The Tribune

By NEIL HARTNELL

Tribune Business Editor

nhartnell@tribunemedia.net

Doctors have warned that the Government’s National Health Insurance (NHI) scheme will remove all incentive for them to invest in new equipment and expanded practices, turning them into cost-cutting machines and undermining healthcare quality.

Several practitioners, speaking on condition of anonymity, told Tribune Business that the meeting between the Government’s NHI Secretariat and medical profession a week ago Saturday “didn’t get down to brass tacks” in terms of how the scheme will operate in practice.

Those present suggested that the meeting was designed to create a ‘feel good’ atmosphere among doctors that the Government was listening to their concerns and altering NHI’s design to meet them.

However, this newspaper was told the meeting dealt with just 11 out of 53 questions raised by family medical and primary care providers. As a result, several doctors said they left the meeting none the wiser as to how NHI will work.

James Cercone, president of Sanigest Internacional, the Government’s lead NHI consultants, listed “nearly 30 changes” made to NHI as a result of feedback from the medical profession and other stakeholders.

His presentation, which has been obtained by Tribune Business, said doctors could opt out of both NHI’s preferred care and payment models.

It says doctors can receive fee-based payments, rather than the proposed capitation method, which gives them a set fee for each patient per annum. And they can remain sole practitioners, rather than embrace the Government’s Patient Centre Medical Home (PCMH) model.

Mr Cercone’s presentation also said the Government had reviewed and adjusted the proposed $212 per head capitation fee, which would be increased based on factors such as practice location and the patient population’s assessed health risks.

As a result, the capitation rate paid per patient will now range from a low of $180 to a high of $325, with doctors able to earn a further 5-10 per cent on top of that if they meet certain quality and performance-based standards.

Many doctors, though, remain distinctly unimpressed with NHI, not least because they fear the proposed design will undermine the quality of care enjoyed by their existing patients.

“If you look at the changes, they were not substantial changes. They were fluffy changes,” one doctor said on the 30 alterations listed by Mr Cercone’s presentation.

“They’re saying you can make anywhere from $180 to $325, but the $300-something is almost impossible to obtain. The criteria you have to meet, it’s almost impossible for any clinic in the Bahamas to meet, in terms of staffing and community health-based initiatives.

“The money they’re throwing at you, it’s not worth it for what you have to do.”

Mr Cercone’s presentation, meanwhile, said the PricewaterhouseCoopers (PwC) accounting firm had “confirmed original estimates” that a $100 million allocation from the Government’s consolidated fund would be sufficient to finance the first year of NHI primary care.

The doctor, speaking on condition of anonymity, added: “They have $100 million, end of story, and they’re going to make us fit into this vision of how to pay doctors, end of story.

“You know what the inevitable is in healthcare right now? Cut your costs, and spend less time with your patients.

“Instead of expanding your practice, buying more equipment and employing more nurses and support staff, you’re talking about cutting, cutting, cutting your costs,” they continued.

“Try as much as we can, that’s what happened in Canada and the UK with the National Health Service (NHS). Don’t think that’s not going to happen here.”

Sanigest’s Mr Cercone indicated to Tribune Business last August that the NHI model is one that will switch doctors from being a low volume/high margin business to one based on greater patient volumes and lower prices.

His recent presentation reveals that the Government has dropped its demands that private doctors take on 5,000 patients under NHI to a maximum 2,500, but reduced prices are still very much what is being demanded.

One doctor told Tribune Business that the cost of a so-called ‘intermediate office visit’, which was referenced in Mr Cercone’s presentation, will drop from the current $168 to $89 under NHI - a 47 per cent decrease.

They added that their increased patient population, and greater healthcare demand given the mistaken perception that NHI is free, would likely reduce the time doctors could spend with each patient.

This, combined with lower practice investment as a result of reduced income, threatens to lower healthcare quality for all Bahamians.

“There’s some things you have to spend money on,” the doctor said. “We have to invest in technology and equipment that makes healthcare better.

“It’s not that doctors make this equipment and sell it to the public at exorbitant rates. This stuff is not cheap.”

Pointing out that a Bahamian colleague had recently invested $80,000 in ultrasound equipment, the doctor said: “I spent $30,000 on an x-ray machine several years ago, and I’ve not seen enough patients to maintain it.

“I’ve not broken even on it, but if I didn’t do it, I will not not have good patient care. It’s not about making money; it’s about seeing patients with good equipment.”

“It was ridiculous,” was how another doctor described the meeting between the profession and NHI Secretariat.

“They keep coming back to capitation. We’d all be taking a 60 per cent pay cut on everything we do. They’re trying to cap the dollars. It’s now to the point where we’re being pushed against the wall.”

Mr Cercone’s presentation effectively confirmed that doctors will have to become financial managers and administrators under NHI, something the Medical Association of the Bahamas (MAB) previously warned could compromise patient care quality.

“As primary health care providers take on more managerial independence and responsibility, they must perform a set of core finance and management functions,” the presentation said. “General management, financial management, information system and human resources.”

Another doctor, meanwhile, accused the Government of “not being honest” about what NHI will ultimately cost the Bahamian people and employers.

In a paper sent to Tribune Business, they estimated that the scheme will cost more than $1 billion when fully rolled-out - a figure in line with previous forecasts by the Bahamas Insurance Association (BIA).

“The Government is not being honest with people about the full cost of a fully implemented national health insurance scheme,” they wrote, on condition of anonymity.

“Based on the cost of systems in the United States, Canada and the United Kingdom, we can expect the Government portion of spending to exceed $1 billion. This is over 50 per cent of the current national Budget.

“The money will have to be found to close the budgetary gap, which will need to be in excess of the amount of money made for government by the current VAT tax. Such an increase in taxes will have recessionary pressure on the economy.”

Pointing out that the Government was still running fiscal deficits on a $1.8 billion budget despite VAT’s introduction, the doctor said any new taxes required to pay for NHI would further erode living standards for thousands of working Bahamians - especially in the current low growth economic environment.