Representatives from 31 countries, including Bermuda, talked about supporting the health of more than 700 million of their people. The representatives grappled with defining a common purpose of healthcare, and having the difficult conversations about health financing and sustainability of systems. This debate is frustrating everyone involved, as health is being talked about more like a commodity rather than what the World Health Organisation would define it to be: a right.This article is not to argue whether health is a right or not, but rather to reflect on ways to improve the health of people within our countries, cities and communities. Healthcare leaders are saying that our view of healthcare has shifted so far into the business of treating sickness that we have forgotten about actually investing in preventing disease, and achieving and maintaining the good health. The healthcare that we spoke of is more than just the care we receive in a hospital or clinic, but also our access to good education, safe homes, social networks and nutritious food. The reality seems to be that we often forget that health first starts with us doing the right things — such as taking walks or talking to someone when we are stressed — while allowing the formal health system to provide extra supports when our journey of wellness stalls. It is only when those individual efforts get out of our control that we should be seeing our health system as a “what treatment can I get?” type of product.Speaking about products, let’s remember that when it comes to healthcare systems, the product we are purchasing is health; therefore, anything we get that is less than health could be seen as a defective transaction between the factors impacting health (the product) — that is, individual responsibility, social determinants and healthcare services. With that said, where do we stand as a country?The NumbersDuring the 2019 fiscal year between April 2018 and March, local health insurers paid $21,505,695.42 for 163,654 primary healthcare visits. The average reimbursement of those visits was $131.41. The visits included office visits, observations, office consultations, home visits and well visits — for all ages. These payments did not include reimbursement for other services such as like laboratory testing or diagnostic imaging. It also did not include any sales of medications or any other specific outpatient procedure conducted in an office.What do these numbers have to do with those global conversations about public health?In Bermuda, we see an increasing number of individuals who have chronic diseases diagnosed such as diabetes (at least 12 per cent), high blood pressure (only 50 per cent is controlled) and asthma (8,000-plus persons) that progress to kidney failure, amputated limbs, strokes or chronic lung disease. These are not conditions that affect only those with lower socioeconomic status (approximately 23 per cent), those who are overweight or obese (approximately 75 per cent), those of a specific racial background (59 per cent black), those with specific health insurance status (more than 48,000 insured, not including children), or individuals in certain employment groups (35,530 formal workers). These health conditions are often listed as lifestyle-related, and they affect people within all demographic and income categories. All of us, even our most healthy, bear the cost of not managing these conditions, and the weight of that burden is only getting heavier. This is especially true as our population ages (11,966 individuals over age 65 today; estimated 20,804 over the age of 65 in the year 2039) and our workforce gets smaller (3.9 working people to 1 senior today; estimated 1.7 working people to 1 senior in the year 2039)What do we need to do differently?We understand that to fight this existing and growing challenge, a holistic approach is needed. This includes things such as developing more public information and education on nutrition and exercise, having better stress management and access to mental health services, and shifting our thinking from a model that some consider “sick care” to one that focuses on wellness. With what we are seeing with our country’s overall health, we have to look to invest more resources into quality primary healthcare services — while at the same time not taking our focus off social determinants of health. We have to start catching things too early instead of treating them too late.What was proposed to address this?The World Health Organisation keeps pushing primary healthcare, and for a good reason. All over the world, like in Bermuda, we are dealing with the impact of lifestyle-related disorders. Can more access to primary healthcare providers support our quest to find that elusive health? Well, it is well studied that a spectrum of primary healthcare providers are universally accepted as critical for protecting our wellness, improving how we manage our health, and changing our scary long-term health cost projections. In late 2018, we did an initial review of local office visit codes and found there to be approximately $7.5 million of these types of visits being reimbursed in this setting. With the goal to invest more into this type of care, we calculated that if 92 per cent of people (the insured) in Bermuda paid $20 per month, we could put more money into prevention and management of health, while reducing the administration in primary care. That reduction in administration could mean more provider-to-patient face time. So, instead of $7.5 million that is being paid for office visits at present, the proposed $20 per month per insured patient equated to an investment of $14.1 million into those same services (92 per cent of 63,779 people x $20 x 12 months).As part of the consultation process for the proposed health system reforms, many interested parties reviewed that $20 per month per person investment proposal. Through good back-and-forth conversation, it was pointed out that we need to consider even more than just the office visit codes if we really wanted to address the types of visits that are made under primary healthcare.How has the original proposal changed?As the original goal was to invest more resources into primary healthcare, we took the feedback and made some changes. We have since included a broader set of visit codes into the actuarial and economic models. Taking into account the broader set of visits, the new figure for the relevant paid claims is $21,505,695.42 — versus the original $7.5 million). Again, the population of insured persons in Bermuda, including children, is approximately 58,677 (92 per cent of 63,779). With this number of insured people, a capitation model with payments of at least $30.54 per month per person would equal what was being previously paid — that is, $21.5 million. In addition to that figure, an out-of-pocket visit fee of $25 was proposed. This additional fee would add an estimated $4,091,350 to the capitated payments (based on 163,654 visits in FY19), bringing this part of primary healthcare investment to $25.5 million.Why this idea of capitation for the basic primary healthcare services?Capitation simplifies the process of administering care; it means monthly payments are made, based on how many people are enrolled with their provider of choice. Payment is made to a provider whether a visit takes place or not. Capitation provides those delivering primary healthcare with a payment at the beginning of a month for all the types of individuals they may see during that month. It removes their need to submit claims to insurance companies, giving them more time to see patients, more flexibility to document data in electronic medical records, and more certainty around their income. It also helps the system to move towards what we think healthcare is meant to be: less of a commodity and more of a way to improve public health.What are the numbers based on this model? All calculations are based on the use of services through FY19. When thinking through the calculations, there also may be the potential that with fewer “barriers” to primary healthcare, the rate of use may increase. This specific implications of this need to be further discussed.However, there is some empirical information that may be of use: a case study in the Bahamas, which recently put in a capitated primary healthcare system, has demonstrated no real change in how much a person on average uses the system. People in the Bahamas continue to make appointments only when they feel they need to or when it is part of their guideline of care — for example, an annual physical. However, more people who had not had care in a long time have begun to re-enter the care system, which is a great thing.According to representatives from the Bahamas, the satisfaction rate with the new primary healthcare model is higher than 90 per cent. Such a system also creates certainty on what the public will be paying out-of-pocket. It is a well-studied topic that higher co-pays lead people to delay seeking care or reduces their visits to primary healthcare altogether. As part of a local model, we still may need to build in a buffer for changes in usage behaviour. For example, if when taking a much closer look at our demographics, and the number of visits by the average person in Bermuda seems like it will increase by 5 per cent, then we would build in an additional 5 per cent into the capitated rate. Also, not to be ignored, the proposed payment does not take into account the full amount that is charged today, which varies by provider. However, based on the data, the average insurance payment is $131.41 per visit, which, when combined with the out-of-pocket fixed visit fee, would in essence value these types of visits at $156.41.Is a flat fee for everyone fair?Again, the real goal is to invest more than has been done in the past in services that will prevent disease, reduce complications of disease and help to better manage wellness. We do have a community-wide chronic disease problem, and we have to adjust our system to meet this new landscape. We understand that there are different health conditions that people face. These differences need to be appreciated and financially compensated as such. That is only fair. At first, those who serve populations with more complex care needs should be reimbursed at a higher rate than those whose patients have less complex needs. Those kinds of incremental payment rates would be in addition to the base rate. For example, a person with three co-morbidities may require more case management than an individual that is seeking only to maintain a healthy state. In the Bahamas, those differences in the complexity of patients have led to an annual capitation base rate of $150 per year, but with adjustments leading to a range extending between $75 and $425 per year per person — depending on where an office may be located or the type of patient that is presenting. Payments there are higher for locations that are in less densely populated areas, and higher if the patients have more illness. The proposed base rate in Bermuda is $366.48 per year per person — $30.54 x 12 months — with, of course, similar flexibility in a range around that base rate. Other factors should also be taken into account when calculating the capitated fee for a practice such as age and sex of the enrolled patients, as different person characteristics come with different risks to the various types of providers. It would also be fair that, as the population gets healthier, financial incentives should be built in for providers — and patients themselves — to maintain that better health.What now?There is a genuine dedication to work together to improve our population’s health. Part of that has to be through implementing a more robust primary healthcare and public health framework — even if that means looking again at and discussing other non-capitation models. The other part, of course, has to be about us as individuals. Although the world may be grappling with the meaning of healthcare in the 21st century, we believe that we can show, through action, what Bermuda believes healthcare should be — a way to be the best parts of ourselves.• Ricky Brathwaite, PhD, is the acting chief executive and the director of health economics at the Bermuda Health Council. He earned a Doctorate in Health Economics from Johns Hopkins University and has, for more than 15 years, worked on improving the operation and effectiveness of health systems, hospitals and provider practices