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Back to basics with healthcare

Cash crunch: King Edward VII Memorial Hospital (Photograph by Akil Simmons)

The revelation that Bermuda’s hospitals had just six days’ worth of cash reserves in hand in December symbolises the problems confronting not only how healthcare is financed, but the whole issue for Bermuda.

This is particularly relevant now as the Government ramps up its reform of the healthcare system and raises red flags about the idea of a single-payer system.

Before the onset of the Covid-19 pandemic, the Government, in fulfilment of its 2017 election promise, carried out an ambitious attempt to introduce universal healthcare.

This was a false start. The reform effort began by looking through the wrong end of the telescope by trying to fix the way health was paid for, and to make it affordable, without looking at why Bermuda’s health system is both wildly expensive and fails to deliver value for money.

The pandemic came at a fortuitous time in that it stalled the process and gave the Government time to rethink its whole approach.

So before the Budget, the Ministry of Health launched what might be best described as Health Reform 2.0.

This time, the Government is starting at the beginning — by examining the whole system — and will eventually get to the point where it can say what the final cost to an individual should be. Then, and only then, should the Government think about the mechanisms for paying for it.

There is no question that a significant proportion of Bermuda’s population has inadequate healthcare. This is not only a desperate situation for those most affected, but a drag on the whole system.

The question of whether adequate healthcare is a human right misses the point. Inalienable right or not, it is not just a nightmare for those who lack it, but it hurts the whole of society, and ends up costing everyone vastly more than it should.

Take, for example, the idea of a simple visit to a doctor’s office for a minor ailment. If an insurance policy covers it, it is relatively low-cost, even with a copay. Without it, it may cost about $100 — a large sum for the people most likely to have little to no insurance. Instead, that person will go to the emergency department, which cannot turn them away, and they will be billed later. The cost then? About $500.

It should be obvious that steering people to a general practitioner rather than the hospital would save the patient and the system huge amounts of money. And yet the system fails to make this possible.

Similarly, the major causes of the two most common chronic ailments — type 2 diabetes and hypertension — are based on poor diet and lifestyle choices, and are eminently preventable. And yet these illnesses cost tens of millions of dollars a year and curtail the lives of many people who should be healthy and productive.

There are other problems. There are doctors who invest in expensive diagnostic equipment and then seek to get a reasonable rate of return on the equipment by encouraging their use even when the value of their use is debatable.

It is relatively easy to diagnose the problem. Finding the cure is harder.

The Health Strategy rightly sets down the requirement for a needs assessment to determine exactly what kind of health services the island needs.

Fortunately, much of this work is already done. A significant part of the healthcare crisis the island faces is owing to the chronic illnesses of diabetes and heart disease, which afflict thousands of people.

The strategy is therefore right to focus on prevention and wellness to reduce the incidence of illnesses that are caused largely by lifestyle choices, whether they are poor diet, lack of exercise or smoking.

So Bermuda can do much to solve many of the healthcare problems it faces by taking more personal responsibility, but doing so requires a massive public education programme and the use of rewards and penalties for healthy and unhealthy personal choices.

Thus, revenues from things such as the sugar tax should be dedicated to public health campaigning and not subsumed into general government expenditure. And if health insurance is going to continue to be the means of financing healthcare, then an example of the carrot and stick should be that non-smokers should pay lower-than-normal premiums and smokers should pay higher premiums. This is because it is demonstrable that smokers will put a greater burden on the health system and should therefore pay more.

Other societal issues also add to the cost of healthcare. If a driver or passenger is injured in a crash, this adds to the cost of health for everyone. Similarly, a person injured as a result of violent crime becomes a cost for everyone.

Finding solutions to these problems and many others would not only make Bermuda safer overall, but they would reduce health costs as well.

To be sure, lifestyle choices will only reduce health problems and costs. People will still get sick, viruses — whether influenza or Covid-19 — will come and go and people will be injured in crashes or through falls.

But the goal must be to reduce the pressure on the health system and, in doing so, to reduce the cost.

Of course, that is easier said than done. But, ultimately, it is the right solution. All other approaches are akin to giving someone a Band-Aid when they are having a heart attack.

If this can be accomplished, it will go some way to delivering more affordable healthcare and making healthcare more universal, since at least part of the reason for people not having access to care is because of its high cost.

For this reason, this newspaper is not going to plump for deciding there should be one provider of health insurance or more than one, or even if it should be delivered in a way similar to the National Health Service in Britain — through taxation.

However, the hospital’s experience of nearly running out of money in December shows the pitfalls of relying on government funding. Until recently, insurance companies paid hospital claims directly to the hospitals. This was stopped, at least in part because it encouraged the hospital to promote use of unnecessary services.

Now insurance claims are paid to the Government, which then transfers the funds to the hospitals in arrears as block grants. But while the hospital’s cashflow problems can be attributed to the problems caused by Covid-19, delays as a result of cumbersome payment systems cannot help.

Coming up with different means of financing healthcare will not solve Bermuda’s healthcare problems in the long run — but healthy and sensible choices will help.

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Published March 14, 2022 at 7:56 am (Updated March 14, 2022 at 7:54 am)

Back to basics with healthcare

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