Should Government restrict HIP to essential medical care?

FRIDAY, SEPTEMBER 9: The BHeC (Bermuda Health Council) and Bermuda Sun have teamed up to answer your questions about the island’s healthcare system.

Visit www.bhec.bm to submit your queries and look for our response in each Friday’s Bermuda Sun.

This week’s question focuses on whether the remit of care under the Government’s HIP (Health Insurance Plan) should be changed.

Q: Based on the National Health Report of 2011 and the increase in spending, when is the Government going to amend the HIP law to allow for healthcare payers (public and private) to ensure that the care received is medically necessary and up to the best practice standards?

Thus only the medically necessary and appropriate care will be eligible for reimbursement.

Honestly, why are we paying for grandma to live in KEMH (King Edward VII Memorial Hospital) when she can be cared for at home with a once-daily visiting nurse service?

The volume of care that is provided inpatient that can be done outpatient is unreal.

A: There’s a lot in this question, so we’ll break it down into three parts on: HIP, reimbursement, and use of inpatient beds.

• HIP stands for Health Insurance Plan; it is the Government’s low-cost health insurance package.

HIP is different from the Standard Hospital Benefit (SHB), which is the minimum mandated insurance package and covers hospitalisation only; it doesn’t cover non-hospital care like doctors’ visits.

HIP and SHB are not the same thing. HIP includes SHB plus supplemental benefits, like doctors’ visits.

You may be referring to SHB not HIP, and the distinction is as significant as the difference between ‘bread’ and ‘flour’ — all bread has flour, but the terms are not interchangeable.  

• What is reimbursable under SHB, and at what rates, is mandated by law and includes medically-necessary hospital treatment locally and overseas.

However, “medically necessary” is not defined or regulated.

There are different opinions on this.

On the upside, it allows clinicians to use their professional judgment to do what is in a patient’s best interest.

On the downside, it provides no checks or balances, and leaves clinicians exposed to all sorts of accusations; both of these can breed mistrust.

Striking a balance is tough.

Regulation leads to accusations of ‘grandma being kicked to the curb by death panels’.

No regulation leads to accusations of misuse or overuse.

There is no doubt that Bermuda needs to get a better balance.

• The issue of inpatient beds at KEMH being used for patients who need other types of care is certainly one health system which stewards are aware of and trying to resolve.

KEMH has been active in appropriately discharging patients wherever possible, and we need to continue finding ways to address the problems.

As long as there are insufficient affordable home care options, however, the problem will be difficult to eradicate.

However, there are moves afoot between various relevant agencies to deal with this matter.

For more information go to www.bhec.bm