Our widening healthcare divide

  • Difficult diagnosis: reducing healthcare costs is a major challenge facing the country

    Difficult diagnosis: reducing healthcare costs is a major challenge facing the country

  • Dennis Fagundo, president of the Bermuda Chamber of Commerce

    Dennis Fagundo, president of the Bermuda Chamber of Commerce

Healthcare cost in Bermuda is a significant concern. It is one of the largest single costs facing Bermuda’s working population and their employers. What is changing? Why is it changing? Why are costs going up when the Ministry of Health has been promising it will go down?

Let’s examine for a moment the big picture. The publicity campaign under way is centred on the theme of providing more standard coverage to more people, with a dash of “How much more?” thrown in.

The number of employed people paying for health insurance, and therefore the “Standard Hospital Benefit” tax, is steady or decreasing. The cost per payer then must go up.

Also, if the new “Standard Hospital Benefit” is better, more comprehensive and more effective than HIP but as cost-effective, as advertised, it would seem likely that many employers and employees would opt to downgrade from the more expensive major medical to the legally mandated minimum.

It would result in reducing the level of cover many working Bermudians enjoy at present — an unintended consequence.

The more detailed noise around insurance companies, profit margins and actuarial studies is simply not significant enough to overcome this basic maths.

The Government will outsource this insurance function to a single entity. That single entity will have a monopoly profit margin, the Government will add a layer of administration, and inefficiency and costs will go up. In the worst-case scenario, it will be outsourced overseas and the jobs, profits and any benefits will flee our economy as well.

But cost will be contained within the Bermuda Hospitals Board, so the story goes.

The BHB will receive a fixed block grant, $20 million less than the projected need, no matter what services it provides or does not provide. Surely, that will have an impact. Is this the solution?

This will lock in the BHB and therefore the King Edward VII Memorial Hospital revenue. This will place the BHB in a deficit position with $20 million less than it needs to cover expenses for the year. What are the very real consequences of this? They may be unintended, but they are not unknown.

The BHB can now control only the expense side of the equation to remain financially stable. It cannot change public-private partnership payments, utilities or labour costs of its unionised support staff.

The only available lever is medical services. Under the new regime that is now in place, the BHB has no choice but to pull this lever.

Let’s consider that for a moment.

The cost for medical supplies is under the control of the BHB. If fewer surgeries are performed then fewer items such as pacemakers, replacement joints, and other implants are required. The money spent on cotton gauze isn’t significant and simply isn’t going to move the needle.

Operating-room hours have already been reduced; anything deemed elective will become either impossible or a very long wait.

Who doesn’t get their surgery then? Those without additional insurance or those without the ability to pay a premium. The haves and have-nots gap becomes even wider. Is this the intent?

The hours of operation for various diagnostics are under the control of the BHB. The MRI machine is expensive to operate, technician costs, power costs, etc.

The wait times for testing for conditions that are not life-threatening will increase. The present guidelines are six weeks. What does this mean if it increases to six months or more?

Who gets their testing done in a timely manner? Those with additional insurance or the ability to pay for private service. The haves and have-nots gap becomes even wider. Is this the intent?

Timing is another lever that is under the control of the BHB. As budgets run short towards the end of the fiscal year, anything not life-threatening can be simply cancelled or postponed to the next fiscal year to avoid overruns.

What alternatives face the patient? Wait or go overseas for treatment. Those fortunate enough to have adequate coverage will go overseas, effectively paying twice for the same treatment — once to the SHB and the BHB block grant, and second to the overseas facility at a premium.

This can only increase the cost of the system as a whole, while widening the gap in outcomes between the haves and the have-nots.

Widening this gap is not in Bermuda’s best interest. It is not in the business community’s best interest. While there is no ideal equation, balance is the key.

Healthcare in Bermuda is a very complex and multifaceted system. It has many flaws. Every complex problem has a simple solution, that doesn’t work!

Many of the cost-of-living issues facing Bermuda today can be distilled into a simple description: a sophisticated infrastructure that requires constant feeding, be it operational costs or capital investment, with a limited number of people paying.

The business community has been struggling to get this balance right, particularly in the past ten years. Looking for efficiency, being judicious with investment when funds are available, carefully considering the goods and services that are needed and can be afforded.

Balancing the revenue and cost sides of the equation so as to provide stability, employment and, when possible, a reasonable return for the risks being taken.

The Government must do the same if Bermuda is to have a solid foundation for sustainable success.

The drivers of cost within the healthcare system are known — systemic factors such as accessibility to patient medical data across providers, and the prevalence of chronic disease. Some have the ability to move the needle and make a measurable impact.

What are the drivers of disease? How can we cost-effectively improve patient outcomes? How can we use alternative and more efficient service providers?

Creating a new and burdensome financing model without fully understanding or recognising the ramifications simply cannot move Bermuda in a positive direction. This breaks the No 1 rule of healthcare: do no harm.

What is the Chamber of Commerce doing? How are we involved? The Chamber was represented on the stakeholder group.

The Chamber has held meetings with the Minister of Health and her permanent secretary, and the chief operating officer and chief financial officer of the BHB, and has addressed the issue in our regular meetings with the Premier.

The Chamber had a healthcare expert from KPMG speak at our annual meeting in 2017.

The Chamber has met with representatives of the health insurance providers, Abic and Abir. Representatives of Chamber member companies sat on BermudaFirst working groups.

The Government must pause and carefully consider its direction. Our healthcare system has its problems, so let’s fix those issues. Creating a whole new system with a whole new set of issues is highly unlikely to move us in the right direction.

Dennis Fagundo is the president of the Bermuda Chamber of Commerce

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Published Oct 17, 2019 at 8:00 am (Updated Oct 17, 2019 at 1:20 am)

Our widening healthcare divide

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