The Tribune

By NEIL HARTNELL

Tribune Business Editor

nhartnell@tribunemedia.net

The minister of health has pledged to seek “common ground” with Bahamian private doctors who have urged the Government to “hit the pause button” over its proposed National Health Insurance (NHI) reforms.

Dr Michael Darville, responding to the Medical Association of The Bahamas (MAB) statement that it “cannot support the Bill” recently tabled in the House of Assembly, told Tribune Business it was made clear that the legislation was “not set in stone” when he introduced it.

He reiterated in a written statement subsequently issued to this newspaper that the NHI Bill is “by no means is in its final form, and sought to ease the concerns of the MAB and its members about not being consulted by asserting: “It is critical that the widest consultation is given for the benefit of the Bahamian people.”

The MAB, in a statement first reported by the newspaper, warned that the legislation “must not be rushed” while adding that NHI must get physician compensation correct. It added that the powers granted to the NHI Authority - the body charged with overseeing the scheme - were “simply too wide-reaching” and could infringe on the rights of both patients and medical providers, with the Government looking at “a deep dive into socialised healthcare through NHI”.

Dr Darville, striking a conciliatory tone, pointed out that there had been a series of consultative meetings held between the NHI Authority and the MAB over the new NHI Bill in early October. “We have to do more consultation,” he told this newspaper. “When I laid the Bill, I said we would be going into more consultation. There’s a bit of wiggling room, and we recognise working with the Authority there’s work to do in communicating on the way it’s been put together.

“We’ve had consultants guiding us through the process. We knew capitation - that, perhaps, would be a sensitive issue for further discussion. What I laid was not set in stone, and we’ll go back to the Association and see what common ground we can find.”

Dr Darville did not identify the consultants he was referring to. However, the NHI Authority’s 2021 annual report reveals that the KPMG accounting firm earned some $4.663m for providing consultancy services to the scheme over a two-year period. 

“The Authority has entered into various engagements with KPMG with respect to the NHI project, which includes [among other things] support for implementing and operationalising of the new policy, project management of the EHR (electronic health records) solution, and advice and assistance for the amendments to the NHI Act 2016,” the annual report said. KPMG was paid some $1.769m in 2020, and a further $2.894m in 2021.

Meanwhile, Dr Darville added of the MAB position: “We take it very seriously, which means we will definitely have to go back to the drawing board... I wouldn’t say drawing board, but we will have further consultation and see if we can work out more of the sensitive issues for the benefit of the Bahamian people.

“The consultation is ongoing, because when I laid that Bill I made clear there would be further discussions. The consultations will continue, and if they are still uncomfortable we will need to figure out where we can find this common ground.”

The NHI Bill laid in the House of Assembly last month by Dr Darville, and which will repeal and replace the existing 2016 Act, aims to make the scheme’s Standard Health Benefit the minimum level of insured medical care for all Bahamians whether they are covered by private insurers or NHI.

Doctors spoken to by this newspaper have argued that the legislation seeks to introduce price controls, similar to those that have rocked the food and pharmaceutical industries in recent weeks, by capping or setting limits on how much they and private health insurers can charge for providing Standard Health Benefit services via fees and premiums respectively.

NHI currently pays its doctors and medical providers using the capitation method, whereby they receive a risk-adjusted sum for each patient allocated to them per month regardless of how often they see the physician or volume of services provided. Private doctors, though, fear this method could result in reimbursement failing to properly cover their expenses associated with providing such care.

Such concerns were detailed in an October 20, 2022, letter sent to Dr Cindy Dorsett, the MAB’s president, by Christy Butler, the NHI Authority’s chief executive. Described as a summary of the Authority’s three consultation meetings on the new Bill, which were held between October 6-October 13 and attended by more than 160 doctors, Ms Butler pledged to review NHI’s capitation rates for doctors and ensure they are competitive.

“Inquiries about the current payment system were also raised on various occasions,” she wrote on the meetings via a letter which has been obtained by Tribune Business. “Most of the questions involved the NHI Authority’s capitation payment system for primary care providers, whereby providers are paid a set monthly fee for every patient actively rostered to them.

“One of the key advantages of the capitated payment system is providing a predictable and stable revenue base for providers, since fees will not depend on the number of patient visits. Capitation payment is widely recognised as the best form of reimbursement for primary care services.”

Nevertheless, she later wrote that the capitation rates were among the issues “warranting ongoing review and potential changes”. Ms Butler added: “The NHI Authority recognises recent economic uncertainty, and commits to ensuring competitive capitation rates for providers now and in the future to ensure a broad participation of providers across country to meet the needs of beneficiaries.

“We intend to take an evidence-based approach to re-evaluate rates and compare across separate jurisdictions to ensure fair remuneration for physicians, based on service utilisation.” Without the co-operation and active involvement of doctors and the wider private healthcare industry, the Government’s ambitions to expand NHI will struggle to gain lift-off.

“The NHI Authority also plans to monitor the existing cap on panel sizes for full-time providers, which currently is 2,000 beneficiaries for those working 42 hours per week committed to NHI,” Ms Butler said. “While our priority continues to be ensuring high quality patient care and access, we are committed to evaluating other alternatives to the current approach. We will continue to engage the MAB as we evaluate new models of care which provide opportunities to expand roster sizes.”

Dr Darville, in his statement, described the new Bill as “another critical step in upholding the Government’s commitment to the transformation of the Bahamian healthcare system and pursuit of universal health coverage as laid out in our Blueprint for Change”.

“All Bahamians deserve a robust and modern healthcare system that puts them at the centre of every decision and, as a result, prioritises the need for expanded access to quality services. The amendment of the NHI Act along with other health system reforms are being undertaken in the best interest of the Bahamian people,” he said, pointing to the fact that some 140,000 persons now access medical services via NHI.

Calling on the MAB “to partner with us and provide a formal response on the Bill, and future plans for the healthcare system”, Dr Darville added: “The Medical Association of the Bahamas, as a key stakeholder, has been included throughout the evolution of the NHI Bahamas programme with a seat at the table via the NHI Board of Directors and the legislative reform process will prove no different....

“Our parliamentary process promotes full engagement. For clarity, when a Bill is tabled and read for the first time, the Speaker orders the Bill to be printed and the Bill is circulated to all Members of Parliament and the public. After debate in the House, a committee of the House will have a further opportunity to amend or delay the Bill.

“In essence, the Bill continues in its consultative process with all major stakeholders. The NHI Bill is by no means is in its final form. It is critical that the widest consultation is given for the benefit of the Bahamian people.”