The Tribune

By NEIL HARTNELL

Tribune Business Editor

nhartnell@tribunemedia.net

Bahamians faced “waiting lines” for treatment under the initial National Health Insurance (NHI) model if costs went beyond the $400 million that the Government already spends on healthcare, Tribune Business can reveal.

A confidential report entitled ‘Full NHI Road Map Overview’, which has never been publicly disclosed, identifies many of the weaknesses and concerns raised by medical industry participants that have yet to be addressed as the Government pushes for a pre-general election roll-out.

It reveals a lengthy list of steps that must be completed if NHI is to be successfully implemented, many of which have not been initiated, and also discloses that the Government was prepared to sideline the Bahamian private health insurance industry if it failed to accept its demands.

The document, which has been obtained by Tribune Business, also concedes that the money going to patient care is “limited” because $100 million, or 25 per cent, of the Government’s healthcare spending goes on non-health expenses.

This was previously confirmed by Dr Glen Beneby, the chief medical officer (CMO), with the ‘NHI Road Map’ report also suggesting that the Bahamas will continue to throw ‘good money after bad’ unless underlying system weaknesses are fixed prior to the new scheme’s introduction.

One doctor, speaking on condition of anonymity, told Tribune Business: “They have pointed out in their own document all the flaws in the system, but they don’t look to recognise what they’ve pointed out and the steps needing to be taken to provide things correctly.”

The ‘NHI Road Map’ report, which appears to have been produced in late 2015 but remains just as relevant today, said the scheme’s launch was designed to effectively ‘cap’ annual costs at $400 million once all phases were in place.

That is the same amount that the Government presently spends on healthcare annually, and the report warned that should claims exceed this sum, Bahamians would have to endure the same “waiting lines” that exist now for non-life threatening illnesses.

“It is important to note that the structure of the NHI launch is designed to guard against significant expenditure beyond the public envelope that has been established of $400 million,” the report said, noting that this figure encompassed NHI’s full roll-out inclusive of the Vital Benefits Package.

“Why? Because the capitation [payment] model limits the potential amount that can be spent by the insurer acting as RHAs (regulated health administrators), and the only potential to have more claims in the year would be in the case of catastrophic, highly unpredictable events which would be covered by the reserve and catastrophic fund that has been proposed to meet this potential demand.

“Any other claims beyond those expected would have to be managed through waiting lists similar to the case of spending now in the PHA or Ministry of Health. The NHI launch considers that NHI manages demand and prices are known ahead of time – through nationally negotiated fee schedules for all procedures –unlike the current system where physicians and providers bill whatever fee they feel is appropriate.”

This effectively states that if the NHI architects get their estimates wrong, in terms of costs and utilisation rates, Bahamian patients may end up suffering by having to wait for essential treatment.

Tribune Business sources said the 20-page ‘NHI Road Map’ was written by James Cercone, president of the Government’s first NHI consultant, Sanigest Internacional, as an overview of where the Government was on NHI reform and the rationale for it.

It is unclear to-date how much of what he detailed has survived, but the current NHI model still seems to retain most of what is outlined in this report.

The ‘NHI Road Map’ also urged the Government to sideline the private health insurance industry and their representative, the Bahamas Insurance Association (BIA), unless they agreed to accept their new roles as envisioned by NHI.

“If no agreement is able to be reached with BIA on a move forward utilising a hybrid model within the required timeframe, it is recommended that a decision be made for the first phase that only the public [insurer] be utilised for the primary health care services phase, or that the National Health Insurance Commission could contract directly with public and private primary care providers,” the report said.

The ‘NHI Road Map’ outlined many flaws in the current healthcare system, noting that Bahamians are not receiving ‘value for money’ for the relatively high per capita spend they make on healthcare annually.

“Maternal health outcomes are well below many other Caribbean countries, lower than other countries at our economic status of a high income country, and significantly worse than countries spending much less than the average $2,300 spent nationally,” the report said.

It thus identifies that the quality of care and treatment outcomes, as opposed to access, are the main issues confronting the Bahamian healthcare system - especially in the public sector.

The ‘NHI road map’ then identified the high level of “waste and inefficiency” in the current healthcare system, which will heighten concerns that the scheme may ‘throw good money after bad’ unless structural reforms occur first.

“The more relevant question beyond that of ‘can we afford it?’ is can we not afford to introduce NHI,” the report said. “The escalating cost of chronic diseases in the country, the wastage and inefficiency, which leads to more than $60 million a year being paid to providers overseas, and to nearly $100 million in non-health expenses, which limits the money going to provide health services.

“Pushing more of those resources into providing medical care in the Bahamas will contribute to improving outcomes, increasing the revenue of Bahamian providers, reducing the costs that families often incur when travelling for medical care, and providing greater continuity of care between specialists and primary care physicians.”

The report also highlighted the need for a greater focus on preventative medicine and health education campaigns, aspects that have received little attention to-date under NHI, given the high level of chronic, non-communicable diseases (NCDs) in the Bahamas.

“Bahamians live five years less on average than those country categories described above,” the report said. “Avoidable mortality accounts for more than 700 deaths per year.

“According to WHO, the Bahamas has the highest percentage of NCD deaths for males under the age of 70 (60.3 per cent of all male NCD deaths) and a very high rate for females (47.5 per cent of all female NCD deaths, 5th of the 35 countries).”

It added that the Bahamas has the “highest prevalence of diabetes in the world”, and is the “sixth most overweight country the world”.