The Tribune

• Ex-minister reiterates ‘medical apartheid’ concerns

• Argues public system care outcomes ‘sub- optimal’

• Bahamian taxpayer not getting ‘value for money’

By NEIL HARTNELL

Tribune Business Editor

nhartnell@tribunemedia.net

AN ex-health minister says “it’s not worth” committing resources to collect legally-mandated user fees from Princess Margaret Hospital (PMH) patients given that $700m-plus remains unpaid.

Dr Duane Sands, who held the post during the Minnis administration’s early years, told Tribune Business that the country’s public healthcare system is failing because treatment outcomes are “sub-optimal” for too many Bahamians while taxpayers are “not getting value for money”.

Reiterating his belief that The Bahamas is practicing “medical apartheid”, because care quality and outcomes in public healthcare are inferior to those enjoyed in the private sector, he argued that while there are multiple ways to produce the necessary improvements this requires “alignment of the moon, sun and stars and I don’t see it happening”.

While PMH and the Public Hospitals Authority (PHA) have had the ability to levy fees for a variety of tertiary care services they have elected not to enforce this even on persons with insurance or the capacity to pay. The International Monetary Fund (IMF), in its recent Article IV report, said reversing this policy and levying fees on those who can pay could save taxpayers over $100m in subsidies annually.

“When you look at the historic generation of fees, we have done a horrible job of collecting fees, gazetted fees, in the public healthcare sector for many decades,” Dr Sands told this newspaper. “When I last looked at it, the figure was in excess of $700m owed.

“Even when you consider those fees are deeply dis- counted fees for accident and emergency (A&E), fees for surgeries.. if you then look at the actual collection, even today, for clinical visits and emergency room visits, it’s not worth the human resources and other resources to collect the small amount if money we collect. That’s before we start to factor in any slippage and wastage....

“At the end of the day, the Bahamian public is not getting value for money in healthcare - certainly in the public arena. We are spend- ing far too much and not getting value for money, so the outcomes remain sub-optimal” he continued. “Do we need to make sure the public healthcare system benefits more from private health insurance than it is presently able to? Absolutely.

“Just simply maintaining this divide between public and private, which is what I have described as medical apartheid, I don’t think would be in the best interests of Bahamians. I think we should get rid of that model. The model would be, as used in every other country, acknowledging that everyone is entitled to the same quality of care” and does not suffer differ- ent treatment outcomes because of ability to pay.

“You might get a better room with private care, but you should not have different mortality and morbidity rates,” Dr Sands said of his philosophy, adding that patients should be able to access that same diagnostic and therapeutic treatments, the same medicines, and same equipment and round-the-clock care regardless of whether they are seeking treatment in the public or private healthcare sectors.

“I’m getting ready to retire from public medicine this year,” Dr Sands said. “I’ve done 30 years, and it’s disappointing we have not been able to move public medicine much further along the quality path. In the remaining few years I have on this Earth I am going to keep trying.

“What I’m saying is that we need to eliminate the gap, the discrepancy between maternal and child mortality rates, between public and private providers, and the quality of care that exists between the two systems.

“Until we do that, unfortunately we’re going to see runaway costs that we cannot recoup and the public purse will never

be able to sustain given the huge level of non-communicable diseases (NCDs). I think we also need to control the runaway expenditure of the National Heath Insurance (NHI) programme because I am not sure the Bahamian public are getting value for money from that.”

Asked how the divide between public and private healthcare systems can be eliminated, or at least narrowed, Dr Sands replied: “This may be the time to go to full-time consultant staff in the public healthcare system so they don’t have an option to straddle both systems.

“This is the time to begin billing and collecting in the public healthcare system in the 21st century. Bring electronic records into the public healthcare system. Remember the All scripts disaster where we wasted many millions of dollars. There are many ways where can move the public health- care system forward, but it must align with the moon, sun and stars. I don’t see that happening yet. We pay lip service.”

Noting that many Bahamians have been sold on the notion that public healthcare is free, even though they are financing it through their tax dollars, Dr Sands reiterated: “We cannot have a situation

where what attains in the private sector allows people to get good quality care and people in the public sector find they are paying through the nose with their taxes hundreds of millions of dollars and the outcomes are drastically different.

“They have the expectation, having paid those taxes, that everything else is free even though the healthcare system’s budget is predicated on people paying those fees. Yet they are told directly, and indirectly, ‘don’t worry about that. We’ve got you’. Very few people pay for hospital emergency care, dialysis, even though bills are generated.”

The $700m in outstanding, uncollected PMH fees is equivalent to more than three times’ the PHA’s annual taxpayer subsidy. Dr Sands likened his preferred healthcare model to a flight where persons, regardless of whether they pay extra for first-class or sit in economy class, all arrive at the same destination safely and at the same time.

“That’s the model that makes sense,” he added, “and when people want choice they get choice, but it shouldn’t be that that choice results in different levels of outcomes or quality of care that you receive.”

The IMF, in its just- released full Article IV report on The Bahamas, estimated that annual taxpayer subsidies to the Public Hospitals Authority (PHA) and Water & Sewerage Corporation can be cut by a sum equal to 0.8 percent of economic output by implementing true “cost recovery” measures.

In the PHA’s case, this would involve the imposition of fees for persons “with greatest capacity to pay” for use of the tertiary care services offered by the Princess Margaret and Rand Memorial hospitals.

These savings, the IMF suggested, could then be repurposed to finance education, social welfare and primary healthcare spending. It noted that the Government’s spend- ing on education, as a percentage of gross domes- tic product (GDP), is well below the Caribbean and Latin American average while the public healthcare system has been producing “worsening” care and treatment outcomes for the past decade.

“Greater cost recovery by public corporations would reduce the net subsidy they receive from the Budget,” the IMF argued. “Collecting payment from patients and enforcing fees for health services would reduce transfers to the Public Hospital Authority

(PHA) by around 0.7 per- cent of GDP.

The combined savings estimated by the IMF from the PHA and Water & Sewerage Corporation measures is 0.8 percent of GDP - a sum equivalent to $116.53m based on the GDP estimates contained in the 2023-2024 Budget. Almost $102m would be generated annually from the imposition, and collection, of PHA user fees.

“Current subventions to the PHA account for approximately half of annual current subventions to SOEs, due largely to little to no cost recovery and a system of exemptions and non-payment for most services,” the IMF added of an entity due to receive a $222.156m taxpayer subsidy this fiscal year.

“Moreover, hospital benefits accrue primarily to those with higher incomes. The collection of fees for most services offered by the PHA, means testing to require those with greatest capacity to pay, linking future price increases to the rise in operating costs, and greater efforts to reduce the write-off of unpaid bills could yield annual savings of up to 0.7 percent of GDP over the medium-term.”