Matters in Healthcare: Why physicians' fees are not regulated

FRIDAY, NOV. 30: The Bermuda Health Council and the Bermuda Sun have teamed up to answer your questions about the island’s health care system. Visit www.bhec.bm to submit your queries and don’t forget to check out the answers in the Sun on the last Friday of every month and on www.bermudasun.bm.

Question: It is apparent that physicians are free to — and generally do — charge fees over and beyond the limits of insurance companies’ fee schedules.

After paying an insurance premium in excess of $1,600/ $1,700 per month, I find it somewhat exorbitant when required to also pay a hefty sum out of pocket to a physician in addition to the funds they will claim from the insurer. Why is this the case?

Answer: Out-of-pocket health costs are a prominent feature of our health system. They make up 12 per cent of the country’s total health costs and amounted to nearly $83 million in 2011.

Out-of-pocket payments include both full charges at the time of service and co-pays. This week’s question focuses on co-pays specifically, or the portion of healthcare costs not covered by a patient’s health insurance.

Proponents of co-pays see them as a way to help insured patients consider carefully the real need for each episode of care — they believe co-pays help dissuade unnecessary use of health services.

But opponents see co-pays as inhibiting access to necessary care. They believe co-pays dissuade patients who need treatment from getting it.

Each camp has a strong position and a lot of evidence to support their case. Whatever view you take, it is a tool all private and public health insurers use locally and overseas.

Question: Do physician fee schedules differ from practice to practice so that one could perhaps choose to align with the lesser “mark up”? Or is there a set-fee schedule utilized by all physicians, similar to, though perhaps not in line with, that used by insurers?

Answer: Bermuda’s health system doesn’t regulate what private healthcare providers can charge or what insurers must pay (for non-hospital treatment). This is because our health system is based on a free-market model that allows each party to set their rates according to what the market can bear.

Physician and other health professionals’ fees vary from practice to practice, so you can shop around and find a provider whose charges are better suited to your budget.

A helpful tool for this is the Bermuda Health Council’s online Healthcare Directory. It lists all known healthcare providers by specialty to help you find the care right for you.

Importantly, another key feature of our health system is that it prohibits co-pays for hospital treatment, but allows them for non-hospital care.

This protects insured people in case of a catastrophic health event; but, unfortunately, it also creates an incentive for individuals to seek hospital care (with no co-pays) rather than primary care (with co-pays).

This trend unfortunately shows signs of growing in the current economic climate, and it is placing added strain on both premiums and hospital costs.

There are no easy solutions — and none that will make everyone happy. But it is something our health system has to grapple with, understanding that persons in your position are, indeed, among those affected.

Jennifer Attride-Stirling is the CEO of the Bermuda Health Council.