The Tribune

By NEIL HARTNELL

Tribune Business Editor

nhartnell@tribunemedia.net

A prominent doctor has warned the Government that its proposed National Health Insurance (NHI) reforms must not “crash private healthcare” and suffocate the “innovation and investment” that drives improved medical care.

Dr Conville Brown, principal of The Bahamas Heart Centre, Cancer Centre Bahamas and The Medical Pavilion Bahamas, told Tribune Business the Davis administration needs to balance its push for universal health care via NHI with maintaining an environment in which private health practitioners can flourish since they are the ones that drive medical advances - especially in tertiary care and complex surgeries. 

He spoke out after the Government last week tabled the National Health Insurance Bill 2022 in the House of Assembly. The legislation, which will repeal the existing NHI Act 2016, was described to this newspaper by one doctor - speaking on condition of anonymity - as the next step in the Government’s “stealth takeover of the healthcare industry since it seeks to introduce price controls similar to those currently roiling the food and pharmaceutical industries.

The Bill seeks to ensure that all Bahamians and qualifying residents have access to a minimum level of healthcare, known as the Standard Health Benefit, which includes primary healthcare services, diagnostic imaging, and screening programmes for cancer and other “specified conditions” among the services offered. However, it also seeks to dictate the premium prices that insurers can charge for the Standard Health Benefit, and the fees received by doctors.

Its section seven, entitled “powers of authority”, stipulates that the NHI Authority, the regulatory body charged with overseeing the scheme, has the power “to fIx fee schedules and payment rates for Standard Health Benefit providers (doctors and physicians”. And the same section states that the Authority can also “regulate the maximum price by approved insurers for benefits rendered under the standard health benefit”.

The fee schedules, payment rates and “maximum price” were not disclosed in the Bill. One doctor, spoken to by this newspaper yesterday, said these were equivalent to price controls and will have the same effect as those concerning food retailers/wholesalers and their pharmaceutical counterparts - that of potentially forcing physicians to provide services covered by the Standard Health Benefit at a loss if they are set too low.

“This is the Government’s stealth takeover of healthcare,” the doctor said. “That’s what they’re doing with physicians and primary care. They’re coming in and telling us as medical practitioners what to charge, and what our overhead costs are, without consulting us. They’ve never had a word with us.

“The Government is steadily positioning themselves for a takeover of the healthcare system in The Bahamas and physicians, pharmacists, allied health care professionals and the insurance industry are going to have this imposed on them if they are not careful and allow them to completely derail the system.”

Dr Duane Sands, a former minister of health and now Free National Movement (FNM) chairman, told Tribune Business that “arbitrarily applied” doctors’ fees and insurance premiums “may have totally unintended consequences” if the NHI scheme was not properly thought through, and warned: “The road to hell is paved with good intentions.”

Speaking to the Bill, he said: “There’s some concerns that have been raised as to what this means. It certainly will impact the practice options for a number of young physicians in particular. What they’re [the Government] trying to do is lock the reimbursement rates for physician encounters or medical encounters, which is fine if they cover the cost.

“If they don’t cover the cost, and we’ve seen this with the brouhaha with the food stores and pharmacies, the road to hell is paved with good intentions. For an arbitrary rate, applied for whatever good reason, may have totally unintended consequences because it doesn’t take into account everything required to run a practice, maintain a practice.

“The cost shifting that goes on in the with what happens in the public sector is not necessarily compatible with what goes on in the private sector. Let’s make some progress, but everybody that comes to the table ought to do so with clean hands and a degree of equanimity,” Dr Sands continued.

“If we pre-empt because there’s a political imperative to do so, it’s not going to get the best outcome. When you see a group of professionals say what’s going on, how is this going to impact me, that dialogue becomes critically important.”

Dr Brown, meanwhile, told this newspaper that the Government “is going to have some challenges with the medical community” over the reforms contained in the NHI Bill and what it is intending to do. He added that “the biggest issue and concern” was that Bahamian private health insurers may use the price-controlled Standard Health Benefit to “negotiate down” below cost all reimbursement rates and payments made to doctors on behalf of their insured clients.

Still, while agreeing that NHI “is very much needed” because access to quality healthcare and outcomes should not depend on whether a person has insurance or the size of their bank account, Dr Brown argued that it needed to be designed and implemented in such a way that it did not crowd out or stifle the private healthcare industry.

Warning that such an outcome would be equivalent to “dumbing down” healthcare, given that private practitioners drive the sector’s innovation and investment, he suggested that his “Partnered Care” model - effectively a public-private partnership (PPP) where his healthcare businesses provide access to services such as kidney dialysis and cancer screening at discounted rates for public sector patients - may prove a better route to take.

“The NHI system is very much needed but we have to make sure we don’t crash the medical profession,” Dr Brown told Tribune Business. “We have to make sure that folks in private practice are not getting screwed by our system.”

Pointing to Medicare, the US government initiative that provides healthcare coverage for persons aged 65 and older, he pointed out that by taking care of 50m persons that programme is able to spread its risk and costs over a much larger insured pool, thereby generating economies of scale.

The Bahamas, though, with a population estimated at 400,000 cannot achieve similar efficiencies with its own government-run NHI to that of Medicare. As a result, Dr Brown said this nation has to be careful and not design an NHI system modelled on developed countries in the belief it can emulate their best qualities.

Pointing out that most if not all healthcare advances, especially at the tertiary care and surgical level, were driven by the private sector, he added: “If you crash your private sector you’ve also crashed your ability to offer advanced services in any kind of timely manner...... That is where your innovation comes in and investment to do it. The Government generally doesn’t have the wherewithal to look at these things.

“If you kill your private sector, you kill your sophistication as well. You kill innovation, and you kill investment. People don’t even think it’s worth doing it. I always say innovation and investment smartens up a system, whereas total government takeover of a system dumbs it down. That’s not to be condescending in any way, shape or form. It’s just what happens.”

Turning to his ‘Partnered Care’ model, Dr Brown added: “I’ve been asked why I’m doing this if I can bill at a higher price. It ain’t about the dollars I’m making. We’re here to take care of people. That’s my goal; I don’t put it on anyone else. That’s what I do. The Government system lags behind contemporary developments and gets overwhelmed. It ain’t the most efficient system, which is why the UK’s NHS is in the paper every day.”