The Tribune

By ANNELIA NIXON

Tribune Business Reporter

anixon@tribunemedia.net

Doctors are warning that National Health Insurance’s (NHI) continuing expansion without first ensuring its financial sustainability could ultimately drive providers away and undermine treatment quality provided by the Government’s flagship initiative.

Dr Denotrah Archer-Cartwright, speaking on behalf of private NHI physicians, said the National Health Insurance Authority’s (NHIA) acknowledgement that patient/beneficiary growth has outpaced its resources validates concerns doctors have been raising about the programme’s financial management.

Her comments came after Christy Butler, the NHIA chief executive and managing director, acknowledged that enrollment has climbed to almost 165,000 beneficiaries with such rapid growth contributing to delayed payments to doctors and other scheme providers. Ms Butler also said the Authority cannot provide a timeline for clearing outstanding arrears because NHI is fully dependent on government/taxpayer funding.

Dr Archer-Cartwright said physicians have no issue with expanding access to NHI, but argued that the programme’s growth must be matched by adequate financing.

“The growth of the programme is managed by the NHIA, and they have been planning to extend the programme for the past few years, knowing that the financing isn’t in place,” Dr Archer-Cartwright said.

She added that the Provider Physicians Association has repeatedly raised concerns about the decision to expand the programme despite existing financial challenges. “We have no problem with the growth of the programme,” Dr Archer-Cartwright said. “We would love all Bahamians to have access to the NHI programme because us being a part of it is a great programme.

“However, it’s important for any management or administrative body to align the finances with the growth of the programme. So it’s almost very irresponsible to continue expanding a programme without matching the finances, and we’re just asking them to take a look at that because you cannot pay the providers now, and you are pretty much bragging that you’ve added new providers to the list. Wouldn’t that compound the current problem that you’re having?”

The NHIA recently announced the addition of 15 providers to its network, including an obstetrician-gynecologist in Abaco, while the number of beneficiaries has continued to increase.

Ms Butler has attributed the payment difficulties to rapid growth, explaining that every additional beneficiary increases costs as more people access doctors, laboratories and other healthcare services. She also acknowledged that NHIA’s reliance on 100 percent government funding is an outlier compared with other healthcare systems and has contributed to difficulties in meeting its obligations to providers on time.

The NHIA has said it is now examining alternative financing mechanisms, including employer and employee contributions and so-called “sin taxes” on products such as tobacco and alcohol, as it seeks to diversify the programme’s revenue base. The Authority has also indicated that the National Health Insurance Act already allows for a contributory funding model, although successive administrations have not implemented it.

Dr Archer-Cartwright said the financial concerns are compounded by what she described as a breakdown in communication between NHIA and the physicians responsible for delivering care to NHI beneficiaries.

“We don’t understand the thought process of what’s happening with the NHIA,” she said. “This is where a lot of the confusion is coming from. What is the long-term objective?

“We wanted to work. We want it to work for the Bahamian people. We want it to work for the physicians. We were promised partnership, and instead, they continue to just want us to be quite silent.”

Dr Archer-Cartwright stressed that private physicians are a critical component of the programme because they provide care to NHI patients through their own practices, and have invested significant resources into ensuring those services are available.

She also challenged NHIA’s claims that it maintains regular communication with providers through various channels, including the Medical Association of The Bahamas (MAB), which has a seat on the NHI Board. She questioned why physicians who have direct contracts with NHIA are not being engaged directly and consistently on the issues affecting their practices.

“They talked about all these different channels of speaking with the providers, but you refuse to speak with the providers directly,” she said. “When you’re talking about non-reply e-mails, WhatsApp groups where providers cannot voice their opinion, speaking through the MAB, which is a different association that has nothing to do with contracted positions agreement. Why is that all those channels necessary when the providers, the physicians who you have contracts with, are requesting that you speak to them directly?”

Dr Archer-Cartwright said the last medical directors’ meeting took place more than a year ago despite assurances that there would be direct dialogue with physicians about their concerns. She also raised issues about deductions from money owed to physicians, and alleged that doctors have been forced to use their own resources to support aspects of the programme’s administration.

Dr Archer-Cartwright was particularly critical of NHIA’s admission that it cannot provide a timeline for clearing outstanding payments to providers. “This is unacceptable,” she said, adding that the uncertainty was one of the reasons private NHI physicians had formed their own association.

She added that doctors have grown increasingly frustrated with what they believe are failures to honour contractual agreements and a lack of respect for the profession.

“I don’t think anyone would accept that they would be paid whenever the money becomes available for a national programme where you enlisted physicians and their companies to provide resources, clinical space and services for the government,” she said. “It’s just preposterous that they would even say something like that.”

The concerns come as the Government and NHIA attempt to address the programme’s long-term financing challenges while continuing to expand its reach. NHIA has said diversifying its funding sources will be critical to ensuring it can meet its obligations and, eventually, expand the range of services available to beneficiaries.

But Dr Archer-Cartwright warned that continued payment delays, additional administrative responsibilities, and what she described as punitive policy changes could eventually make participation in NHI unattractive to private physicians.

“What I’m seeing is if this continues to happen, and every day we have some new punitive policy change that’s being handed down to us, as well as administrative duties which we are not being compensated for… eventually, the programme is going to be something that is not attractive to physicians if this continues,” she said.

“And then it will naturally not be sustainable. And so I see that as quite inevitable because they’re going to eventually run out of doctors who are willing to take on this opportunity.”

Dr Archer-Cartwright argued that continually adding new doctors to replace providers who become dissatisfied with the programme would only mask the underlying problems.

“Cycling through adding new physicians to me is just a band aid because eventually everybody is going to realize what they are dealing with,” Dr Archer-Cartwright said.

She warned that the consequences could extend beyond the financial viability of individual medical practices and affect the quality of care available to NHI beneficiaries.

“Either you’re going to have a system where people are just in it, and they’re not really putting their best foot forward, which is a shame because I think the whole reason why they came to the private physicians was to elevate the level of care outside of what they were already providing,” Dr Archer-Cartwright said.

“And so to see that it becomes another government initiative that is being sabotaged by bureaucracy would be a shame.”