The Tribune

By NEIL HARTNELL

Tribune Business Editor

nhartnell@tribunemedia.net

Bahamian doctors have expressed “gave concern” over the Government’s National Health Insurance (NHI) cost estimates, warning that this could create an unsustainable, underfunded scheme that actually increases mortality rates.

The Medical Association of the Bahamas (MAB), in a letter to Prime Minister Perry Christie that was released to its membership last week, questioned both whether NHI’s costs had been “underestimated” and the feasibility of financing its initial phases from the Government’s Consolidated Fund.

Backing the Christie administration’s decision to re-hire the PricewaterhouseCoopers (PwC) accounting firm to conduct a further evaluation of NHI’s likely costs, the MAB said numerous “unknowns” surrounded the Government’s proposed healthcare model.

It added that the proposed NHI payment system threatened to turn Bahamian doctors and physicians into financial managers and cost administrators, a development that would compromise the delivery of high-quality healthcare.

And the MAB’s letter was especially strident in warning that the public health system represented “the Achilles heel of NHI”, given that little attention had been paid to deep-rooted problems of “underfunding”, high waste and inefficiency and the complete absence of accountability.

It then criticises the Government for “largely ignoring” the recommendations coming from the committee appointed last year to advise on strengthening the public health sector, saying little had been done towards this goal despite NHI implementation being less than three months’ away.

Bahamian doctors and physicians have thus joined their private health insurer counterparts in pushing back against the Government’s proposed NHI scheme. The combined opposition of these two groups, both of whom will play a key role if the scheme is to be successfully implemented come January 1, 2016, raises significant doubts as to whether this objective can be achieved.

“The MAB has grave concern regarding the proposed costing of the NHI plan,” the letter to the Prime Minister, seen by Tribune Business, reads.

“The proposed plan is to be implemented with no new taxes or contributions, and totally financed by the Consolidated Fund. We question the sustainability of such a programme given the current costing and the financing mechanism.

“We express concern that any underestimation of the cost will lead to an underfunded system which would compromise the effective delivery and accessibility to quality care, resulting in increased mortality and morbidity.”

The MAB’s letter backs the concerns expressed by the Bahamas Insurance Association (BIA) that the Government is wildly underestimating NHI’s costs for even the Vital Benefits Package, which represents the basic level of coverage that will be offered by the scheme.

This has already led to frequent clashes between the BIA and Sanigest Internacional, the Costa Rican consultants hired by the Government to devise and implement NHI.

The BIA has argued that the scheme will cost $947.3 million to implement, producing a sharp riposte from Sanigest president, James Cercone, who accused it of “comparing apples with oranges” because it had based its estimates on Aruba’s Expanded Benefits Package - not the smaller, less costly Vital Benefits Package that NHI will initially employ.

The Government has applied a $400 million price tag to the Vital Benefits Package, which it expects to finance from existing tax revenues in its Consolidated Fund and the ‘re-purposing’ of existing spending.

Mr Cercone previously told Tribune Business that the $400 million would come from the $260 million allocated to the Public Hospitals Authority (PHA) in the 2015-2016 Budget; the $30-$40 million received by the Department of Public Health; and the $60-$70 million currently spent by the Government on insurance premiums for civil servants and public sector workers.

The BIA last week again accused Sanigest and the Government of “misrepresenting the cost” associated with NHI, and suggested that the $640 million ‘gap’ between its estimates and those of Sanigest would lead to increased deficit spending to bridge it.

While not going that far, the MAB joined the BIA in backing the Government’s decision to re-hire PwC to conduct an “independent assessment” of NHI’s costing. And, like its private sector counterpart, it called for the accounting firm’s report to be provided to it.

Meanwhile, the MAB also expressed concern over the Patient Centre Medical Home (PCMH) model that NHI is striving to create in the Bahamas.

It added that this was a relatively new healthcare model, and its benefits in terms of quality, patient experience and other indicators was “largely unknown”.

“There is currently no evidence to support the development of PCMH in the Bahamas, and the MAB proposes that pilot projects should be conducted to validate their use,” the letter to the Prime Minister said. “The implementation of new health care services must be culturally relevant, and must take into consideration the geographic distribution of our islands.”

More fears were expressed over NHI’s ‘capitation’ payment system, which bundles payments to physicians together. This, the MAB said, would require Bahamian physicians to manage a network of healthcare providers, while also being responsible for monitoring treatment quality and patient use.

“The essence of capitation is a shift in financial risk from insurers to providers. As previously mentioned, one of the components of quality is the separation of financial and clinical decisions,” the MAB said.

“Therefore, high quality care must allow for financially-neutral clinical decision making. The MAB strongly objects to the current model as proposed, as we believe that it will force us into the administration of cost rather than the delivery of care.”

The MAB warned that when a similar system was implemented in California in the 1990s, it caused “significant financial collapse and created enormous tension within the health care community that disrupted care to thousands of patients”.

“This model, while empirically has some merit, it may not be culturally appropriate for the way health care is delivered in the Bahamas, and we fear that it may be more disruptive and lead to delivery of inferior quality of care,” the MAB warned.

“We therefore reject the proposed medical home structure. We suggest a partnership approach to care that engages the health provider and individual patients and their families.”

Then, pointing out that high quality healthcare was dependent on the organisation of the institutions delivering it, the MAB added: “We have said repeatedly that the Achilles heel of NHI will be the care offered in the public system.

“When NHI was conceptualised it was envisioned that significant health system strengthening will be required to properly address the access to care concerns. The current system suffers from being underfunded; poorly managed, leading to significant inefficiencies and wastage; and a pervasive culture of no accountability. The primary reason for this is that services are poorly organised and infrastructural capacity is lacking.”

Backing the work done by the Health System Strengthening Committee, which was part of the original NHI structure, the MAB said: “It appears that their recommendations have been largely ignored, and no significant changes to the health system have been implemented.

“We firmly believe that these recommendations should be carried out prior to the implementation of NHI. NHI cannot proceed without an electronic medical record system for integration and co-ordination of care. We cannot compromise quality and miss an opportunity to dramatically change our health care system.

“An alternate means of financing will not solve the gaps in our health care system without first addressing the fundamentals that are necessary to improve the health of our nation.”

Sanigest’s Mr Cercone himself admitted during a 2014 presentation to the Bahamas Institute of Chartered Accountants (BICA) that NHI’s implementation would not succeed without the existing public sector health system - inclusive of Princess Margaret Hospital and the various clinics - being strengthened.

The Government allocated an extra $60 million in the 2015-23016 Budget for supposed public health sector strengthening, although to-date it is difficult to determine what has been done or how this money has been spent.

The MAB’s letter, meanwhile, also called for the creation of a Patient’s Bill of Rights that it wanted to work with the Government on, developing a “list of guarantees for those receiving medical treatment”.

As with the BIA, the MAB also backed the concept of universal health coverage, although not the Government’s preferred method of achieving this - financing it through the current NHI version.

“The MAB looks forward to its continued active participation in designing and implementing the proposed National Health Insurance scheme,” the letter to the Prime Minister read.

“It is our intent to advance a plan that is sustainable and provides the best quality care in the national interest of our patients, and has its principles rooted in the ‘Doctor-Patient’ relationship.”