The Tribune

By DR KENNETH D KEMP

ON a daily basis, I meet and interact with patients from all walks of life. Last week, I wrote about how a friend from an affluent background complained about the rising price of water lilies, which she needed to purchase for the Koi Pond in her garden. Within hours of that conversation, I was speaking to a patient frantic with worry over the rising cost of health insurance and with good reason. His health was ailing and both he and his wife visited their doctors with greater frequency and urgency but neither could afford to do so privately for much longer. How would they survive with any quality of life if they had to ignore medical care because of the burden of maintaining health insurance? It is unfortunately, dinner table conversation for many people throughout our nation and I suspect more widely throughout the Caribbean archipelago.

More can be said about the dichotomy between the have and the have nots and the grandiosity versus commonality of their concerns, but I made the analogy that health insurance was much like water lilies, not essential for life but the coverage allowed the entity under its protection to thrive better than without. In both circumstances, the burgeoning costs of either forced even those able to afford it and still fully aware of its essentiality, to question their affiliation.

Individuals can have health insurance their entire life and rarely require it but over time as they near retirement, their payments increase and it becomes too expensive to maintain. On the flip side, insurance companies feel that they’re doing the best they can to minimize increases while faced with their own inflationary costs, which they pass on to the patient. But I believe we’re nearing a tipping point. Across the board inflation has tightened purse strings for the average consumer and half the Bahamian population either never had or no longer enjoys health insurance coverage.

One important factor in this triangular equation that I didn’t mention in last week’s column, however, is the doctor. So, perhaps today I can shed some light on the inverse relationship between doctors and insurance companies and how that directly affects patients and, more specifically, their wallets.

When a doctor opens a clinic and signs on to be a health care provider with various insurance companies, a contract is signed stating, among other things, that he or she or their practice will accept whatever the insurer pays once a claim has been submitted and outside of their obligated co-payments, they won’t go after the patient for the balance. Hospitals, incidentally, are not beholden to this contractual arrangement. So, to ensure that pricing remains fair and equitable across medical professionals, we follow the physicians fee reference book, which is a standard fee guide produced in the US annually since 1983. Using that book, we’re able to determine the lower to upper limits of what should be charged for an examination and procedure. Insurance companies have access to the same book and use it to guide their reimbursement policies.

Where the first break-down occurs is that every year, the fee guide is adjusted to account for inflation based on changing costs for supplies, equipment and instrumentation but most local insurers continually pay according to a fee reference book that was published several years ago. So, when they state that physician charges were above usual, reasonable and customary fee limits it’s more often than not based on fee limits from an outdated fee guide.

The best analogy I’ve ever read that describes billing as a private physician was written over a decade ago by Dr. Megan Lewis, a renowned family physician practising in rural Colorado. She asked the reader to imagine if the restaurant industry started accepting insurance. Customers would pay the restaurant insurance company and get a subscriber’s card to use at a list of restaurants in their portfolio. To dine at the restaurant of your choice, you’d only have to pay a small co-payment. But before the change, dining was pleasant and now it feels rushed and the quality of the food served was no longer on the same par as previous experiences.

Behind the scenes, Dr. Lewis explains that the restaurant owner sent a bill for a patient’s meal of let’s say $75 but at first, the insurer rejects payment because of a coding error. The restaurant didn’t list all the components of the meal by numerical code and no suggestions for the correct code are offered. To rectify it, the owner uses a coding book and notices that he incorrectly used the code for a dinner salad and not a main course salad. The error is corrected and re-submitted.

In response to that, the insurer requests more information, such as why garlic was used and if the restaurant had requested permission from the insurer to use garlic before the meal was served. They request the full recipe with details of the preparation be submitted. Law mandates that the restaurant get permission from the customer before submitting any details pertaining to the meal served to the customer. Over a month goes by and the insurer finally pays the restaurant $20 for the $75 priced-meal with no explanation, deciding arbitrarily that the meal was over-priced. Then to top it off, there’s the understanding that the customer has already paid their $5 co-pay so you can’t ask them for the balance.

Another element to this is the government 10% Value Added Tax (VAT) on all goods and services. As in the scenario above, the bill was $75 and the physician ultimately collected $25 in payment but in healthcare, VAT has to be paid on the full amount that the physician billed and not what he or she collected. Multiply that loss by the number of patients seen per year and the net loss is significant. Even further, not only are you taxed on the full amount billed, but by the time of VAT filing, there’s a good chance that you haven’t been reimbursed for the patients you saw during the filing period. There is an opportunity to seek reimbursement or credit for future filings but the process is more onerous than accommodating, and certainly more cumbersome than necessary.

Physicians who are incapable of surviving on co-payments, often forced to wait months for slashed insurance reimbursements, find it challenging to keep their doors open. So, they offset costs by working for the government or moonlighting at multiple clinics to garner a steadier pay cheque. In other cases, they charge reduced fees for the uninsured who pay faster, but less.

Medical practice in other countries is generally far more lucrative than it is in The Bahamas. “My daughter, the doctor,” is a mother’s proud cry in the US whereas in The Bahamas, “my daughter the doctor” is more likely to mean she will live at home post-degree and internship until she marries, will struggle to survive the first few years of practice when she finally is permitted to enter private practice and may even have to turn to family for bridge funding.

Ironically, The Bahamas benefits from the lucrative practice of medicine elsewhere with many physicians, surgeons and hospital executives choosing our country for their second home.

In The Bahamas, most physicians enter the profession out of dedication, seeking the reward of healing. That is not to say that North American or South American doctors are not interested in healing. Of course, they are. But they also know it comes with financial reward. Many of our younger or newer physicians who work extra shifts wind up stressed and tested by financial pressure and exhausted by the additional hours to stay afloat.

With that said, insurance companies aren’t filled with greedy, uncaring monsters. On the contrary, they employ beloved family members and friends who like physicians, want to see the needs of patients met as quickly and affordably as possible. It remains to be seen if or how National Health Insurance will in the long-term assist in this effort or counter some of the concerns. In the very least, it does offer an opportunity for more individuals to feel comfortable seeking health care.

The administration of health care is complicated for the insurance company, the physician and most importantly the patient, who in the end has the most to lose. To date, there remain no easy solutions so once again I implore patients to engage in healthy eating habits and exercise routines so they don’t have to visit the doctor as frequently. Take your health into your own hands because prevention is always better than attempting to find a cure.

Water lilies no longer simply beautify water gardens and offer protection to Koi fish. They are now being used as a medicinal ingredient to help regulate insulin levels and promote liver health, which may account for its rising prices. If even wealthy individuals now lament the rising cost of a luxury item, imagine how difficult it must be for everyday individuals to comprehend how to afford the insurance that could possibly save their life. Rising prices affect us all, but none more so than those who need or provide medical care. We are in this together. The need did not end when the pandemic ended. We simply turned another page in the complex world of survival.

This is The KDK Report.

• Nicknamed ‘The Prince of Podiatry’, Dr Kenneth D Kemp is the founder and medical director of Bahamas Foot and Ankle located in Caves Village, Western New Providence. He served as the deputy chairman for the Health Council for five years and he currently sits on the board of directors for the Princess Margaret Hospital Foundation in his role as co-vice-chairman.