Savings can be made without affecting health services

Letters to the Editor

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  Bill Shields, Bermuda Hospitals Board CFO (Photograph supplied)
  

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Dear Sir,

Dennis Fagundo makes a number of interesting points and observations in The Royal Gazette of October 17. I think it may be helpful to the community to place these in context.

The Bermuda Hospitals Board was informed in November last year that pressure on governmental spending in Bermuda would require a change in how the BHB was paid: the portion of funding previously paid by insurers for BHB claims that came under Standard Health Benefit was going to be replaced with a fixed payment from the Government’s mutual reinsurance fund.

The total funding from the Government was capped at $322 million — the $330 million often referred to includes the BHB’s estimate of funding from other sources such as overseas patients. This amount was lower than the BHB’s expenses in fiscal year 2018-19, so savings would have to be made for the BHB to achieve its statutory break-even duty in 2019-20.

Our estimated savings requirement this year is $14.1 million or 4 per cent. International evidence suggests that the maximum level of ongoing savings, which can be delivered by a healthcare organisation without affecting clinical services, is between 2 per cent and 2.5 per cent. The BHB determined that a portion of these savings could, therefore, be delivered from one-off means to meet the one-year shortfall. The balance of 2.5 per cent is being delivered through productivity and efficiency improvements.

This includes optimising how our operating rooms are rostered, obtaining best value for the prices we pay for medical devices and equipment, and ensuring overtime is rigorously managed and used only where operational pressures require it.

These cost savings can be sustainably delivered only when developed and implemented with the full participation of clinicians. This means being fully aware of the clinical impact, adverse consequences and hidden costs of each initiative, and adopting robust sign-off processes to ensure such impacts are minimised.

Mr Fagundo highlights the challenges inherent in making savings within a constrained cost base where fixed payments for the Acute Care Wing and union collective bargaining agreements clearly have an impact. However, it is possible to improve space utilisation in buildings, and optimise the use of overtime as highlighted earlier while remaining compliant with the CBA, and without affecting the number of full-time employees. Equally, utilities can be a variable cost and be reduced through energy efficiency, recovery and management.

Finally, the BHB reviews wait times for its services on a continuous basis to ensure that emergency and urgent care are prioritised, and routine care is delivered within internationally acceptable clinical standards. The needs of our patients remain our priority.

Quality and Patient Safety Data is shared quarterly on our website for anyone who wants to follow how well we are performing. In September, our average wait times for non-urgent diagnostic imaging tests ranged from one day (radiology, mammography), to two days (nuclear medicine, bone density), to four days (ultrasound), to 13 days (CT) to 18 days (MRI).

To summarise, Bermuda, like much of the developed world, faces the conundrum of delivering high-quality health outcomes while checking the inexorable rise in per-capita costs.

The BHB put reducing these costs at the heart of its 2016-2021 Strategic Plan. While the level of savings we have had to achieve this year — 4 per cent or $14.1 million — cannot be delivered year on year without impacting services, the existing position is a temporary step and we will continue to work with the Government as it develops a permanent funding solution based on payment related to value, drawing on international experience of successfully implemented solutions.

Working towards a quality and cost-effective healthcare service for all of Bermuda is something that needs to involve all stakeholders and the community. We welcome the interest and discussions, are happy to share the BHB’s data, and look forward to continuing to play our part in helping to deliver high-quality, better-value care for all of Bermuda.

BILL SHIELDS

Chief Financial Officer

Bermuda Hospitals Board

http://www.royalgazette.com/letters-to-the-editor/article/20191022/savings-can-be-made-without-affecting-health-services

Reminder of health disparities for people of colour

Leana S. Wen

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  Invaluable legacy: Elijah Cummings (Photograph by Patrick Semansky/AP)
  

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Last week, Baltimore lost its representative, America lost a hero, and I lost my mentor and the namesake of my son, Eli.

Elijah E. Cummings leaves behind an invaluable legacy as a congressman for Baltimore for more than two decades and as a champion for social justice. His passing is a call to cherish the many gifts he imparted on all those fortunate to know him, but it’s also a reminder of a painful reality facing people of colour: shorter life expectancy.

Congressman Cummings died at the age of 68. This is young, but it’s not far from the average life expectancy of non-Hispanic black males (71.5), according to the latest figures from the Centres for Disease Control and Prevention. The average life expectancy for white men is five years longer, at 76.4.

The congressman was well aware of this fact. In 2015, after the announced retirement of longtime senator Barbara Mikulski, he tamped down calls that he run for her seat, citing his love for Baltimore. But he also noted as a reason disparities in life expectancy for black men. That same year, a child born in the Clifton-Berea neighbourhood of Baltimore, which is 95 per cent African-American, could expect to live 67 years. Another child born just a few miles away in Cross-Country/Cheswolde, a neighbourhood that’s 73 per cent white, would live an average of 87 years.

That’s a 20-year difference in life expectancy, based on one’s zip code and race.

When I gave lectures on public health in Baltimore, I would show maps of disease incidence. I stopped when it became apparent that it was essentially the same map, just with different codes in the legend. The same areas with low life expectancy also had the highest rates of infant mortality, skyrocketing drug overdoses and the worst incidence of cardiovascular disease. They were also the areas hit hardest by concentrated poverty and gun violence, with the most barriers to education, housing and transportation.

It is these social determinants of health that affect how long and how well people live. It is these social determinants that account for the huge disparities in Baltimore.

This is the same story we see playing out in communities across the country. People of colour face more barriers to healthcare, as do low-income individuals and those living in underserved rural and urban areas. There has been progress removing these barriers: the Affordable Care Act has narrowed differences in health insurance coverage, and local programmes have reduced some neighbourhood-specific disparities. But eliminating disparities requires attention to the systemic factors that lead to ill health, including poverty and structural racism.

When health is affected by so many factors, it’s often hard to know where to begin. Cummings, however, served as inspiration for what’s needed to make society more equitable.

The congressman urged city leaders: “Don’t talk about what you can’t do. Do what you can do — and do it efficiently and effectively.”

He was distraught that as many as 10,000 public-school students needed something as basic as eyeglasses but were not getting them. With his encouragement, we in the city’s health department started a programme for all children who needed glasses to get them, free of charge. He helped us to obtain federal grants that expanded mental health and trauma services in schools.

And when the legislature was mired in a debate over a contentious needle exchange programme some 25 years ago, it was Cummings who delivered the defining speech that broke the barrier of stigma. As a result, in Baltimore, the percentage of people with HIV from intravenous drug use went from 63 per cent to 7 per cent.

He also used the weight of his moral authority to stand behind other controversial public health programmes, including my blanket prescription for the opioid antidote, naloxone, which has since saved nearly 3,000 lives. When federal funding ended for a citywide collaboration to improve child health, he refused to take no for an answer. This programme ended up reducing infant mortality by nearly 40 per cent.

“The cost of doing nothing isn’t nothing,” he often said, reminding us that our job must be to level the playing field. Inaction will always have a disproportionate impact on those who are the most disadvantaged. Through his example, we changed every health metric to include a disparities measure; a major point of pride for our Healthy Babies programme is that it cut the disparity between black and white infant mortality by more than 50 per cent.

We still have a long way to go. Continuing the legacy of Elijah E. Cummings requires that we fulfil our destiny to fight for the world as it should be. We cannot rest as long as the currency of inequality is years of life. We cannot be content as long as where our children grow up and what colour they are determines whether they live.

• Leana S. Wen is an emergency physician and a visiting professor at George Washington University Milken Institute School of Public Health. She was Baltimore health commissioner from 2015 to 2018 and chief executive of Planned Parenthood Federation of America from November 2018 until July

http://www.royalgazette.com/opinion/article/20191022/reminder-of-health-disparities-for-people-of-colour

Health alert after mumps case confirmed

Fiona McWhirter

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  Symptoms of mumps include swelling of salivary glands (Photograph supplied)
  

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Health officials are investigating at least one case of mumps.

The Ministry of Health revealed on Monday that one case was confirmed with a second case suspected.

Investigations were being carried out by the Epidemiology and Surveillance Unit.

The ministry explained that mumps is a vaccine-preventable disease caused by a virus.

It said: “Mumps typically starts with a few days of fever, headache, muscle aches, tiredness, and loss of appetite, followed by swelling of salivary glands — located in the area between the neck and jaw, below the ears — on one or both sides.

“Symptoms may appear from 12 to 25 days after you are infected.”

Although most people with mumps make a full recovery, some people, especially adults, can suffer complications.

These can include painful swelling of the testicles in males or of the ovaries or breast tissue in females, inflammation in the pancreas, swelling in the brain and spinal cord, and deafness.

The ministry said that anyone who is not protected — either through a previous mumps infection or via vaccination — could catch it.

It said: “Mumps is spread easily by droplets of saliva or mucus from the mouth, nose or throat of an infected person, usually when the person coughs, sneezes or talks.

“Items used by an infected person, such as cups or soft drink cans, can also be contaminated with the virus, which may spread to others.

“In addition, the virus may spread when someone with mumps touches items or surfaces without washing their hands and someone else touches the same surface then touches their mouth or nose.

“Precautions must be taken to prevent spread of the illness to others.

“Close contacts of the person and physicians are being contacted and advised.”

The public was asked to be alert to symptoms of fever, headache, muscle aches, tiredness, and loss of appetite, followed by swelling of salivary glands. Symptoms can occur in children and adults.

Anyone displaying symptoms should stay away from work and keep their children out of school.

The ministry added: “Persons with mumps must be isolated to prevent spread. Call your doctor or the emergency room prior to seeking medical attention. This is to reduce the possibility of spread to others while waiting to be seen by the doctor.

“Check your child’s and your own immunisation record to see if you have had the mumps or MMR — Measles, Mumps and Rubella — vaccine.

“The MMR vaccine is the best way to prevent mumps.

“The first dose of the MMR vaccine is routinely given when children are 15 months old, and a second dose is given when they are four years old. Teenagers and adults should have received two doses of MMR.”

Anyone who has not been vaccinated should contact their doctor, or visit the school or child health clinics at the Hamilton Health Centre in Victoria Street to get immunised.

The public should wash hands, cover coughs and sneezes, and clean surfaces that are often touched to help prevent the spread of the disease.

For more information, contact the Epidemiology and Surveillance Unit on 278-6503.

http://www.royalgazette.com/health/article/20191021/health-alert-after-mumps-case-confirmed

Healthcare burden on course to double

Jonathan Kent, Business Editor

Bermuda’s working population can expect to paying out twice as much on healthcare in 20 years as they do today — and that’s if the island’s healthcare costs remain the same.

That is the view of Ricky Brathwaite, acting chief executive officer of the Bermuda Health Council, who was speaking about the impact of demographics on the healthcare system.

Total annual healthcare spending on the island is about $700 million, or $11,300 per person, Mr Brathwaite said during a panel discussion at the Bermuda Insurance Market Conference, organised by the Bermuda Insurance Institute.

“The number of working individuals to every senior is 3.9 — in 20 years that number’s going to shrink to 1.7,” Dr Brathwaite, a health economist, said.

“That means that even if we stayed at $700 million, and unless we want seniors to pay more, that 3.9 to 1.7 means a doubling of the cost for those contributing.”

The panel, which also featured Michelle Jackson, senior vice-president, group lines health and life at BF&M, and Michael Richmond, chief of staff at the Bermuda Hospitals Board, agreed that the Bermuda healthcare system needs transformational change as it faces pressures from the growing prevalence of chronic diseases and an ageing population.

“The burden of the population not growing, but ageing, will fall on you,” Dr Brathwaite added, referring to a relatively youthful audience. “Solutions have to be arrived at now, or you will face the results of non-action.

“Unless something is done in the next ten to 15 years in transformational ways, you’re going to bear the cost of a system that didn’t adjust to deal with higher levels of chronic conditions. That has a huge effect on productivity and on the economy.”

Dr Richmond joined the BHB two years ago, having previously worked in Qatar, where he said the health system’s challenge was dealing with 20,000 more people every month.

He expected Bermuda, with its stable population, to be less challenging, but soon discovered the island’s complexities.

“The demographics facing Bermuda are simply quite staggering, the growth of chronic disease is staggering, the lack of integration in the health system is staggering, the lack of information is quite staggering, and we have a primary care and community care system which is under enormous pressure,” Dr Richmond said.

He added that the pressures on the healthcare system had shifted from infectious to chronic diseases over recent decades. In the US, he said the obesity rate had gone from 11 per cent in 1973 to 70 per cent today. In Bermuda, 75 per cent of people are obese or overweight, according to research cited by the BermudaFirst group.

The management of chronic disease should be much more in the domain of primary care than the hospital, Dr Richmond said. “The role of the hospital is when those chronic diseases get out of control,” Dr Richmond said.

“Have we reached that point?” asked Kim Wilkerson, the panel moderator, who is head of claims at Axa XL in Bermuda.

“We reach it every day,” Dr Richmond replied.

Asked about the impact on the hospital of the ageing population, Dr Richmond said an increase in chronic diseases, such as diabetes and dementia, could be expected in an older population.

“If nothing were to change, we would need another 70 to 80 inpatient beds at the hospital,” he said. “That’s an enormous cost and it’s also not a very good plan.”

Most other jurisdictions facing similar issues had looked to increase community care provision, he added.

Ms Jackson said the solutions to the healthcare challenge had to be comprehensive. Blaming particular parties, such as insurers, the Government or physicians, was not the way forward, she said.

“The system is multifaceted and we need a multifaceted solution,” Ms Jackson said. “We all have a part to play.”

The solution had to encompass technological, educational, social and regulatory components. “You can’t achieve transformational change with one magic bullet,” she said.

Ms Jackson defended the health insurance industry against the notion that they took too much out of the system in profits.

“All of the health insurers have diversified businesses, so to think that the financial statements of these companies are all about health inurance is missing the point,” she said.

“It’s not a high-margin business — quite the opposite. The margins are really slim and if you’re profitable, you’re lucky.

“To suggest that health insurers are making out like bandits in this environment is way off the mark.”

The medical loss ratio of the government health insurance plans was about 140 per cent, she said, meaning that for every dollar in premium, $1.40 was spent on claims.

“If the private insurers did that, there would be no private insurance available,” Ms Jackson said. “If you think of the risks and the extreme probability of high catastrophic claims that are absorbed, it’s a very challenging business.”

Mr Brathwaite said naturally private insurers were in business to make a profit, but posed the question of whether healthcare should be regarded as a social service, rather than a profit-making business.

He added: “There’s only a certain amount of money in healthcare and if some of that money that could be going towards prevention is going on profit, then you have to take a step back and ask: are we benefiting the population in how we allocate the money?

“So it’s not a question of whether health insurers should make a profit, it’s a question of are we using all the money we have to spend on healthcare in the best way for the people?”

Ms Jackson said health insurers contributed through the valuable data they provided to the regulator and through the incentives they provide to clients to live healthier lives, she added.

“The health insurance business does better when people are healthier,” Ms Jackson said. “So the insurers on the island spend a lot of time trying to put together packages to try to get people to live healthy lifestyles.

“It’s simply good business for health insurers in a business where frankly, the demographics are not in our favour.”

The BermudaFirst group has proposed a change from the “fee-for-service” approach to an outcome-based system.

Dr Brathwaite said: “Are there incentives within physician practices to make money based on the number of services provided? Yes.

“Are there individuals who may take advantage of the opportunity to do so? Yes.

“That doesn’t mean that they’re wrong. It means that the system is set up for them to be able to do it.”

He said the outcome-based approach needed everyone in the industry to work together and agree to the same set of standards.

Ms Jackson said: “The vast majority of physicians on the island are high quality, but there are perverse incentives within the Bermuda healthcare system.

“There are tremendous conflicts of interest where physicians own additional services — labs, or pharmacies, for example. I think there are some fundamental things there that we have to address to eliminate those conflicts of interest.”

http://www.royalgazette.com/re-insurance/article/20191004/healthcare-burden-on-course-to-double

Jason Hayward

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  Under strain: change is needed to ensure the sustainability of Bermuda’s healthcare system (File photograph)
  

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The Bermuda Health Strategy Report 2014-2019 states: “Compared to other high-income countries Bermuda’s health system is not providing value for money as measured by health outcomes for the level of expenditure.”

It is indisputable that Bermuda’s health system is overly strained and failing Bermuda’s residents. This is evident as all residents do not have access to basic health insurance coverage and healthcare contributions are not affordable.

In addition, the long-term healthcare needs of our seniors are not being met. At the core of this issue, healthcare provider fees are largely unregulated and too often lead to co-payments that out of reach for working people and seniors. Some fees seem to place profit over people.

According to Bermuda’s 2018 National Health Accounts Report, Bermuda’s per capita health expenditure stands at $11,336, outranking most other countries.

Many senior citizens are finding it extremely challenging to cope as a large portion of their pensions are earmarked to pay for prescription drugs, diagnostic tests and other associated healthcare costs.

This financial burden depletes their limited disposable income leaving seniors with limited resources for other basic necessities. Too many Bermudians are electing to go without health insurance coverage because it is simply unaffordable.

The problem is exacerbated by an increasing number of employers who are offering workers vendor contracts in order to avoid having to pay benefits, especially the mandatory health insurance premiums.

Bermudians are demanding relief from ever-increasing healthcare costs and drug prices, and want a system that places Bermudian healthcare needs over profit.

What is needed is a sustainable and improved healthcare system and the Bermuda Health Plan 2020 will ensure all residents have access to basic health insurance coverage and will make health coverage contributions more affordable, allowing all residents to have access to healthcare services.

Health protection coverage is crucial for every human being and to the economy as a whole. In fact, good health is a prerequisite for sustainable development, economic growth and equity.

We must press forward for a healthcare system that has equal access to needed healthcare for all people.

Equitable health coverage does not occur automatically. It requires inclusive policies addressing inequities resulting from access barriers both within and beyond the health sector. When the private sector refused to provide coverage to residents with pre-existing conditions, the Government was forced to ensure that this segment of our population received coverage through HIP.

The introduction of a unified model will mean that one system will cover everyone creating a single insurance pool to spread insurance risk, ultimately reducing cost.

The new model will also create a uniform and comprehensive benefit set for everyone that is affordable.

The government reform goals are to cut healthcare cost by reducing copays and tackling fee levels and overutilisation that drives up cost.

The Bermuda Health Plan 2020 and additional reforms can make significant contributions to the realisation of the right to health, notably by ending financial exclusion and by contributing to strengthening national health systems that provide healthcare that responds to local needs, contributing to the progressive realisation of the right to health in Bermuda.

Those who profit from the status quo will almost certainly resist the Government’s plan to reform healthcare. However, the Government will remain steadfast in ensuring universal health coverage is achieved.

It is important that all stakeholders, including insurance companies who will still have a critical role to play in providing supplementary healthcare benefits, actively participate in the consultation process planed over the next three months.

I also encourage the public to review the detailed information put out by the Ministry of Health at www.gov.bm/healthplan

• Jason Hayward is the junior health minister and a government member of the Senate

http://www.royalgazette.com/opinion/article/20190916/reform-can-bring-down-healthcare-costs

Health plan feedback sought

Press release

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  Neville Tyrrell, the Acting Minister of Health (Photograph supplied).
  

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The Acting Minister of Health, the Hon. Neville Tyrrell, JP, MP has reiterated the Ministry of Health’s call for the public to review the proposals under the Bermuda Health Plan 2020.

Calling the public input “essential” Minister Tyrrell today urged the public to use this opportunity to provide feedback using the Citizen Forum on the Bermuda Government website, www.gov.bm/healthplan

Minister Tyrrell said: “The proposed Bermuda Health Plan that we have drafted for public consultation aims to address how we can move from sick care to a wellness (prevention) model.

“The Plan includes access to doctors, home care services and basic coverage for medicines, dental, vision and overseas care. But what is out for consultation is a draft for everyone to give feedback on.

“We want the community’s voice to determine what our future health plan should be.”

Minister Tyrrell added: “This basic plan is designed to help make us healthier and will result in real savings to individuals.

“The Bermuda Health Plan would replace the current Standard Health Benefit and we estimate that the sample ‘mock’ plan that has been drafted could be provided for $514 a month for adults and $178 for children.

“This would be $257 each, when shared between employer and employee.

“A family of four could save more than $8,000 a year and have reduced out of pocket expense in co-pays for doctors’ visits.

“With affordable access to care under this new plan we can offer coverage for screening, early intervention and proper management of chronic diseases like asthma or diabetes.

“We are encouraging all Bermuda residents to take time to review the comparisons plans.

“Your ideas, suggestions and contributions will help us to design a truly useful basic health coverage.

“The Plan comparisons for individuals, families, one child and one adult, and children are all located on the website which includes a direct link to the Citizens Forum.”

*Press release from the Government of Bermuda

http://www.royalgazette.com/news/article/20190822/health-plan-feedback-sought

Health insurance Act amendment passed

Paul Johnston

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  Establishing criteria: Kim Wilson, the Minister of Health
  

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Legislation to amend the Health Insurance Act 1970 was approved at the weekend.

The change will allow the health minister to make any additional benefit “subject to criteria, including means test criteria, and authorise the Health Insurance Committee to determine the criteria”.

Kim Wilson, the Minister of Health, said that amendment will allow the ministry “to continue to provide all persons in Bermuda access to health insurance by ensuring the plans we provide are affordable, focus on quality and ensure access to benefits”.

She said the Act will allow for the Health Insurance Committee to provide additional benefits outside of the legislated requirements of the plans, including the home-care benefit. The benefit allows for payment to people caring for elderly and disabled people in their homes.

Ms Wilson said that the ministry had to ensure that additional benefits are available to the people most in need.

She added that the amendment “provides for the establishment of some criteria for these additional benefits that would include means testing”.

Ms Wilson said: “The HIC would also be authorised to determine what the criteria will be for these benefits.”

The Health Insurance Amendment (No 2) Act 2019 was passed by MPs in the House of Assembly on Friday.

It amends the additional benefits orders made under sections 13(2) and 13B (2) of the Act in respect of the Health Insurance Plan and the FutureCare plan.

Ms Wilson said that means testing will only apply to policyholders who apply for HIP and FC after the start of the means-testing provision near the end of the month. She added that 341 people used the home-care benefit at a cost of about $6 million a year.

Ms Wilson said: “We want to ensure the viability and sustainability of these plans.

“To do so is to ensure that the population that needs them the most have access to them. “We cannot do that without establishing some criteria and ensuring there is a process for persons to show they are eligible.”

Ms Wilson added the legal change allows the HIC “the ability to do just that”.

She said the amendment also reduces the amount reimbursed from HIP and FC for services by overseas providers outside of the Health Insurance Department’s preferred networks. Ms Wilson added that the reimbursement rate would remain untouched for providers inside the network.

Jeanne Atherden, a One Bermuda Alliance backbencher, said that it was important to consider those who would be most affected by the change.

She explained: “The people who first started to use HIP and FC were those who couldn’t afford private plans.”

Ms Atherden added: “Changes today ... are going to affect some of the people that, at this point in time, we really wouldn’t want to affect.”

She questioned what the Government was doing to reduce costs.

Ms Atherden said: “I don’t see enough to indicate where we are in terms of reducing the utilisation. I don’t see enough to indicate where we are with educating people on the role that they play in healthcare.”

Michael Dunkley, another OBA backbencher, compared the amendment to “putting a half-inch Johnson Band-Aid on stab wounds”.

He added: “It’s not even going to last in the time we put it on.”

http://www.royalgazette.com/politics/article/20190716/health-insurance-act-amendment-passed

Duncan Hall (Published Jan 28, 2019 at 8:00 am (Updated Jan 28, 2019 at 12:11 am)

Costly system: the island's healthcare spending has soared over the past decade (Data source: the Bermuda Health Council)

In the first of a five-part series examining the impact of the ageing of Bermuda’s population, we look at the healthcare sector.

A shift in population demographics over the next seven years is expected to have a dramatic impact on the provision and cost of healthcare in Bermuda.

Government expenditure on healthcare is already the largest area of spending in the budget, exceeding debt interest. The rising cost of healthcare is a serious burden for businesses, which are legally bound to provide healthcare coverage for their employees, while also being a drain on household income.

According to a recent report, the current situation will worsen as the island’s population ages, resulting in increased demand for healthcare services, and a corresponding upward pressure on costs, at a time when Bermuda’s health system share of gross domestic product — 11.5 per cent — is already the third highest among Organisation for Economic Co-operation and Development countries.

Only the US and Switzerland outstrip Bermuda in that regard.

The island’s shifting population demographics, as outlined in Bermuda’s Population Projections, 2016-2026, means that, based on current projections, the proportion of the population 65 or older will rise from 16.9 per cent in 2016, to 24.9 per cent in 2026. This will occur as life expectancy increases and large groups born during past periods of high fertility become older. The overall population will decline by 111 people by 2026 as the number of deaths exceed births.

The increase in the number of retirees will be mirrored by a corresponding decrease in the number of people in the workforce paying into the system.

According to the United Nations, a country in which more than 7 per cent of its population is over 65 is considered “aged”; Bermuda reached that milestone in 1980. By 2026, one in nine of us will be 75 or older, increasing demand for long-term care. The median age will be 49.

The old-age dependency ratio, which measures the ratio of the population 65 years and over to the working-age population (15-64), is expected to soar from 24.7 to 39.9 by 2026. This means that there are expected to be 40 seniors for every 100 people of working age. The ratio is used as a gauge of a society’s capacity to maintain the quality of life of its seniors.

Citing 2010 census data, the report says that 77 per cent of seniors had a long-term health condition compared with 35 per cent of persons under 65. Moreover, 14 per cent of seniors had a disabling long-term health condition in comparison to 4 per cent of the population under 65. Overall, 40 per cent of the population reported having a long-term health condition in 2010 compared to 18 per cent in 2000.

The island’s Fiscal Responsibility Panel said in a recent report that our ageing population will result in increased demand for more or larger retirement facilities, senior citizen daycare programmes and in-home care services. It agreed with the population projection report’s findings that purpose-built residential facilities with trained staff for very elderly residents with chronic health challenges would be required in future.

John Wight, chief executive officer of BF&M Ltd, a health insurer, said it was important that the island develop new healthcare facilities.

“One important aspect of the current healthcare model which needs to be understood and addressed relates to the setting where many residents receive their care,” Mr Wight said. “In the early 1970s, the Hospitals Act came into force at a time when it made sense to drive people to the hospital for medical treatment. In 2019, we have to re-examine that approach and work on a new model of treating residents in the most efficient and cost effective manner, which often is not the hospital. We need to have a healthcare system that is flexible, where there are facilities other than the hospital to care for our aged population. Our lack of facilities is a critical issue both financially and emotionally for families as their loved ones grow older.”

Mr Wight’s colleague at BF&M, Michelle Jackson, agreed. “A lot of families have a loved one at the hospital because there aren’t very many options if you don’t have the finances,” said Mrs Jackson, senior vice-president, group lines, health and life, at BF&M.

“Long-term care is a huge issue in Bermuda. The hospital can’t be the place where people seek long-term care, it’s not ideal. Generally, we want to get out of the hospital as soon as possible. It is not the best place for people to age well.”

The panel also pointed to rising demand for medical services from the more elderly segments of the labour force (over age 50) with annual per capita claim costs for outpatient services rising by more than 50 per cent in 2017.

“[That rise] contributed to a 6.4 per cent increase in the Standard Premium Rate in 2018-19 and even larger increases in the premiums charged for supplemental private insurance schemes. The premiums paid by the Government on its much more comprehensive health insurance plan — the GEHI — may have to rise at a much faster rate than the SPR, most likely between 12.5 and 15 per cent.”

The panel said it warned in its 2017 report that over the medium and long term, the cost of healthcare must be addressed. “The island’s costly healthcare system risks overwhelming the budget and the whole economy as the population becomes increasingly elderly and frailer, with more and more requiring long-term care,” the panel wrote. “We said it would be important to pursue with determination measures to control and reduce costs and to better target government subsidies to those most in need.”

In its more recent report, the panel said measures must include:

• Encouraging elderly residents with chronic diseases to use more cost-effective prevention and treatment within the community rather than make costly hospital visits.

• Devising a more effective approach to the treatment of some chronic diseases, pointing to the rising incidence of kidney disease on the island and the $20 million annual cost of dialysis treatment for the less than 200 people in Bermuda requiring such treatment.

• Developing for all of us — seniors included — greater on-island treatment of certain categories of inpatient care in order to reduce expensive overseas trips for treatment as well as partnering with insurers and designated overseas hospital centres for the treatment of Bermuda residents. “We are encouraged by the recent partnering agreements with the Johns Hopkins University for on-island treatment and the work of the Health Insurance Department to explore opportunities for care in low-cost settings with good health outcomes,” the panel wrote.

• Making health insurance mandatory, and revisiting Government’s annual block grant of $30 million that is used to subsidise healthcare for children, the indigent and the elderly in order to redirect subsidies for those who do not have healthcare covered by employers — and, using means testing, allocating premium subsidies for anyone who meets set criteria related to income and health status (irrespective of age). This, the panel says, would also result in a fairer and more satisfactory outcome for the health condition of all Bermudians.

• Broadening the coverage of the standard health benefit to include prescription medications, preventive care, and access to providers that offer effective disease management (rather than being limited only to hospital care).

The panel said it was encouraged by Government’s efforts to begin to address some of the sources of chronic disease in Bermuda. “Witness the Bermuda Health Strategy, the Bermuda Health Action Plan, the Long-Term Care Action Plan, and a number of initiatives to contain costs and promote a healthier lifestyle (the Enhanced Care Pilot, the Patient Centred Medical Home, and the Personal Care Benefit),” it wrote. “The new 50 per cent duty on sugary soft drinks, candies and pure sugar imports (which will be raised to 75 per cent in April 2019), represents a further initiative. The revenues to be raised (roughly $10 million in a full year at the higher rate) should be clearly seen as earmarked to specific programmes that expand health promotion and encourage healthy lifestyles.”

Moreover, the panel says, the private medical care sector must come under some form of regulation.

“The private medical care sector in Bermuda is largely unregulated, raising concerns about both the cost and quality of the care provided, of diagnostic testing and of pharmaceutical products,” the panel writes. “Further efforts are needed to strengthen the regulation of private sector providers (including their use of health technology) as a means to reduce duplication that adversely impacts healthcare costs and exposes patients to unnecessary risk. As in our 2017 report, we believe that an appropriate regulatory infrastructure with enforcement resources remains a necessary element of any strategy for cost containment in Bermuda’s healthcare sector.”

http://www.royalgazette.com/business/article/20190128/healthcare-coming-under-strain

Dear BMDA Members,

At present, we are not aware that any of the  products on island are affected by the recall, but the pharmacy inspector, BGA and Pharmacy Council are continuing to explore the situation to confirm there is no risk. Once the risk assessment is complete, there will be an explanatory notice to the public.

In the first instance and in the meantime, physicians should recommend that their patients contact the pharmacy that supplied the medication for specific information and advice. 

When the Ministry receives medication recall information, we inform the hospital pharmacy manager, BGA and Pharmacy Council (who informs Pharmacy Association and pharmacies). When BGA receives recall information (which includes batch/lot numbers and expiration dates) they inform the pharmacies with instructions as to what to do with any affected product.  I have been informed that most of the ACE/ARB medications used on the island are imported from the UK and not the US which is where all  of the recalls have originated.  It appears that the European product has not been affected. 

We will inform the community more fully when facts are confirmed.

Cheryl Peek-Ball, MD, MPH

Chief Medical Officer

Duncan Hall (Published Jan 28, 2019 at 8:00 am (Updated Jan 28, 2019 at 8:21 am)

Costly care: the Bermuda Government is planning reform of heathcare financing

By April, Government is expected to announce its plans for reforming the way that healthcare is financed in Bermuda.

The Health Financing Reform Steering Committee has, since June of last year, been consulting with stakeholder bodies about two financing options. The committee has been tasked with delivering a programme that provides affordable and sustainable healthcare for all Bermuda residents.

Kim Wilson, the health minister, last year said that the cost of the island’s minimum health package was shared across 48,000 insured people in Bermuda. However, supplementary benefits are shared across much smaller groups, leading to greater healthcare costs for treatment covered thereunder.

By expanding the proportion of healthcare that is protected by the larger risk pool, she said, healthcare costs can be stabilised. Under the reforms, she said, the cost of healthcare “will be better than what most people pay for this level of coverage today”.

Referring to medical care inflation of about 6.4 per cent in Bermuda, Ms Wilson said: “There were no fee increases and only negligible benefit changes. So the only reason the premium for the minimum package increased is because our people are sicker, older and receiving more healthcare.”

The island’s Fiscal Responsibility Panel observed: “Regardless of which of the two financing proposals is adopted, Bermuda’s healthcare system needs to address: how to ensure any government subsidies are used most productively and fairly directed; how to ensure resources for healthcare in the economy are used effectively and with effective control of costs; and how to ensure that healthcare is at least accessible to all Bermuda’s citizenry.”

According to the report, Bermuda’s Population Projections, 2016-2026, released last year:

• Average household spending on healthcare was $7,000 in 2004, a 156 per cent increase on the amount spent in 1993 that was well in excess of the 32 per cent rate of inflation for the same period.
• By 2013, the amount each household spent on healthcare was roughly $10,300, a 47 per cent increase on 2004. The rate of inflation during the same period was 30 per cent.
• In 2013, households headed by seniors spent $10,919 per year on healthcare, up from $6,000 in 2004. Some 76 per cent of that expenditure was comprised of health insurance.

According to the 2018 National Health Accounts Report, released last week by the Bermuda Health Council, the total public and private expenditure neared $723 million for the fiscal year 2016-17. That was a dramatic increase on the total expenditure of $460 million for the fiscal year 2006-07.

http://www.royalgazette.com/business/article/20190128/healthcare-financing-reform-on-way