By NEIL HARTNELL
Tribune Business Editor
A well-known physician says it is “going to be incredibly difficult, if not impossible” for Bahamian doctors to run quality medical practices with the 66-77 per cent compensation cuts proposed by the National Health Insurance (NHI) scheme.
Dr Duane Sands, also the FNM’s candidate for Elizabeth, said a February 2017 NHI draft showed that doctor fees were being determined by the need to fit the primary care phase into the $100 million budget allocated by the Government, not the true cost of services.
He warned that the dramatic cuts in doctor compensation, compared to the Medical Association of the Bahamas (MAB) fee schedule, threatened to compromise quality of care by forcing physicians to treat patients as “human cattle”.
Dr Sands said this would be the natural consequence of the proposed fee cuts for providers that signed on to NHI as is, for they would be forced to dramatically increase the number of patients seen - and reduce the time spent with each one - to make their practice’s economics work.
He added that many private doctors would see such a payment reduction as “untenable” for maintaining practice and patient care quality, which was why many were not registering to offer services under NHI.
The February 2017 document, branded ‘confidential’ but now circulating widely in the healthcare industry, promises that NHI doctors’ fees will be determined by ‘fairness’, ‘simplicity’ and based on local and international industry ‘best practice’.
“The financial impact on physicians will be taken into account, and rates will be set in such a way to ensure a fair outcome for all physicians, while accommodating the public interest,” the NHI document states.
However, it states on the same page: “Rates will be developed in such a way that does not put the country’s finances at significant risk.”
And, on the following page, the NHI document effectively admits that doctors’ fees have been determined by the need to fit the primary care phase’s costs into the Government’s $100 million budget.
Noting that the ‘impact on total costs’ is one of they three key criteria for determining fees, the NHI document states: “Adjust to minimise the risk of total cost exceeding the $100 million available for year one.’
“There is no honest, objective assessment of what things ought to cost,” Dr Sands told Tribune Business. “It’s start off with a budget and work back from that, not look at needs, demographics and health profiles. Let’s start with a dollar amount and work back. You’re trying to force it into a budget plucked out of thin air.”
The NHI paper proposes to reduce the existing 39 ‘fee codes’ used by primary care doctors to five basic payments, on the grounds that these accounted for more than 70 per cent of claims submitted to one private health insurer in 2014.
Besides “largely aligning” with current doctor claims, the NHI document said such a ‘five-fee structure’ would “simplify the billing process” for the scheme and its administration.
It thus proposed fees for a ‘Simple Doctor Visit’ at $36; ‘Intermediate Visit’ at $60; ‘Complex Visit’ at $78; ‘Periodic Health Assessment’ at $66; and ‘Telephone consultation’ at $24. Premiums of 15 per cent and 25 per cent are to be added to these fees for ‘new patients’ and a ‘home visit’ by a doctor.
Dr Sands said that compared to the recommended MAB fee schedule, the ‘Simple Doctor visit’ fee represented a 71 per cent reduction.
He added that the ‘Intermediate’ and ‘Complex’ visit fees represented 66 per cent and 71 per cent reductions, respectively, and ‘Periodic Health Assessment’ was a 77 per cent cut.
“It is highly likely that such a drastic reduction is highly untenable for practices,” Dr Sands told Tribune Business. “The only way you could survive is on the basis of volume and drastic reductions in face-to-face time, and things detrimental to quality of care.
“It basically turns patients into cattle. To maintain revenue across the board, you will need to be seeing a huge number of patients and no way is that tantamount to quality of care.”
Dr Sands said the current MAB fee schedule was “not high margin at all”, saying it was “pretty inexpensive relative to existing norms”.
In a nod to the Government’s likely response, which may seek to portray private doctors as greedy, he continued: “Physician costs are not anywhere near top of the scale compared to regional norms.”
Dr Sands said the most expensive elements of healthcare were facility use charges, such as for patient hospitalisation, and equipment use. The latter costs, he added, were exacerbated by import duties and VAT.
“When you look at these charges, how do you get to see a patient for $36 of office time,” Dr Sands said, breaking down the costs incurred by Bahamian doctors. Besides providing a sterile sheet for patients to lie on, he said physicians also had to cover medical waste management; blood pressure and vital signs readings; the costs of reception, care management and nursing staff; the provision of water coolers and maintaining a reception area.
“How does that get paid from $36,” asked Dr Sands again. “If you look at this now, that says it is going to be incredibly difficult, if not impossible, to run a medical practice with any level of quality.
“What I think this may force people to do is not look at this in terms of the specifics, but distill it to its core; to say this is untenable and can’t be done.
“Fundamentally, what they’re basically trying to do is nonsensical, and the solution is not to argue over the details but vote them out and then do it properly,” Dr Sands continued.
“It’s sad to reduce a discussion that is so important to these terms, but as I listen to my colleagues, this draft for consultation is absurd. How do you make a business model without information?”
All healthcare industry stakeholders have backed the concept of Universal Health Coverage (UHC), enabling the Government to at least start on common ground with them.
They have also agreed on the need to provide Bahamians with modern, affordable and accessible healthcare, and that no one should be denied access to this on the basis of income, age, gender or pre-existing conditions.
Where the Government and healthcare industry stakeholders disagree is on the method for achieving this goal, with many viewing the financing mechanism for UHC - NHI - as a politically-driven solution whose implementation is being rushed ahead of the upcoming election.
The NHI Secretariat, though, has achieved some success in encouraging private doctors to register as NHI providers, such as Dr Brian Tynes, Dr Leo Ignacio and Dr Tyneil Cargill.
Dr Sy Pierre, the MAB’s president, previously told Tribune Business that the economics of individual doctors’ practices would largely determine who registered as NHI providers, with physicians needing extra patient volumes likely to register.
The NHI document, meanwhile, made it clear that while doctors would be paid fees for specific services initially, within three to five years the scheme wants to convert remuneration to its preferred capitation - a per annum, per patient fee.
It adds that the base capitation fee is calculated from the $60 ‘Intermediate Visit’ fee, multiplied by an average of two visits per patient per year, and a 25 per cent ‘provider ‘incentive’ - giving the grand total of $150.
When adjusted for pharmaceutical, laboratory services and diagnostic imaging services, the ‘estimated base rate’ increases to $300-$350 per patient, per year.
Adjusted for factors such as age, gender and the island on which patients are located, the rate is calculated at between $225 to $725 per patient, per year.