Being as I am home sick today, health care seems like a good topic for the blog. I am surviving on the 4 food groups of people with colds and flu's -- Popsicles, liquid meal replacements, soup broth, and hot drinks laced with phenylepinephrine hydrochloride. I have not even wanted coffee for 2 days, a poor prognosis indeed. The cough syrup with codeine gives me some relief. If "Man-Flu" were real, I would have it, I have all the symptoms of despair and all consuming self-pity, which I have done my best to share with my lucky friends. The Panthers were horrified after their long vigil at my side overnight that I felt so bad yesterday that I neglected to restock the Whiskas they like for breakfast. They were forced to eat their healthy lunch food at the wrong time. They too are wallowing about in despair and self pity now. Lexi cat is, of course, is happy to lay about and share the misery.
For a patient, health care is very simple in Bermuda. By law, you and your employer share the cost of the standard hospital benefit through a group plan. You may opt to purchase higher tiers of service, which can lower fees at the doctor and include more dental and vision care. Bermudian seniors may purchase a discounted government insurance policy called FutureCare, and the Bermuda government provides a subsidy to any hospital care of children or the indigent. My monthly deduction from my pay cheque for the most comprehensive package is $503 per month, plus my employer pays an additional sum to the insurance company each month for their 50% of the basic hospital care package. I would guess they are paying between $150-$200. So my insurance premium as a single is about $650-$700 per month. I do pay a few things out of pocket, a portion of prescriptions, a user fee to go to the general practitioner or certain specialists (anywhere from $3-$40 at the GP, no idea what they are charging for, they are neither friendly nor informative when I have asked, to $200 when I had to see a dermatologist to find out that the antibacterial gel we have in the workplace has a very bad effect on eczema, i will spare you the description, just trust me if you have eczema stick to soap and water). Other than that, I have full coverage. If I lose a contact, it's covered, if I wake up blind in one eye on a weekend morning and they have to call in a specialist to make sure my retina is still attached, its covered. If I get sick here or overseas, I am fully covered. If my retina would have fallen off, I would have been flown to the US on the next flight. Although pricey, it is really good insurance coverage, and when you aren't seeing a high income tax payroll deduction it doesn't seem like a bad expenditure at all.
I decided to look up the insurance differences for other situations though. Of course in Canada we are fully covered, and depending on your location and employer, the fees may be nothing at all. The most I ever paid is $30 there was a month. I think everyone who has watched the news in the past 2 years knows something about Obamacare in the US. I decided to plug in my numbers and see what my premiums would be there -- about $210 per month for the 70% coverage plan, but I would be liable for up to another $6300 per year in out of pocket medical expenses if needed...an average of $480 per month, so my "real" cost could be $680 per month. And I guarantee my salary is less in the US than in Bermuda for my profession, so I am better off in Bermuda for health care. Going back to Bermuda though, the FutureCare package for seniors provides less coverage. FutureCare is just over $400 per month and does not cover major medical. Some things, including overseas surgery is only covered at 75%, meaning you could be faced with a financially debilitating situation. When it comes to being a senior, I will be better off in Canada.
Looking at the provision of health care services in Bermuda is where the system gets a little complex. It is hard to look at the whole system without seeing some areas critically. I don't mean to devalue the system. It is most important to remember that residents of Bermuda receive excellent coverage and have rapid access to care locally, and a system of overseas partnerships to provide medical treatment for any services not available on the island. But health care costs in Bermuda have escalated to some of the most expensive costs per person in the entire world. The Bermuda Sun cited an average of over $10,000 per person per year in 2012. What I am sharing is observations from the outside perspective of someone coming from a public health care system, and examples of where the system is failing to keep costs in control -- primarily because in the system some health care is tied to politics, and other parts operate as private entities with not enough regulation to contain costs. As a disclaimer, I have no financial background, no administrative certifications, and am not political enough to know every angle. This is just what I see through my experiences.
The island has one hospital, King Edward VII Memorial Hospital. As opposed to being a private facility, like one sees in the US, or public like in the UK or Canada, the hospital operates under a Quango. Quango was another new word for me when I got here, it stands for a "Quasi-Autonomous Non-Governmental Organization." It stands to reason that anything with such a complicated name is going to get a little complicated later down the road. However, the concept is that a Quango acts as a semipublic administrative body outside the civil service but receives financial support from the government, which therefore has some external control over it. The upside is that government will subsidize certain aspects of the hospital's operating expenses, and should be able to ensure a quality service. There are downsides as well. While not everyone may see this as a downside, the government can appoint staff into certain positions, but I see this as a downside because political appointments can very suddenly make a non-government body a very political body. The government can also influence certain decisions, such as proceeding with construction of new wings and centers, which is a win for the government in growing jobs and the economy. However, a change in government can change the subsidies and focus of expenditures, leaving the health care in the center of 2 different political agendas and a financial crisis when there is a transition in Government. For example, an Urgent Care Facility was constructed in 2009 in St. David's, and staffed with physicians, nurses, x-ray techs, and lab personnel. But this little island of 60,000 already had the major hospital plus many private facilities which operate outside of the quango providing laboratory services and diagnostic imaging services, generally operated by a physician or group of physicians who like the convenience and huge revenue of having their own facility. In short, the Urgent Care Center was underutilized from the start. The plans to develop a similar facility in Somerset were quietly discarded. The lab staff were pulled a couple of years back. There was a nurse on duty until 4 and a physician after 4. After major changes to funding from Government, the hospital was pressed to make major changes and savings. Late in 2013 the Hospitals Board announced that it was closing the Urgent Care Facility as part of responsible fiscal management. It had been operating at a loss, redundancies were given, money would be saved. Or so it seemed. Some citizens decided they liked the idea of having the center there. They didn't want it to close, even if it was only really used for sprains, headaches, and colds which could be treated by a general practitioner at a lower operating cost. Marches were planned, and 2000 people signed a petition to keep the center open. Because the hospital is a quango, 2000 signatures could also mean 2000 votes in the next election, and so politics take precedence over sound financial practice. The closure of the Urgent Care Center by the Bermuda Hospitals Board was overruled by Government due to public pressure after the fact, and reopened with a plan to come up with a new plan in the future (still waiting to hear what it is), but for now the hospital is forced to continue operating it, at a loss. And of course there were redundancies...those are not reversible and can be added to the operating cost losses. This is an real life example of the downsides of a Quango.
Basically, the structure of health care is such that patients can get exactly what they need, and sometimes what they want and don't need, in a timely and convenient matter, but the overall system is very costly due to its structure. The government provides some subsidies, which can rapidly change with the face of government, and gets a say in how the entities that use those subsidies must operate. There is no limit on the amount of private facilities that can operate, and each one is in business to make a profit. Common sense and good financial practice would seem to dictate that if a doctor has a laboratory in their office, they are profiting from tests ordered, and a system of checks or audits must be in place to ensure only relevant tests are being ordered. Even so, I don't know that this is acually being done, and if it were, it is nearly impossible to tell from the office desk of an insurance company whether a test is being ordered in good faith, it is really up to the honor system. Many countries have abolished this practice because it seems to increase health care costs without improving the health of the population. I have experienced cases where tests were ordered that were not required based on the nature of my visit or history, but that a physician could argue should be done on anyone in a set age group. It may or may not be intentional, they may simply get into the habit of ordering specific panels of tests on patients in a certain age class, when doing a more detailed history would rule out the need for many of those tests. It may fall under the "Doctor House" argument that patients lie and you should run tests that don't fit the history. Or it might just be a good way to increase revenue. Another issue is that in most situations there will be a test that will confirm a diagnosis, and several others that will rule out the other less likely possible diagnoses. The physician is almost forced by the current system to order all of these tests to cover their butts in the unlikely situation that it is the less likely diagnosis -- because ultimately they are solely responsible for choosing how much or how little to order, and therefore solely liable if they do too little. I think a system of standard ordering protocols would relieve them of this responsibility and liability, and decrease the financial burden of diagnostic testing on the health care system and the economy. This idea has been roughy presented recently in Bermuda with many objections -- they call it pre-approval, and opposers play it out in the public as though a patient and doctor will have to face delays or not be able to order what they need. This is not true. The same concept is used in many countries, and all it means is responsible reflex testing. For example, currently the physicians may order a screening test plus all the specific tests that narrow down the results of an abnormal screen. If the screen is negative/normal, none of the others need to be performed. An efficient system is to automatically reflex to the additional tests when a screening test is positive, rather than perform them upon request in the absence of a positive screen. It's a good change. It's just that people have a hard time with change. And of course anyone making revenue from diagnostics will not appreciate the change, it will lower their revenues...but it also may help stop the annual rise in your personal premiums. Responsibility also lies on the patients. It is not unheard of for a patient to attend the Urgent Care Center, their general practitioner, and the emergency room on the same day as they hop from place to place looking for the answer they want. I have never spoken to so many people who have had MRI's done. I would love to know the usage of MRI on the island per capita compared to the rest of the world. Because MRI's sound cool. Everybody wants one here, and many will make demands on their physicians. That's a quick way to drive up health care costs. Responsibility also lies with the insurance companies -- if there was a better system in place to pay for only what was necessary both patient and doctor may be more responsible. If the doctor could say "I would like to do an X-Ray to prove the aliens didn't put a tracking device in your arm (a made up but not unfathomable request believe it or not) but it's not covered by insurance, it will cost you $xx," then the health care system wouldn't be paying for each visit the same patient does to different care providers until they get their X-Ray. The public may need to readjust their thinking of what they are entitled to, and learn that doctors can tell them no, and the system needs to evolve so the patients learn to hear no, that the answer is given consistently, and that it will be backed up by the rest of the system, putting a stop to "service jumping" from place to place. This is all necessary because Bermuda's financial position has changed considerably for the worse over the last decade. Everyone is aware that change must happen. But there is not yet an agreement among Bermudians as to how that will happen. So in the mean time, things continue as they are, and construction continues on the new wing of the hospital, a $247 million dollar construction project expected to be complete in June 2014.
Leaving the burden of health care costs behind, one has to say that the amount of services available for such a small population are impressive. The range of specialists and high tech equipment exceeds what would be ordinarily present for an equal size population in a larger country. The relative isolation of Bermuda demands that essential services be on hand, and the high insurance cost of sending patients overseas for what is not available commands that more services be offered on the island than would be to a mainland population in the 60,000 person range. All in all, it's a good service, it just has room for increased fiscal responsibilities amongst partners to make it more sustainable. I am sure it keeps the current Government awake at night, and am hopeful that they find the right solution, and soon. And now, I return to my $40 of prescriptions and $40 of over the counter remedies to try to kick the most miserable cold/flu that I have had in years. I am grateful that I was able to see a doctor and be out of the pharmacy in less than 2 hours total. Like most people everywhere, I worry about healthcare sustainability. But for today, I am just happy that I had access to everything I needed, when I needed it, and that I don't live somewhere like Afghanistan where the annual healthcare expenditures per person are $47. That would have only gotten me a package of Claritin and some Vitamin C. I guess our First world problems aren't so bad.
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