The Tribune

Health care is essential, a fundamental right, good - and extremely expensive. With the latest National Health Insurance scheme set for implementation at the start of next year, Dr Robin Roberts sets out what is at stake and urges Bahamians - the people who matter most - to engage in the debate and make their views known.

The Government has declared that it will implement the National Health Insurance scheme in January 2016.

There is much activity already around this major health care reform: the ‘consultants’ have been summoned and recommendations submitted to the Cabinet. Stakeholders are being engaged. Committees have been formed, members appointed and meetings ongoing. The Government means business.

As a senior member of the medical community, I have been invited to participate and, I would like to believe, be actively involved in this process. It’s a difficult undertaking, a major task. I hope we do it better this time and propose a plan we can all buy into.

The cost of health care in The Bahamas is high and many can’t afford to pay for private care. The political mantra is that no one can be denied care in government institutions because of an inability to pay. So people are flocking there and the hospitals are bursting at the seams. The care available is limited and the wait times are too long. Those who need care can’t get it as needed, when needed, and those who need more, can’t get more.

In this major reform of the health care system to fit the health care needs of the populace, the greatest stakeholder is the public. My concern is, and always has been, that while there are those feverishly working to get it right, the public has not yet been engaged to have their voices heard.

Considering the clamour on the gambling referendum and the gender constitutional issues, I anticipate that the screams and the sparks would fly, as citizens from the newborn to the retirees, need and want to have their say.

I am seeking to jump-start the process and propose a framework for discussion on this complex issue. This requires an appreciation of the issues involved. In this series in The Tribune this week, I will attempt to do just that.

To start with, I am defining the numerous and complex issues that need to be discussed in preparation for this national undertaking.

High cost of health care

The Government spends a lot of money on providing health care; it’s an essential service, a must for everyone. This spending applies for all, the young and the old and those in between. For the sick and the healthy, the Government spends 15 cents of every dollar earned to provide health care services for all Bahamians when they need it. But, this is not enough.

• For non-emergencies, it could take months to get an appointment to see the doctor in the Government services. The booking times for clinic appointments are too long; in some clinics it’s a three- to six-month wait.

• The waiting times in the clinics to see the doctor are too long; some patients come from 7am just to ensure that they see the doctor for the 1pm clinic. Some may still be turned away because of clinic overbookings; even 7am may not be early enough.

• Emergency visitors fare no better - all day and all night, people seek and await medical attention for hours. Some will tell you they wait in excess of 24 hours for care in the Accident and Emergency Department at the Princess Margaret Hospital.

• People can’t be admitted to hospitals. All the wards are overcrowded, all the beds are occupied, patients are on stretchers filling the aisles wherever there are extra spaces. In some wards, patient bed occupancy exceeds 100 per cent almost every day of the year.

• Surgery wait times could be six months or more and then, on the day of admission, the patient cannot be admitted because there are no beds available in the hospital. It’s a several months wait.

• People get sicker waiting. Some die in the process.

We need more clinics, a bigger Emergency Department, more surgical operating rooms, more hospital beds, more doctors, and nurses. The Government needs more money to provide more efficient and effective health care services.

Then there are those services that we don’t have in the pubic sector, that patients must seek outside the realm of the government-owned facilities, such as Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET) scan, nuclear medicine, open heart surgery and radiation services. We need capital funds for these new major developments. Advances in medicine are dynamic; new discoveries occur every day, all promising us better and longer lives. But funds for capital development for expanding health and creating new services are very limited; the budget pessimists claim there is no more money available.

There is no question about it; we need more funds desperately if we are to keep pace with modern medical advances and bettering the lives of Bahamians.

The critics protest ‘the issue is not increasing our resource capacity’. ‘Too much is spent on sickness’. We should be focused on prevention: “An ounce of prevention is worth a pound of cure.” Advancing health education, health promotion and wellness programmes, inculcating healthy lifestyles would result in tremendous savings in health care spending.

But we need money for prevention too. The expense of staying healthy can be just as high as the expense of sickness. A healthy diet of fruits, vegetables, low fat and low carbohydrate foods does not come cheap. Membership for gyms and tennis clubs also comes with a price. A national health promotion and education programme is a costly undertaking. Suffice it to say, there is a need for much more money. Government needs more money to provide improved and expanded health care services; what we have is not enough.

The Bahamas is not alone. The high cost of providing adequate health care services is a global challenge. In the Organisation of Economic Co-operation and Development (OECD) countries, the governments spend on average about $3,500 per person annually; the United States spends twice as much. By comparison, The Bahamas government spends an estimated $2,000 per person per annum. The Bahamas still has a long way to go in health care spending - there is a lot of spending yet to do. The money, however, is just not there. The pertinent questions to ask: Are we getting our money’s worth? Are we getting value for what we do spend? The evidence suggests we certainly are not.

Paying for

health care

So how do other countries pay for health care for their residents? Do we have to reinvent the wheel? We certainly get a better appreciation of how to do this if we take a glance at providing for health care from the historical perspective.

After industrialisation in the 19th century and even more so after World War Two, welfare programmes emerged and became a staple of national development. Health care became a societal good. The debate of health care as a right of all citizens or not, in today’s world, is moot. There is a collective persuasion that health care delivery should meet the criteria of the five As:

• Accessibility: the right or opportunity to receive health services

• Availability: all resources required would be supplied

• Affordability: can be readily purchased individually and/or collectively

• Appropriateness: the right care for the right problem

• All the people: universal - provided for all citizens and residents.

This collective responsibility is a challenge but it was not insurmountable. The options reflect three basic principles: where will the money come from, how will it be collected, how will it be paid out and what should we be paying for?

Who is going to pay for the health care services being delivered - the Government, the individual or will it be a third party payer, a private insurance company or a government corporation? Could it be a combination of these?

How will the money be collected to pay for the care and who will collect it - will it be done via general taxation or via dedicated health insurance funds deducted directly from wages? Can patients pay directly out of pocket as medical care is needed?

How are providers to be paid - will it be via a single payer system or via dedicated insurance entities? Will it be paid as the service is being provided - fee for service? Or will the providers be pre-paid and then held accountable for the service delivered? Could they be full-time government employees versus independent service providers contracted individually or collectively? Or can services be outsourced and paid for collectively?

It has become quite evident as medicine advances, the options for diagnosing and treating illness have become a compendium of choices. The physicians outline the shopping lists and the patient selects: which X-rays or laboratory tests? Should it be the minimally invasive or the traditional open type, or should it be surgery at all? There is a blurred line between what is needed versus what is wanted. The former is referred to as essential services and defining this list is a national debate. In the US, the Oregon state health care plan was predicated on the list of diseases the population voted to be essential, and thus the government would pay the providers to take care of these diseases.

The funding elements highlight two other issues for debate in paying for health care as a national directive: Who should own the health care services? Should health care be solely a government-owned entity or should it be solely privately owned? If private owned, should the owners be for-profit or non-for profit entrepreneurs?

Who owns and who pays are intimately involved; “he who pays the piper calls the tune.”

As a collective good, what should be the fundamental role of Government in the provision of health care? There are those who contend that Government’s role should be as a regulator only and health care delivery should be privately owned, administered and funded. Governments do not have a stellar record in running things. At the other end of the spectrum, there is the philosophy that by the very nature of being a fundamental right of all people with equal access and availability when in need of health care, it should be solely owned and administered by the Government and funded from the public purse. In between are the various combinations of who and how to fund, collect and pay, and who should deliver and who is accountable and for what.

The truth be known, paying for health care reflects the values of a people. It sits within the revered halls of our belief systems like religion. Who should dictate and be responsible for our healthy lifestyle choices? When, what and how much to eat? When, if and how to exercise? If, when, where and who should determine our/choices to access health care providers? Health as a collective responsibility for individual rights and choices - no other public issue could be more controversial than this essential human need.

The first national effort to address and conclude the health care issue as a public need in a collective effort to provide equal access and availability for all and to be implemented was introduced in Germany in 1883. Britain did so 65 years later, Canada in 1973. The US had a vicious national debate as the Accountable Care Act was introduced in 2013; the efforts to undermine and overturn it had to be settled by the Supreme Court. Legislators are still seeking to have it overturned.

The Bahamas government introduced a national health insurance scheme in 1988 and 2008. Have we really had a debate as to what is best for Bahamians? Have we really had a say and input, or has government in its usual way as the representative of the people, decided what is best for us? Is this what Bahamians want? If not, we must act fast - the government has set a target for its implementation: January 2016.

But before we tackle this issue of the national design of a health care system for The Bahamas, it is imperative that we address first the issue of the high costs of health care. Health care is good - but damned expensive. The constant mathematical factor to the health care design equation is its costs, how much we have to spend and what we can afford. There is only so much we can spend; there are other essential services like education, transportation and housing that we have to pay for too. “If wishes were horses, beggars would ride.”

The costs of health care

At the time of introduction of national health insurance schemes in the 19th and 20th centuries, the cost of medical services could be defined and contained.

There were the fixed costs, attributed to our investments in:

• technology and pharmaceuticals, the two major drivers of the costs of health care services and;

• education in our human resource development in health: doctors, nurses, allied health practitioners, health managers and administrators. Health care providers make huge financial investments and commitments in their education; reimbursing their services is costly.

There were the variable costs:

• The frequency and amount of services needed to diagnose and treat diseases, the so-called utilisation of services. This is particularly noticeable in our elderly population - the reality is that as we age, we incur more diseases.

Nowhere was this more noted than at the time of the original Beveridge Manifesto for introducing the National Health Service (NHS) in Great Britain in the 1940s. Sir William Beveridge believed that the NHS would defeat one of five “Giant Evils”. As better health services became readily accessed and available for all with no fees to pay, more people would be healthy; the disease burden and the costs of care would decrease. Within two years of introducing the NHS, the plan was heading for bankruptcy and fees had to be introduced.

The high cost of health care per se, however, is only a small part of the funding issue. It’s how fast it’s increasing. Medical care cost is increasing at an exponential rate, higher than the rate of inflation, and it’s doing so at the expense of other goods and services in the country.

This high and increasing, unbridled cost of health care services has become the central issue in health care, in every country and in every jurisdiction. It’s a political hot bed, representing the key issue on every political agenda. A plausible solution to funding health care defines a political platform and the politicians’ career; take note of President Barack Obama, President Bill Clinton or Prime Minister Tony Blair.

With the introduction of these national health funded schemes in recognition of this public good and hence, so should be funded, the current health care issues of high and mounting health costs were not as problematic then as it is currently. For those were the times when choices were few and the “doctor knew best”.

Medicine has changed - every facet of it. It happened in our lifetimes, right in front our faces.

• Medical education has changed, both in content and process, there is so much more to know. There are specialists, subspecialists and super specialists;

• The practice of medicine has changed: doctors no longer know best and are held accountable for every action; malpractice is rampant, two out of every three doctors in the US have been sued at least once. In a 2011 New England Journal of Medicine study, 75 per cent of physicians practising in a low-risk specialty will have been sued by the age of 65, 19 per cent will have made an indemnity payment. For those in the high risk specialties, 99 per cent will have been sued by 65, and 71 per cent will have lost.

• The patients have changed: they are more knowledgeable and seek to direct their care. Doctors no longer dictate but inform and patients choose their options.

• A new perspective of medicine has emerged: it is consumer and industry driven and the laws of supply and demand economics and monopolies have inculcated the everyday language managing health services. The facts are that medicine has become commercialised. In the US, the burden of change has proven too much for some doctors; feeling a loss of control of the profession and their practice, many have sold their practices, some have quit.

In developing countries, many have yet to acknowledge that these changes have occurred; access and availability of health care still eludes them. They pay an additional price - the medical care providers - their nurses, doctors and allied health professionals are migrating to the developed countries for better working conditions and quality of life. Brain drain is a reality. In a 2009 study, Brain Drain and Caribbean-EU Labour Mobility from the Shridath Ramphal Centre for International Trade Law, Policy and Services in Barbados, the Caribbean region is reported to have some of the highest brain drain levels in the world. On a regional scale, on average more than 65 per cent of CARICOM nationals with tertiary education migrated to the OECD countries between 1990 and 2000; some countries having emigration rates reaching over 70 per cent.

In the final analysis, we must believe that everyone desires a health care system that seeks to deliver quality health care services with continuing better outcomes and one that is financially sustainable.

To design a National Health Care Initiative for Bahamians, first we must recognise our values and the idiosyncrasies of Bahamianism.

Despite our societal ills and dysfunction, we remain a country deeply rooted in Christian principles of daily living; we are our brothers’ keepers. We believe fundamentally that health care is a right of all people and as a societal right, the government has a fundamental role to play in the delivery of health services or to ensure that individuals are guaranteed that right. In our Christian values of doing unto others as we would ourselves, we believe that the right and availability of health care services for all must be underlined by the principle of health care equity: those who need care, receive the care they need and those who need more, can get more. These values and beliefs are noble and exemplary; but they carry a heavy cost.

The second dose of reality is our deeply engrained American values that we have inherited by the very nature of being on the doorstep of the world’s largest marketplace, and with unfettered access to travel to the US. We are indoctrinated. Like them, we have become consumers of every possible commodity. We have accepted and embraced the concept that health care products and services have evolved into an industry with a multiplicity of products and production lines and with all the trappings of marketing and branding.

It is within this new dynamics of health care funding, where patients have become the purchasers of health care and the providers the sellers, financing health care takes on a new perspective.

At the turn of the new millennium, an appreciation and application of health care economics and its determinants, have emerged as the linchpin to advancing any health care delivery system or reform that seeks to deliver quality health care services with continuing better outcomes and that is financially sustainable.

Dr Robin Roberts is a consultant urologist and Director and Senior Lecturer at the University of West Indies School of Clinical Medicine and Research in The Bahamas.

TOMORROW: Designing a National Health Care initiative for Bahamians.