A fundamental review of the Isle of Man health service has been launched amid concerns that current funding levels are "unsustainable".
The 12-month study will look at the Department of Health's escalating costs and examine the options for free healthcare on the island.
Means-testing in some areas is believed to be one option being considered.
The report will be led by Sir Jonathan Michael, former chief executive of three UK NHS hospital trusts.
"The continuing inability of the Department of Health & Social Care (DHSC) to remain within budget is of great concern," said a government spokesman.
"However, the DHSC cannot deliver services effectively for which it is not funded adequately.
"At present, there is insufficient evidence with which to determine whether the budget is too low or that our health and social care services are not appropriately designed and/or delivered."
'Not about privatisation'
Government statistics show that by 2035 the number of over-65s on the Isle of Man is expected to increase by 75%, something which is expected to put the NHS under "severe pressure".
The Council of Ministers has estimated that current funding would have to increase by 23% - an additional £60m - to maintain standards of care by 2022/23.
Treasury Minister Alfred Cannan MHK said: "I believe we have reached a critical juncture.
"Financial projections point to funding levels becoming unsustainable in the years ahead. Unless positive action is taken there is a concern that healthcare provision may deteriorate or funding for other public services will suffer.'
Health and social care minister David Ashford said: "This is not about wholesale privatisation."
"No one is proposing such a move but the reason the health service has survived for 70 years is because it has adapted - if it hadn't, it would have collapsed in the late 1950s".
Other topics within the scope of the report include patient safety, pace of change and the possibility of outsourcing of more care to hospitals in the UK.
Alf Cannan said: "We are committed to the principles of the NHS but we must have some perspective about the level of funding needed."
The independent review will be presented to Tynwald in May 2019.