-help budget," a minister said.
The IMF wants the Government to look again at the means-testing system in place for medical cards, but with growing unemployment and a rise in the number of elderly people, it's become a sensitive issue.
A minister told the Irish Independent that the problem was not providing the benefit of a medical card to those who needed it, but the manner in which it was so widely available.
The number of medical cards has risen in less than a decade from 1.4 million to 1.9 million.
"It's not sustainable and can't be afforded any more. It was never meant to be for half the population. It's totally out of control," said a source.
"The Government is going to have to tackle pay and the GMS scheme."
During a routine visit to Dublin during the summer, the IMF identified medical cards as an area that had to be examined, specifically mentioning the contentious question of medical cards for the over-70s.
Meanwhile, Mr Howlin is reportedly finding it tougher to identify areas to cut in Budget 2013.
He is going to cabinet colleagues with his begging bowl asking them for extra funds from their departments.
Mr Howlin is trying to scrape together more savings to ease the burden of health and social welfare cuts.