The Ministry of Health launched its Bermuda Health Strategy 2022–2027 last month in a bid to make sure that everyone has access to essential, quality health services without suffering financial hardship. FIONA McWHIRTER takes a look at some of the proposed solutions to the island’s healthcare crisis.

Where are we starting from?

About $736 million was spent in 2017-18 on healthcare. The health strategy highlighted that the island’s health system was “challenged by unsustainably high costs and does not provide equitable access to quality care for our population”.

There is a legal requirement for employers to provide health insurance for employees working more than 15 hours a week and more than two months in a calendar year. Non-working spouses of employee must also be covered.

Premiums are paid to health insurance providers, including private companies such as Argus, BF&M and CG, and the Government — through the Government Employee Health Insurance programme and the Health Insurance Department, which runs HIP and FutureCare.

Every plan includes the Standard Premium Rate made up of two components — the Standard Health Benefit, access to a base package of mandated health benefits, and Mutual Reinsurance Fund benefits, a contribution to select high-cost benefits as well as health system administration.

The Bermuda Health Council website explained that services, reimbursement rates for the SHB and MRF benefits, and the SPR were set by the Minister of Health and reviewed every year.

SHB benefits for 2021-22 included some diagnostic imaging services as well as set home medical services and medicines.

Supplemental benefits determined by each provider could include services such as vision and dental care, as well as overseas medical treatment.

What are the problems?

The Government’s health strategy said that health results do not reflect the amount spent in the sector and more than a third of the population was unable to get quality healthcare without financial hardship,

The plan showed that, according to pre-pandemic figures, 11.6 per cent of the island’s gross domestic product was spent on health — the third-highest rate among the 38 member countries in the Organisation for Economic Co-operation and Development.

Health spending grew by 69 per cent between 2006 and 2017 and about 12 per cent of the population is uninsured.

Another 23 per cent is either underinsured — when someone has health insurance but the package does not cover everything they need — or has defined unaffordable health insurance, where people struggle to pay health insurance premiums, co-pays or both.

Bermuda has major health problems including its diabetes rate, which is the third-highest in the OECD with more than 13 per cent of residents diagnosed.

Half of residents have at least one chronic condition such as diabetes, heart or kidney disease and 75 per cent of the population is overweight or obese.

What is the plan?

A five-year strategy was developed to focus on eight key areas:

• Promoting healthy living and preventive care

• Understanding the population’s health needs

• Providing access to healthcare coverage

• Strengthening the island’s healthcare workforce

• Harnessing healthcare technology

• Focusing on person-centred care

• Partnership and collaborative working

• Preventing wasteful care and promoting efficiency

Action scheduled for the first year included the trial of integrated pathways for essential care as examples for setting up universal health coverage and delivering better value.

Another target was to establish the economic case for strengthening the healthcare system and delivering universal health coverage to support the wider economic case for the island.

So, what is universal health coverage?

UHC is an essential benefits package for all residents. This is a World Health Organisation challenge to countries to view healthcare as a basic human right.

The WHO said: “Universal health coverage means that all people have access to the health services they need, when and where they need them, without financial hardship. It includes the full range of essential health services, from health promotion to prevention, treatment, rehabilitation and palliative care.”

It added: “Universal health coverage should be based on strong, people-centred primary healthcare. Good health systems are rooted in the communities they serve. They focus not only on preventing and treating disease and illness, but also on helping to improve wellbeing and quality of life.”

The WHO said that “robust financing structures” were key to strengthening health systems in the move towards universal coverage.

Bermuda is not starting from scratch: the island already has an established health system; it’s just very expensive.

It will take time and consultation to determine what should be included as essential health services under UHC, based on the present and future needs of the population, as well as the resources available.

Kim Wilson, the Minister of Health, insisted that there will be a need for supplemental insurance. That means that insurance companies will still be required.

Does this mean UHC will replace what comes under the Standard Premium Rate?

It is expected that some of what is included now across the SHB and MRF provisions will overlap with items in a universal health coverage package.

But the present set-up tends to be treatment-focused with services provided after someone has become ill. It is thought that UHC could include preventive components such as wellness checks in the hope that health problems were spotted early.

What about the single-payer system that we heard discussed before?

The terminology could change, with a shift now to dominant payer system — recognising that supplemental coverage will be provided by different insurance companies to those who want to buy it.

A dominant payer would supply the UHC package to everyone, then people could buy supplemental health insurance packages from any other insurers.

It has yet to be determined which organisation would take on the role of the dominant payer.

But Ms Wilson has said she does not anticipate that UHC in Bermuda will be a government-run scheme.

It is thought that economies of scale could be achieved through a single-payer system.

A 2016 article from Harvard Health Publishing, the consumer health education division of Harvard Medical School, said that “a single-payer system has more incentive to direct healthcare spending towards public health measures”.

But it added: “Lengthy wait times and restricted availability of certain healthcare services, such as elective surgery or cosmetic procedures, are important criticisms.

“Thus, despite its advantages, single payer will not ease the constant tension of balancing access, quality and cost in healthcare.”

The Ministry of Health’s strategy highlighted that a combination of “governance and the right skill set” in the healthcare workforce was crucial to the delivery of high-quality care.

It said that care pathways — the steps taken by patients and providers to tackle health issues — would be mapped out “to see how we can improve our services further through more efficient care delivery and collaboration between care providers”.

The health ministry and its partners added they planned to identify opportunities to achieve better value.

Procurement will be reviewed to make sure that there are “aligned, efficient and create economies of scale”.

How long will all of this take?

Years.

The health ministry team pointed out: “It took us years to get to where we are and it will take us a considerable period of time to undo what we’ve done, but a huge part of that is health promotion and preventive care.

“Health promotion and prevention will involve working with your doctor or nutritionist or other allied health provider like a physio prior to becoming ill.”

• Graphics used in this article were taken from the Bermuda Health Strategy 2022-2027. To read the document in full, click on the PDF under “Related Media”

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Bermuda Health Strategy 2022-2027