The Tribune

By NEIL HARTNELL

Tribune Business Editor

nhartnell@tribunemedia.net

Doctors fear the Bahamas will be left with “a dysfunctional health system” if the Government forges ahead with National Health Insurance (NHI), as the current model is plagued by funding shortfalls and threatens to increase their costs by “a minimum” 25 per cent.

Physicians spoken to by Tribune Business have disclosed that there is an $80 million ‘funding gap’ on the proposed $400 million Vital Benefits Package, the basic level of care that NHI will offer, with the Government seemingly unsure how that will be made up.

Expanding on the concerns outlined by the Medical Association of the Bahamas (MAB), they also revealed that the $250 per patient annual fee that NHI proposes to offer them as compensation is up to ‘three times’ below their estimated costs.

The doctors accused the Christie administration of “not being transparent” in how NHI’s structure will work, and suggested its description of the scheme as ‘multi-payer’ was disingenuous at best.

And they repeated the MAB’s demand for the Government to enact a Patient’s Bill of Rights, arguing that this was the only way to ensure Bahamians had ‘freedom of choice’ in being able to select their doctor and insurer under NHI.

Tribune Business has spoken to several physicians, all of whom only spoke on condition of anonymity, citing fears of ‘victimisation’ by the Government should they be seen as speaking out.

Their comments came after this newspaper understands that the MAB’s NHI sub-conmmittee met last Thursday afternoon with Peter Deveaux-Isaacs, who the Prime Minister has tapped to lead and co-ordinate the scheme’s implementation.

It appears, though, that little has occurred to-date to bridge the wide divide between the Government and the medical profession, especially when it comes to NHI’s financial sustainability and quality of care offered.

“The impact is going to be creating a dysfunctional healthcare system,” one doctor said of the current NHI model’s impact.

“We have some major challenges to the administration of healthcare, both public and private, the public being more difficult than private.

“When you go to a system where there is a lack of planning, lack of financial resources available to develop the concepts of NHI and Patient Centre Medical Home (PCMH), there is bound to be a repercussion associated with that.”

The doctor said such a ‘repercussion’ could be reduced access, quality of care or an unsustainable NHI healthcare financing system that ultimately collapses.

Another physician said that assuming the $400 million costing placed on NHI’s Vital Benefits Package by the Government’s consultants, Sanigest Internacional, was correct, it had only been able to identify $320 million in available funding.

The Vital Benefits Package is supposed to start rolling-out to NHI registrants by April 2016, but multiple doctors suggested the Government’s existing healthcare funding was short of what was required by $80 million.

“There’s this shortfall of $80 million that they’ve not been able to allocate and identify as yet,” one doctor told Tribune Business. “They’re really not sure how they’re going to get up to $400 million.”

James Cercone, Sanigest’s president, had previously told Tribune Business that the $400 million would come from the $260 million allocated to the Public Hospitals Authority (PHA) in the 2015-2016 Budget; the $30-$40 million received by the Department of Public Health; and the $60-$70 million currently spent by the Government on insurance premiums for civil servants and public sector workers.

That, though, would still leave a ‘gap’ - albeit a smaller one at around $30-$40 million. Still, MAB members told this newspaper that they had not seen any financial analyses showing how Sanigest had derived the $400 million figure.

One doctor, pointing out that total healthcare expenditure in the Bahamas was estimated at around $800 million annually, pointed to the “disparity” and questioned whether the $400 million had been obtained from “very limited resources” and information that were extrapolated into a figure for coverage of the whole Bahamian population.

Further concerns were expressed both over the method that will be used to compensate doctors under NHI, and the healthcare model the system intends to usher in.

NHI will use a capitation payment system, which pays doctors a set fee per year for each patient assigned to them, regardless of whether these people seek care.

The Government and Sanigest are proposing that the capitation fee be set at $250 per patient, a figure that is between half and three times’ less what it costs private Bahamian physicians to treat their patients annually.

Several doctors also told Tribune Business that the Christie administration was effectively putting the ‘cart before the horse’ in setting the capitation fee at $250, given that it had yet to decide which healthcare services (benefits) were to be included in the Vital Benefits Package.

“As it relates to this payment mchanism, they’re talking about a $250 capitation fee per person, per year,” one physician told Tribune Business. ‘You can’t come to me and tell me you’re going to pay me $250 per person, when I know my fixed cost is $650 per person.

“And if you have not defined the Vital Benefits Package, how can you say you will pay me $250 per person if you do not know what all the expenditures? There are so many cracks, so many things not thought through in terms of how things are going to work.”

Bahamian physicians are also concerned that NHI is foisting on them the Patient Centred Medical Home (PCMH) model - a model that studies have shown remains unproven in the US.

PCMH envisages a doctor’s primary care practice evolving into something that is “so patient-centric”, with the patients and comunity-based medicine entrusted with a large chunk of their initial healthcare.

However, the MAB in its letter to Prime Minister Perry Christie last month warned that the PCMH model had no history in the Bahamas, and might be unsuited to this nation’s multi-island geography.

And, combined with the capitation system, it expressed concern that Bahamian doctors would be turned into financial managers and administrators under NHI, diverted from their primary healthcare responsibilities.

“That will definitely be a significant part of what will have to happen,” one doctor agreed. “If paid on a capitation basis, you have to constantly manage the economics of your practice: Is this person coming to see me too much; what do I have to do to curb their visitation ratio?

“It is a very administration driven thing. Once you look at the costs associated with PCMH, you’re looking at a minimum at a 25 per cent increase in overhead costs.”

One doctor argued that the private health sector did not have the capacity to absorb the thousands of new patients that the Government and Sanigest want them to.

He revealed that the Costa Rican-based consultants want him to double his patient numbers under NHI, seeing a total of 5,000-6,000 persons per year.

“We said: ‘Look, we want to keep our existing patients’. I don’t need 2,500-3,000; 500 maximum,” the doctor said. “They’re saying: ‘No, we want you to take on another 2,500-3,000’. You’re not allowed to choose, as picking and choosing is not fair’.

“I’ve spent years developing relationships with my patients, and now you want me to take on overnight a new group of patients? It’s not going to happen.

“What the Government has not really accepted is that private healthcare, at this point in time, does not have the capacity to take care of all these patients.”

Several doctors also revealed that while the Government is proposing to finance NHI’s first year from existing healthcare spending/the Consolidated Fund, it is looking at a 3 per cent increase in National Insurance Board (NIB) contributions (payroll tax) to finance the scheme from year two onwards.

That 3 per cent, Tribune Business understands, will be split 50/50 between employer and employee, meaning each will contribute a further 1.5 per cent of their earnings to NIB.

Yet two physicians pointed out that, based on the $244.5 million in contribution income that NIB earned in 2014 from a 9.8 per cent contribution rate, the proposed 3 per cent increase will only generate $70-$80 million in additional NHI financing.

This, they added, would be nowhere near enough to finance the expanded NHi versions proposed by Sanigest, the most expensive of which is priced at $633 million.

The doctors also pointed out that NIB’s administraive costs, which were equivalent to 19 per cent of its contribution income in 2014, were another burden that NHI must bear given that it will likely be selected to administer the scheme.

Those doctors spoken to by Tribune Business also argued that the Government and Sanigest were being disingenuous in describing the proposed NHI structure as a ‘multi-payer model’.

The involvement of private sector insurers, ostensibly to ensure a competitive market post-NHI implementation, has led Sanigest to brand NHI as ‘multi-payer’.

Yet one doctor said it should really be labelled as a ‘single payer, multi-administrator model. This was because all financing was coming from NHi, which was being administered by multiple insurers.