Hospital’s billing system under scrutiny
A “fee-for-service” billing system at King Edward VII Memorial Hospital is being reviewed by health chiefs who claim that it “incentivised” physicians to carry out tests and invasive examinations on patients in order to increase the hospital’s revenue.And even terminally ill hospital patients may have undergone unnecessary medical tests and procedures because of the arrangement, health advocates claim.The billing system — also known as case-based reimbursement — was introduced by the former Bermuda Hospitals Board (BHB) in 2009. According to the Board’s website, it is “a fairer, more transparent way to charge people for services used”.“It means someone who is admitted to hospital will be charged based on the type of treatment and services associated with their diagnosis. Previously, the hospital charged one daily rate, no matter how many services were needed,” the website added.But Government MPs have criticised the method, saying that it needs to be re-examined to ensure that vulnerable patients are not being taken advantage of.And according to one health watchdog, the process has been “abused to the extent that medical tests were recommended and used purely as a means to increase revenue”.Backbencher Jeanne Atherden, who is also chairman of the Bermuda Health Council and a member of the new BHB, said: “We’re looking at the whole system of charges to see that they are not being abused.“Nobody wants to see duplication or over testing because that can have a negative affect on the patient. One never wants to have a system that encourages revenue generation — the emphasis needs to be on patient care and patient outcomes.“If you have incentives for people to generate income, what we really should have is a system that encourages quality. I have real concerns when I see salaries that were related to things not related to quality of care”She added that the hospital appeared to place “great emphasis on revenue growth which was very much encouraged”.“The health council is now looking at utilisation management, standards of care and regulation.”Those concerns were echoed by Economic Development Minister Grant Gibbons, who said: “You don’t want somebody paid or incentivised on the basis of the more tests or more time.“What you want them to be compensated on is the quality of the outcome — how successful has the treatment been and how efficient have you been in administering that. Pay was connected to utilisation which is not good at all. There was a complete lack of attention to cost control at the hospital.”Last month the BHB said it was aware “that there is a perception that BHB charges too much, makes too big a surplus and yet squanders its resources”.“We believe there was not enough focus on cost control at BHB, as its strategy over the last seven years had been to grow its revenue and increase the number of services available on Island,” Chairman Jonathan Brewin said in an open letter to the community.“This contributed to the increasing use of services — utilisation — further driving healthcare costs up.”Last night hospital watchdog the Bermuda Health Advocacy Group welcomed news of the review, claiming that the billing system had put dollars ahead of care in the hospital’s list of priorities.“The premise for change was purely economical and in an endeavour to increase profit margins,” a BHAG spokesman said. “To date the BHAG has had numerous complaints from a wide spectrum of the community complaining about costs and unnecessary procedures.”
The Royal Gazette has received copies of two recent letters written to Preston Swan, President of Quality and Risk Management at the hospital, expressing concerns that patients were put through procedures that were unnecessary.In one letter, dated February 19, widow Susan Plant explained that her husband Colin endured a five-day stay at King Edward VII Memorial at the end of January in order for cystoscopy and biopsy procedures to be carried out after an earlier ultrasound had identified a large bladder tumour.A later CT scan showed “invasive bladder cancer with metastases to lung and lymph nodes”. Mr Plant died less than four months later.Mrs Plant has now questioned why her husband was forced to spend five days at the hospital and claims the biopsy was not required.“When my GP called on January 15, he told me that the ultrasound showed that it was bladder cancer — that could be seen without a biopsy,” she said.“The CT scan was ordered after the biopsy. So if the doctor had gone straight from the result of the ultrasound to the CT scan, the biopsy could have been avoided as it was pointless as far as I can see — just to find out what type of cell was causing the problem. As it was metastatic, there was no treatment for it, whatever type of cell it was.”In another letter, a health advocate who asked not to be named, summarised a meeting she had with Mr Swan in April.The health advocate listed a number of concerns that had been discussed at the meeting including: “That every care and attention should be given to the palliative needs for peace, respite and comfort of very elderly and dying patients; that patients identified as being close to death should not be subjected to invasive, painful and unnecessary tests and procedures and that these patients and/or their immediate families should have the right to refuse procedures where there is no immediate medical benefit to be gained.”Concerns about overtesting were supported by one General Practitioner who spoke to
The Royal Gazette on the condition of anonymity.The doctor said that one of his patients, who he diagnosed with terminal cancer, subsequently went to KEMH for further tests — and was even sent overseas for chemotherapy treatment, only to die a few weeks later.
