Good evening, everyone
It’s a pleasure to see you all here today. As you know, the purpose of today’s forum is to provide an update on the Bermuda Health Strategy and discuss upcoming developments with you.
You are our closest stakeholders – the persons and organizations best placed to assist us in achieving my personal goal of affordable and accessible healthcare for all our residents.
As you know, the Ministry of Health is one of the largest Ministries in the Government. Our mandate is very significant and we oversee a sector that represents over 11% of the Island’s GDP. But the Government is concerned about health not only for its financial value, but also for its social, ethical and economic value.
I want you to know that I am personally committed to improving access to primary care and preventive services for all of Bermuda’s residents.
That is, in fact, the goal of the Bermuda Health Strategy, which is our National Health Plan.
Some of you may have wondered what happened to the National Health Plan, or what would become of the Bermuda Health Strategy under the new Government. I’m pleased to tell you that the work of the Health Plan has progressed and we intend to press ahead with the reforms needed to contain health costs and ensure decent coverage is affordable to all.
One of the first things I looked into when I took over the Ministry was the status of the National Health Plan. And I realized right away that the Bermuda Health Strategy is, effectively, the same strategic plan to reform the health system.
Although some time was lost in between the two, many good things have advanced, and we are pressing ahead with more.
You will recall that the Bermuda Health Strategy outlines the priorities to reform our health system. Its mission is “to provide affordable and sustainable healthcare for all Bermuda residents”. This encompasses the spirit intended by this Government: to achieve Universal health coverage. That is our goal, and we have every intention of achieving it.
The Health Strategy is founded on three core values: Quality, Equity and Sustainability. I want to tell you about the progress made to date and what’s coming next.
Starting with the core value of ‘Equity’, the Ministry truly wants to achieve access for all.
This means improving access for underinsured and uninsured persons to primary care and specialist care in the community. This is vital to keep our working population economically productive and able to care for the dependent population – whether young or ageing.
To this end, the Health Insurance Department introduced two significant benefit innovations to deliver better care to patients who often end up on a revolving door at the hospital. Namely, the Personal Home Care Benefit and Enhanced Care Pilot. In addition, BHB established the Patient Centred Medical Home for the un- and under-insured. These benefits cover all necessary care for specific chronic conditions, including prescription drugs. They are pilot programmes and they are being evaluated to get their design right.
I would like to see these benefits rolled out to the full population, so not only HIP and FutureCare patients, or the very, very ill, have access to them. I want us to find ways to reduce out of pocket costs for essential care, so that people can access services before problems get out of hand. I want the public to have benefits that help them sustain health, not just patch them up when they are already broken. Frederick Douglass’s phrase comes to mind in this regard: “It is easier to build strong children than to fix broken men” [and women]. How true this is in health.
I believe that better and timely access to preventive services and early intervention will yield savings in the long term. “An ounce of prevention is worth a pound of cure”; and saving these persons – often from themselves – means better quality of life for them and their families, better use of healthcare resources, and better, more equitable health outcomes for the country.
The second value of the Health Strategy is ‘Quality’.
Good quality care reduces health costs because it avoids over-treatment and prevents the need for costly interventions. I know I’m preaching to the choir here, but I do want to talk about some of the developments in this regard.
An important part of quality will inevitably come back to reimbursement. The way payment works in our health system currently has led to a lot of inconsistency and inequality in what gets paid for. We’ve ended up with ‘haves’ and ‘have nots’ in terms of patients, providers and payors.
Some patients get all the care they need, and often more. But other patients are blocked out of the system by co-pays they can’t afford and inadequate insurance coverage.
Some healthcare providers have fine reimbursement – but some are paid a fraction of what their services cost.
Some insurers have impressive medical loss ratios of 80% or less. While others’ loss ratios are in excess of 150%, leaving them to pay $1.50 in claims for every dollar they collect.
As a system we want to move to more effective and fairer ways to pay for healthcare in order to improve the quality of care and ensure access for all. But we are far from that sweet spot yet, and there are no easy solutions.
What is clear is that there is no solution that will make everyone happy. We cannot reduce health spending or premiums without reducing health revenues. Our system has backed itself into a corner, and it won’t be easy to work our way out of our current payment system to one that will enable better quality, rather than just more and more quantity.
To this end, the Health Insurance Department is experimenting with a different way to pay healthcare providers so they are rewarded for good outcomes. The Enhanced Care Pilot pays providers a set monthly fee to manage a patients’ chronic conditions, plus a bonus at the end if health outcomes are met.
In addition, right now we are working to modernize the BHB fees and convert them to a rational, transparent methodology using the relative value system. We are looking to implement this with a Bermuda conversion factor and this method will form the basis for other healthcare fees in due course.
In this journey we are also conscious of the essential need for a health information system – a means of connecting all healthcare providers and the health surveillance system so that important population health information can be readily obtained, and clinical care can be better coordinated between providers.
We are hopeful that the development of the Unique Patient Identifier will serve as a critical first step in the right direction, and we’re grateful to the practices that are helping us to trial it, adjust it and get it right.
In addition, the Residential Care Homes Act was amended in December to bring dramatically improved standards to rest homes. We are also implementing long-needed updates to the mental health act to improve the quality of care for persons in need.
Lastly, many of you know that we are looking to make improvements to the oversight of healthcare professionals to make sure health professional boards are appropriately supported to regulate their own professions.
As I said, these are just examples to give a flavour of progress to date.
The final value of our Health Strategy is Sustainability.
It is well established that some of the primary drivers of health costs in Bermuda are chronic disease, the ageing of our population, and utilization of expensive treatment options, in particular emergency room and hospital beds. A great deal of work is underway to improve things in this regard.
First is the Department of Health’s Obesity and Diabetes Framework, which was a Throne Speech initiative under this Government to tackle chronic non-communicable diseases.
I’m sure you heard about the framework when we held the “Commit to Change Symposium” in January. This framework was developed with wide community consultation and engagement and it is our best hope at “halting the rise in obesity and diabetes” in this country.
In addition, we are working on the Sugar Tax, which I’m sure you’ve all heard about by now. This initiative was in our platform and our Throne Speech, and it has developed quickly presenting an exciting opportunity to send the strongest message to the community that this Government is serious about tackling obesity and chronic diseases. The initiative will raise some revenue that will be earmarked for health education, promotion and preventive programmes in the community.
And, in addition, there are the innovations in healthcare benefits which we are piloting to try to reduce healthcare costs by delivering better chronic disease management and driving care out of the hospital, to the community, where it rightly belongs.
I made reference to a couple of these benefits earlier, but I want to pause to highlight the singularly most popular offering by the HIP and FutureCare plans: the Personal Home Care Benefit.
The popularity and demand for this benefit should not have surprised anyone given the frankly dire needs in the long term care arena.
I am acutely conscious of the reality that Bermuda’s population is ageing, and that we are getting old sicker, which is driving up health costs in an unprecedented and unsustainable way.
For this reason, I’m especially glad that this year I was able to secure funding to re-open 10 beds at the Sylvia Richardson Care Facility. The country desperately needs this long term care capacity, particularly as we know the strains put on acute care beds at KEMH by long stay patients.
To this end, the Personal Home Care Benefit also offers some relief. The benefit offered by HIP and FutureCare covers skilled and unskilled assistance with personal care and/or dementia care at home for eligible policy holders. It includes home care, nursing and day care services. The benefit has exceedingly high levels of patient satisfaction and strong indication effectiveness.
The Personal Home Care benefit has also stimulated positive workforce opportunities as the caregiving sector has expanded and demand for the Bermuda College nursing associate programme has increased. Given its popularity, cost effectiveness and early promise, I am looking at how this benefit can be extended to the full insured population.
However, I know that it alone will not fix our long term care problems. In addition to the bed blocks at KEMH, which are costly and interfere with acute procedures, there is also a shortage of beds in the community. And even if a bed is found, most people simply can’t afford $5,000 a month for the care, and homes can’t afford to provide quality services even at that rate.
We have just completed an analysis of long term care funding, and are developing a three to five year strategy to tackle the country’s grey tsunami, as well as long term care services for persons with disabilities.
As you can see, a lot of movement has been taking place under the auspices of the Health Strategy, and I’m proud that the seeds we planted with the National Health Plan is what led to all of every one of these initiatives.
However, we are still short of the major prize: affordable and accessible health coverage for all. Where are we with that?
Actuarial work was completed pricing a whole new basic benefit package developed under the National Health Plan, and presenting options to reform our health financing in order to achieve universal coverage.
We are looking for a new basic package that can include preventive as well as curative and specialist services. And we are looking at the options available to pay for it.
Financing option models were proposed by the Finance and Reimbursement Task Group together with our actuaries, and we are gearing up to share more on these proposals. But in a nutshell we need to change the model to a more streamlined way to finance healthcare than what we have currently.
This is the work that I’m most excited about for the coming year. I’m pushing my teams because I want these reforms in place for 2019, and we have no time to waste.
To wrap up, that summarizes the achievements to date under the Health Strategy, the priorities underway and the next steps coming soon.
Now, I have to be honest: it’s not going to be easy. We are talking about changing entrenched behaviours and expectations – of patients, providers and insurers. But the goal is to reform the system for everyone’s benefit.
I, personally, am steadfast and committed to seeing the financing reforms through, and I look forward to working closely with you to make healthcare accessible and affordable for all.