fp Turks and Caicos

UPDATED OCT. 29: Today the Ministry of Health and Human Services released the following explanation of the costs of various options proposed for health care reform. This is a revised version of a statement released Oct. 27. The ministry is seeking public input through Oct. 31.

INTRODUCTION
On October 11th the Government of the Turks and Caicos Islands (TCIG) published a document entitled the Health Care Funding Challenge. The objective was to outline to the public the facts surrounding the affordability of the new Health Care System and to garner feedback on the best way forward. We wish to thank the public for their valuable contribution and the media for graciously disseminating the information.

This document is a follow-up to the Health Care Funding Challenge. It presents the impact of increased revenue as documented in the Health Care Funding Challenge and provides specifics on the cost reduction measures that are being explored by the Government.

In terms of organisation, the paper provides an overview of the option followed by the estimated increase in revenue or details of the proposed cost reduction.

PROPOSED INCREASED REVENUE

1.    The suggestion is that all beneficiaries should contribute to the plan. Currently only those who are employed contribute. There are approximately 11,000 dependants being supported by 18,000 contributors. If each spouse paid the minimum monthly contribution of $25 and each family contributed up to a maximum of 2 children at $10 (the final figure to be determined by actuarial projected calculations) the fund could increase its income.
a.    Increased revenue to be realised through implementing the minimum contribution to spouses of $25 and each family contributed $10 per child for the first two children would be:
Spouse (1578 persons)            -    $ 473,400
Dependents (5065 contributors)        -    $1,056,000
Total                    -    $1,529,400

2.    Another option is to increase the contribution rate to a higher percentage.
a.    Based on the 17,520 primary contributors each 1% increase in contributions would raise an additional $3,334,000 per annum.

3.    Establish a minimum contribution rate of $25 per month.
a.    Establishing a minimum contribution rate of $25 would generate an additional $90,742 pa from 912 contributors; however if this was increased to $50 this would generate $578,209 pa from 3,409 contributors.

4.    Increase co-payments for services provided.
a.    Interhealth Canada Ltd (ICL) reported that $413,680 was received in co-payments in the 9 month period to the 31st March 2011. Based on this if co pay was increased by an additional 10% this would mean a further c. $55,157 might be receivable in a full year. Please note this figure is a very rough estimate as an increase in co-payments would tend to reduce demand for health services.

5.    Allow voluntary contributions by long-term residents currently not eligible, retired person and winter visitors. These could be for a full benefits package or a local treatment only package.
a.    Due to the lack of data available detailing the numbers of long-term residents it is not possible to ascertain the incremental revenue associated with this option.

6.    Increase revenue by encouraging health tourism. The current hospital contract allows TCIG to benefit from 50% of any net revenues generated by third party revenues.
a.    The Ministry of Health and ICL are pursuing a number of proposals for medical tourism. The current hospital contract allows TCIG to benefit from 50% of any net revenues generated by third party revenues. So far approval has been granted for prostate and cosmetic treatments. Further, tentative proposals have also been received from third parties for, stem cell interventions, sports medicine and pain management.

PROPOSED REDUCTION IN COSTS

It is not yet possible to estimate the savings that might be made as result of the various possible cost-reduction measures. The following comments are therefore offered so as to help the public understand the non-cost implications of the proposals.

1.    Review of the ICL contract by both ICL and the TCIG to right size the service to meet the current need and provide greater flexibility for the future TCI requirements. The goal would be to size the clinical services to meet the needs of the people and to repatriate long-term patients resident overseas back to TCI.

2.    There will also be a review on how Primary Healthcare Services are delivered from the hospital setting. This would reduce the demand on hospital delivered services.
a.    Any move towards significant changes in the contractual relationships between TCI and Interhealth Canada (ICL) cannot occur before 2012. In the meantime, discussions are underway with ICL to reduce cost to the healthcare provision as follows:
i.    Reduction in interisland travel for certain basic diagnostic procedures by either improving scheduling, or where possible, better use of technology and or equipment .
ii.    ICL has committed to jointly reviewing the procedures for overseas referrals with a view of identifying those procedures that with proper staffing and equipment can remain on island.
iii.    Reducing the reliance on medical consultants from out of region and increasing the use of professionals from the regional “preferred provider network”.
iv.    Giving priority to the employment of regionally- based persons or persons with a “Belonger” status across all non-core positions.
b.    The Cockburn Town Medical Centre in Grand Turk is significantly under-utilized and efforts must be made to maximize use of this facility in support of the overall sustainability challenge. Talks are being had on use of part of the facility for TCI residents in long-term care and/or geriatric care.
There is also the potential of providing practicing rights to visiting consultants which may be best located in the Hospital based on Providenciales.

3.    Capping or limiting NHIP benefits.
a.    The NHIP suggests that it should discontinue all tertiary treatments out of region, where regional capacity exists. Only cases which are outside of the scope of the regional “preferred provider network” will be transported to an out of region provider once approval has been given by the medical advisory team.
This has already been implemented although it is difficult to quantify the savings that will accrue.
b.    The NHIP Regulations might also be amended to limit the benefits available to temporary residents and to persons on work permits. This would probably involve limiting services to on-island hospital and emergency care. Work permit holders would not be eligible for overseas treatment under the NHIP. It would of course be open to such individuals or their employers to buy health insurance to cover additional treatment.
Based upon the costs incurred by the plan during 2010/11 and 2011/12 to date restricting overseas treatments to non work permit holders would reduce expenditure by approximately $411,000 per annum.
If restrictions were placed on all pharmaceuticals this would attract savings of $150,000 per annum.
c.    All first time registrants to the NHIP might have a six-month waiting period before they can receive benefits under the plan. This amendment is fair as all original beneficiaries were required to wait the same time period.
Whilst this might not save costs directly but merely act as a deference to access the scheme it would contribute to the provision of general reserves to fund contingency.
d.    Non-contributors to the NHIP will not be eligible for overseas treatment. Such cases will be repatriated to their country of origin.

4.    NHIP could fund the delivery of TCIG primary health care programmes by several methods.
a. The TCIG is committed to imroving the delivery of primary health care. Together with the reform exercise and the strategic health planning exercise a model is being developed for primary health care. This involves developing and procuring primary health care services at the community level, either through the Government or through the private sector. However, at the same time efforts will be made to make better use of the hospital facilities, particularly on Grand Turk.

5.    Development of a more cost effective drug programme.
a.    The Ministry of Health is in discussion with PAHO with a view to improving our pharmaceutical procurement processes. A first meeting is planned in mid November to explore the feasibility of a bulk purchase approach under which the NHIP would procure the drugs and utilize the local pharmacies and/or ICL to dispense them.
b.    Another option to consider might be a proposal to introduce a national pharmacy dispensing body thus introducing competition and maintaining a fair pricing policy body
c.    The NHIB is also working on a revised National Drug formulary whereby the NHIB will only fund drugs for chronic illness. This programme is similar to drug funding programmes in the Bahamas and Jamaica.
Based on restricting pharmaceuticals in line with the Jamaica model it would save approximately $530,000 against the forecast position for 2010/11.
d.    ICL and NHIP will implement a Drug Advice Form. This form will be issued to patients who require over the counter drugs (OTC). This would prevent OTC drugs being dispensed as prescription drugs, and consequently reduce the NHIP payments of OTC drugs.
Cost savings generated through this is anticipated to achieve $50,000 per annum.
e.    There is a need to limit the period on which prescriptions are offered, i.e. routine prescriptions should be limited to a maximum period of 28 days only with the exception of chronic conditions and or long-term repeat prescriptions to a maximum period of three months.
f.    The pharmacy IT system should be expanded to detect abuse and/or fraud

6.    Increase services offer by ICL
a.     Chemotherapy and Radiology. ICL has committed to advancing the establishment of on- island Chemotherapy and radiology services; and is currently in negotiations with a group out of the Bahamas who will be providing the said services.

Notes to the Public

1.    The above statement is a follow-up to the Health Care Funding Challenge which was published on 11th October. It presents the impact of increased revenue from the proposed options and provides specifics on the cost reduction measures that are being explored by the Government.

2.    The Government invites comments from the general public on the proposed options.

3.    All comments should be emailed to This e-mail address is being protected from spambots. You need JavaScript enabled to view it and/or mailed to:

CEO Turks and Caicos Islands Public Service
C/o Tito Lightbourne
NJS Francis Building
Grand Turk

4. Comments should be mailed no later than October 31st 2011.

Questions for Consideration
The government is seeking public comment on the following questions until Oct. 31:

1. Should the government aim to renegotiate the contract with InterHealth Canada Ltd.?
2. Should the present National Health Insurance Program (NHIP) financial imbalance be addressed by increasing contribution rates, or reducing benefits, or both?
3. Should NHIP contributors with dependants pay higher contributions than those without dependants, if they can afford to?
4. Should co-payments on pharmaceuticals, dental and optical care be increased for those that can afford them?
5. Should co-payments be introduced for all health care treatments, except for those that cannot afford them?
6. Should a minimum residency period apply to membership of the NHIP and new immigrants would only receive the minimum benefits required under international conventions?
7. Should NHIP benefits be restricted to urgent treatments only?
8. Should medical practitioners be expected to take their share of reducing health care costs?