The Tribune

By NEIL HARTNELL

Tribune Business Editor

nhartnell@tribunemedia.net

Doctors have slammed the 70 per cent “across-the-board” fee reduction that will be imposed upon them by the proposed National Health Insurance (NHI) scheme, and warned they will not sign up for “something that will fail”.

Numerous physicians, speaking on condition of anonymity, told Tribune Business that the capitation fee structure unveiled by the NHI Secretariat last week would leave many struggling to cover their overhead expenses.

And, in potentially forcing many practices into a loss-making position, and having to potentially downsize staff and cut other costs, they warned the Government’s proposals threatened to compromise healthcare quality for Bahamians.

They accused the Government, its NHI Secretariat and consultants, the KPMG accounting firm, of adopting an “ass backwards” approach by trying to design a scheme to fit the $100 million budget.

They suggested the NHI architects were trying to squeeze everything into this figure, resulting in the proposals for a huge cut in doctors’ fees compared to the current norm for many private physicians.

Tribune Business was told that the NHI scheme is proposing five types of code or capitation payments, a form of reimbursement that will see doctors paid a set annual fee per patient.

A ‘simple office visit’ is priced at $36; with ‘intermediate and ‘complex’ visits to the doctor carrying price tags of $60 and $78 per visit, respectively.

The NHI scheme currently prices periodic visits, such as annual physicals, at $66 per visit. Tribune Business was also told that NHI will include several “modifiers”, such as a $24 fee for a 10-minute phone conversation with a patient, plus another fee for home visits.

One doctor, speaking on condition of anonymity, said NHI’s proposed ‘simple office visit’ fee effectively represented a 64 per cent cut to the $100 he typically charged. And the scheme’s ‘complex office’ fee, meaning that extensive treatments were offered, was around a 50 per cent discount to what he currently charged.

“You’re looking at a 70 per cent reduction across the board,” he told Tribune Business of the proposed NHI fee structure. “You’re going to be hard-pressed to cover overheads.

“At the meeting, one doctor said to the rest of us: Within this group of physicians here, does this fee schedule look familiar? Everyone said: No. Clearly, from what we’re used to and the current practice, this is a huge deviation from what is normal for physicians in the Bahamas.”

Asked why the Government was pushing such drastic fee cuts, the doctor added: “It’s going to totally blow their $100 million budget from the Government. $100 million, it has to fit. Take it or leave it.”

Dr Duane Sands, the former FNM senator, told Tribune Business that the ‘complex office visit’ proposed by NHI was lower than his ‘basic office visit fee of $83.70 - a level at which he “barely breaks even”.

Dr Sands said his fees went to a high of $246.60, and that all were in line with the coding and pricing recommended by the Medical Association of the Bahamas (MAB), which had not changed in a decade.

Another source said that at one of the Nassau meetings, Dr Delon Brennen, the Government’s NHI project manager and the person who did most of the talking, “almost glossed over” the proposed capitation-based reimbursement fees.

They added that several doctors interrupted Dr Brennen, and asked him to go back to the proposed fees for further discussion, given that this was the central topic for discussion.

The NHI Secretariat declined to provide copies of the presentation to the attending doctors, Tribune Business was told, who identified numerous concerns with both the fees and other aspects of the Government’s planned healthcare reforms.

The accounts of the New Providence meetings differ greatly from the NHI Secretariat’s official release, which seemingly barely scratches the surface of what occurred.

“The initial discussions we’ve had with primary care physicians specialising in primary care have been positive, and I’m pleased to say that many of them are excited to register and provide services under NHI Bahamas to patients in need,” Dr Brennen said.

“These providers will play a key role in shaping a health care system that is modern, affordable and accessible.”

However, directly contradicting Dr Brennen, one doctor present at the meetings said: “

“No one we have spoken to has agreed to provide services at this point in time

“No one wants to sign up for something that is not going to work. They’re hell bent on doing something that we feel as a medical group is not in the best interests of the country.”

Given the Bahamas’ population, and the fact that NHI wants physicians to take 2,000 patients each, one source suggested that around 190 private sector doctors would need to participate.

One doctor suggested this number simply did not exist and, with physicians declining to sign up for NHI to-date, it was impossible for the scheme to get off the ground. Without the participation of private doctors, they emphasised, NHI cannot come into being

The doctor added that the Medical Association of the Bahamas (MAB) and its members had yet to even see a proposed contract to provide services under NHI, and there was “no way to have a relationship” with the scheme.

“Nothing is currently in place,” they added. “The physicians, and everyone in our sphere, is in disbelief that they want to move forward with this plan we know is not sustainable and flawed. The economics, based on the current package, are not sustainable.”

Tribune Business was told that NHI’s proposed doctor fees were being based on assumptions that include 70-80 per cent of patient visits falling into the ‘intermediate’ category, multiplied by the number of expected visits per person, per year.

Risk adjustments will be made for the age and gender of a doctor’s patient population, with Family Island-based physicians compensated at a greater rate than New Providence.

Tribune Business was told that among the flaws pointed out by doctors was the ‘bundled care’ package for pre-natal and infant/child care.

The NHI Secretariat was warned this was “setting up for physicians to practice outside the scope of their training” and care specialty, with no mechanism in place to monitor this.

Other concerns related to the absence of care co-ordination payment, and the Government marketing NHI to the Bahamian public as if it was going to provide free healthcare.

It was also pointed out at the meetings that private sector physicians simply do not have the capacity to absorb the extra patients NHI wants them to take, which will result in many Bahamians having no choice and being forced back to the public health sector.

This is despite the NHI Secretariat saying last week: “Over 200,000 Bahamians currently do not have health insurance, and many of them will be choosing their doctor in the public or the private sector in Phase two of NHI Bahamas, enrolment, which will begin in 2017.”