Bermuda Health CouncilAnnual Report 2013 - 2014

The 2013-2014 Annual Reportof the Bermuda Health Council

Contact us:If you would like any further information about the Bermuda Health Council, or if you would like to bring a healthcare matter to our attention, we look forward to hearing from you.

Mailing Address:PO Box HM 3381Hamilton HM PXBermuda

Street Address:Sterling House, 3rd Floor 16 Wesley StreetHamilton HM11Bermuda

Phone: 292-6420Fax: 292-8067Email: healthcouncil@bhec.bm

Published by:Bermuda Health Council (July 2014)Copyright © 2014 Bermuda Health Council

Reference as:Bermuda Health Council (2014) The 2013-2014 Annual Report of the Bermuda Health Council.Bermuda Health Council: Bermuda.

Printed by:Bermuda Health Council

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S2 Minister of Health and Environment’s Message

3 Chairman’s Message

4 CEO’s Message

5 Mission, Vision, Priorities

6 Delivering on the Priorities

6 Care quality and standards

7 Regulation

11 Utilization Management

13 Stakeholder Relations

16 Efficient Operations

17 Who we are

18 Financial Statements

Message from the Minister of Health and Environment

As Bermuda's Minister of Health and Environment I am pleased to offer this brief message for inclusion in the 2013/14 Bermuda Health Council Annual Report. Once again, the Council has worked closely and commendably with the Ministry this year on many initiatives and reforms vital to the future of Health Services in Bermuda.

I wish to commend them for their continued efforts in providing regulatory oversight to health professionals to ensure quality healthcare services. In particular, for BHeC's collaboration with the Bermuda Medical Council and the Pharmacy Council to develop each professions' Standards of Practice, which are essential to improve healthcare quality.

Throughout 2013/14 BHeC has continued to enhance employers' compliance with their health insurance obligations to ensure Bermuda's population has the coverage they are entitled to.

The Council should also be applauded for conducting public education on health costs and health system issues through the media, presentations and their excellent website.

Lastly, I wish to thank them for continuing to provide independent analysis and technical advice to the Ministry and the health system through published reports such as the National Health Accounts and the Actuarial Review.

I would like to take this opportunity to express my sincere thanks to everyone at the Bermuda Health Council for their hard work and for their support in maintaining the Council's outstanding reputation as the leading voice on Bermuda's health system.

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I am pleased to present the 2013/14 Annual Report for the Bermuda Health Council, my second report since my appointment as Chairman in February 2013. The Bermuda Health Council’s mission is to regulate, coordinate and enhance the delivery of health services and our commitment to this mission is demonstrated in the year’s achievements.

During the last fiscal year, the Council focused on three priority areas that included: care quality and standards, regulation, and utilization management.

In particular, the Council collaborated with professional statutory boards and associations on projects to enhance the standard of care delivered on the Island. BHeC worked with the Bermuda Medical Council and the Pharmacy Council in developing their respective Standards of Practice, which help to improve the quality of care locally. The health system also benefited from BHeC’s increased enforcement and monitoring of employers’ health insurance obligations. In addition, the Health Council has prioritized projects focused on reversing the health system’s trends of increasing utilization and ensuring more effective use of services that will result in cost containment.

On a very sad note, in January, the Health Council and the Island as a whole suffered a tragic loss with the passing of Council Member Louise Jackson, MBE, JP. She was a staunch advocate for the health system taking passion, and energy to every cause she supported. The Health Council will always remember her contribution.

As we move forward there is a need now, more than ever, to focus on reducing the health cost burden that many on the Island are feeling, while ensuring the quality delivered is always at the forefront. With the Board’s continued commitment, the dedication of the Secretariat and the support of our stakeholders, BHeC is well-placed to tackle the challenges ahead.

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Jeanne Atherden, CA JP MP

Jeanne Atherden, CA JP MPChairman

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CEO

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Jennifer Attride-Stirling, PhD

This year marked a change in direction for the Health Council in light of revised strategic priorities. While the routine, legislated functions – such as the actuarial review for the Standard Premium Rate, enforcing employers’ health insurance obligations, licensing insurers, and active engagement

with stakeholders – continued to be implemented as always, the focus this year shifted to the regulation of professionals and utilization management.

The monitoring and regulation of health professionals by BHeC increased significantly with a focus on enhancing quality and engaging providers. This led to closer scrutiny of the quality of care on the Island and greater emphasis on the processes to assure sound healthcare delivery. In addition, the need to manage utilization more proactively was recognized and much discussion and consultation with key stakeholders took place to identify ways in which Bermuda can reduce healthcare costs.

Our previous focus on the production and dissemination of health system trends and analyses was generally reduced. Nevertheless, BHeC continued to monitor health costs and trends by publishing the National Health Accounts and Actuarial Review reports. We are excited about the Department of Health undertaking the STEPS survey and the Department of Statistics conducting the Household Expenditure Survey in 2014, as these vital analyses will enable evidence-based policy decisions in the coming years.

Monitoring trends is as important today as ever, particularly as it becomes increasingly apparent that the impact of the economic environment is being felt across the health system. The number of complaints we received increased, and these were mostly related to health costs, billing practices, and employers’ health insurance challenges.

Nevertheless, this year saw further, positive engagement with health professionals, which has been invaluable in promoting standards of practice and enlisting the assistance of many dedicated professionals to step in where the system cannot meet patients’ needs. We are grateful to the many healthcare providers who have gone the extra mile to assist us and patients, at times bearing the cost directly. It is heartening to know that so many are willing to live by the principle of “shared sacrifices”.

The most significant milestone this year, however, was the National Health Accounts finding that health costs flattened in 2011/12. This was the result of a number of factors and prior years’ actions, which bore fruit in the latest year measured. Nevertheless, the actual cost of goods and services continued to rise, resulting in health costs taking up a larger share of GDP and of many people’s income – particularly for the most disadvantaged socio-economic groups. Clearly, we must continue to implement measures to ensure health costs are affordable for individuals, families, businesses and the Government. It is imperative that such measures be based on the best available evidence, for the benefit of patients and the public.

Jennifer Attride-Stirling, PhDChief Executive OfficerBermuda Health Council

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Mission

To regulate, coordinate and enhance the delivery of health services in Bermuda

Vision

Achieving a quality, equitable and sustainable health system

Priorities

The Bermuda Health Council’s (BHeC) objectives are organized around three priority areas in order to meet our legislative mandate. All activities under these priority areas seek to promote quality, contain costs, and ensure accountability and collaboration across the health system. The three priority areas are:

• Care quality and standards

• Regulation

• Utilization Management

BHeC’s Corporate Plan 2013-14 focused on these three priorities, and our accomplishments for fiscal year 2013-2014 are outlined in this Annual Report.

Mission, Vision and Priorities

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Delivering on the Priorities

Collaboration with Professional Statutory Boards

This year BHeC worked closely with professional statutory boards and associations to provide assistance with their registers, licensing and complaints handling procedures. BHeC’s work in this area is in keeping with the Health Council’s mandate to regulate health professionals by monitoring their activities and assuring quality controls are enforced by the professional bodies.

Standards of Practice

In conjunction with the Bermuda Medical Council and the Pharmacy Council, BHeC developed and rolled-out Standards of Practice for medical practitioners and pharmacists. The establishment of these standards of practice was widely embraced across the health system.

The Standards are based on those from Australia, United Kingdom, Canada and the United States. The documents outline practice guidelines for areas such as clinical quality, ethical practice, fees, relationships with patients and working with colleagues.

The establishment of standards of practice for local providers is a long-awaited and much-needed shift, and the public will be the beneficiaries of improved quality of care. BHeC has also initiated the development process with the Dental Board and the Nursing Council for their repective Standards of Practice; completion is anticipated in 2014-15.

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Reg

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nHealth Insurance Compliance

The Health Council tracks employers’ compliance with the Health Insurance Act 1970 to assure eligible persons receive the mandated health insurance coverage. The Act requires that employers provide health insurance coverage for at least the Standard Hospital Benefit (SHB) to their employees and their non-employed spouses.

During the last fiscal year, BHeC collaborated with health insurers, the Department of Social Insurance (DOSI) and the Department of Public Prosecutions (DPP) in order to monitor and follow-up on errant employers. This year BHeC increased enforcement capacity further, which led to significant improvements in compliance by employers. As shown in Figure 1, the number of inactive policies and affected employees decreased over the year, and BHeC follow-up actively resulted in employers becoming compliant. Enhanced monitoring resulted in reduced delinquency generally and at least two cases were put through the court system.

The Council will continue to increase its enforcement actions to ensure Bermuda’s employees and their non-employed spouses are aware of, and receive, the health insurance coverage to which they are entitled.

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Policy Status Figure 1: Inactive health insurance policies through 2013

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Claims Reimbursement

The Council is responsible for enforcing compliance with the Health Insurance (Health Service Providers and Insurers) (Claims) Regulations 2012. These Regulations which are better known for ending the practice of upfront payments, also clarified the claims processes to ensure providers are paid promptly. BHeC’s monitoring indicates good compliance across the health system. Exempted providers are listed on our website.

In addition, this year BHeC worked with the Bermuda Hospitals Board, Approved Facilities and health professionals to ensure that the information required for Standard Hospital Benefit (SHB) claims is submitted in line with the Claims Regulations. This change will improve the system’s capacity to manage utilization, and will enable better understanding of local disease trends.

Home Medical Services Benefit

The Home Medical Services (HMS) Benefit was rolled-out in October 2013 under the Health Insurance (Standard Hospital Benefit) Regulations. This benefit is expected to improve care quality and contain costs, as it allows eligible patients to be discharged from the hospital, and receive care in their homes.

Prolonged stays in a hospital environment are not only expensive, but unsafe for patients who could be discharged. Since the introduction of HMS, patients have been able to have select medical procedures such as IV therapy and wound care in their homes fully covered by their insurance.

In order to qualify for HMS, patients must be referred by their physician to a BHeC-approved agency, who will perform the procedure in the patients’ home. With the introduction of HMS, BHeC has remained committed to ensuring the quality of health services provided for patients, while striving for sustainability in the health system.

Facility must submit claim

with the information

required

Approved Facility or

BHB perform procedure

MISSING INFORMATION

Health professional orders tests

Patient sees health professional

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Responsiveness

The Bermuda Health Council receives complaints and queries about the health system from the public and other stakeholders. These complaints and queries serve two purposes: they enable the opportunity to mediate concerns between health system stakeholders, and they allow BHeC to identify systemic problems in need of resolution.

It has been five years since introducing the process in 2009 and the Health Council has received an increasing number of complaints and queries (See Figure 2). In 2013-14, the majority of complaints (see Figure 3) were about employers’ health insurance (42%), while the majority of queries (see Figure 4) were about costs, fees and billing (31%).

BHeC’s increased role in addressing health system issues demonstrates stakeholders’ confidence in the Council’s ability to mediate and resolve concerns.

Figure 2: Complaints and queries since 2009

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Complaints and Queries

Complaints and Queries Complaints Queries

Health Technology

The process to introduce Health Technology Reviews (HTR) was advanced this year. HTRs are being developed in order to control the entry of health technologies into Bermuda’s health system to avoid excess capacity and duplication which inevitably increase health costs. The HTR process will consider the effectiveness and appropriateness of high-risk health technologies as well as capacity and need, in order to improve health system planning. Implementation is expected in fiscal year 2014/15.

Careers in health system

8%

Costs/fees/billing31%

Data/Statistics6%Employer health

insurance6%

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Quality of Care17%

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Figure 4: Nature of Queries in 2013-2014

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Costs/fees/billing28%

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42%

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3%

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Quality of Care23%

Upfront Charges2%

Figure 3: Nature of Complaints in 2013-2014

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Licensing

BHeC licenses insurers and approved schemes annually and since 2012 the Health Insurance Amendment Act increased the reporting requirements for re-licensing, changed the licensing timeline to align with the returns to the Bermuda Monetary Authority, and increased the annual licensing fees and penalties. These regulations have enabled BHeC to improve regulatory oversight and transparency, leading to more powerful data and evidence about the costs and utilization patterns in Bermuda’s health system.

Health Spending

A fundamental contribution of the Health Council is the analysis and reporting on Bermuda’s health financing and expenditure. Annually, BHeC publishes the Island’s National Health Accounts (NHA), which enables stakeholders to identify trends and develop policies to improve the health system.

The National Health Accounts 2013 reported financing and expenditure up to fiscal year 2012. The analysis found that Bermuda’s total health spending that year was $678 million dollars or $10,562 per capita. This indicated a levelling of health costs for the first time this decade (See Figure 5). The Island’s curbed health spending was due primarily to the prior years’ cap on payments to the hospital, less overseas claims, and reduced spending on programmes and services by the Ministry of Health and Environment.

While the levelled health spending is a positive indication, it’s important to note that the actual cost of goods and services continued to rise, resulting in health costs representing a larger proportion of GDP. This is an important reminder of the need to continue applying measures to ensure the financial sustainability of the country’s health system.

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$10,562Figure 5: Per capita health expenditure

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Premiums

BHeC conducts the actuarial review of the Mutual Re-insurance Fund (MRF) and the Standard Hospital Benefit (SHB) in order to recommend the Standard Premium Rate (SPR) annually. The actuarial review is based on data received from all private and public health insurers for the minimum mandated package of insurance.

This year a number of changes were made to the SHB due to the continued pressure on Government finances. In order for the Ministry of Health and Environment to secure necessary budget reductions of $17.6 million, subsidies for seniors were reduced by 10% and SHB portability was suspended. These changes impacted the SPR. To offset the impact of these changes on the public and the Health Insurance Plan (HIP) and FutureCare, it was also necessary to transfer MRF benefits to SHB and increase MRF transfers to support public programmes.

The Actuarial Review Report is published annually to ensure transparency in this process, and to provide information on headcount, utilization and claims trends with respect to local and overseas hospital services, which are the main drivers of premium increases.

Cost Containment

Curbing Bermuda’s health costs has been the focus of the Health Council’s activities since 2010. In 2013, the Council was tasked with implementing pre-certification to reduce medically unnecessary diagnostic tests. Extensive discussion and consultation was conducted with more than 100 key stakeholders in 2013-14 and the process continues to evolve. Implementation has now been assigned to the Health Insurance Department, and BHeC is assisting by producing the guidelines for pre-certification on behalf of the Ministry.

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Stakeholder Relations

Public Education

BHeC recognizes the role the public play in controlling health costs. Therefore in 2013-14, the Health Council conducted an information campaign with a household mailing of the Guide to Bermuda’s Health Costs and a cost containment series featured in The Royal Gazette. In addition, the Health Council has provided relevant and timely information through our monthly article in the Bermuda Sun “Matters in Healthcare”, as well as our contributions to other publications including Bermuda Parenting Magazine. The Council also disseminates its own quarterly Newsletter to more than 700 stakeholders, providing regular health system updates.

One of the Health Council’s roles is to deliver information about the Island’s health system and changes to the system in an accessible and transparent manner. To do so, this year BHeC produced a number of documents to help explain more complex issues, such as the National Health Accounts, and the changes in the Standard Hospital Benefit (SHB).

In addition, the Health Council introduced SnapFacts, a new communication initiative. SnapFacts are emailed to over 6,000 stakeholders fortnightly. With these brief and accessible facts on the Island’s health system, the Health Council seeks to inform the public and stimulate public dialog to recognize the system’s challenges and identify solutions.

Since April 2013, the Health Council has also coordinated 25 discussion forums and seminars, attended by more than 750 stakeholders, to inform, educate or consult on a range of issues. In addition BHeC presented at the 8th Annual Caribbean Conference on Health Financing Initiatives in Jamaica on “Ageing in Bermuda: Impact on Health Costs and FutureCare as a Strategy.”

Did you know… Nearly half of Bermuda’s adults

don’t know if they have HIV

Visit our website: www.bhec.bm or

follow us on Facebook.

Did you know… In 2012 Bermuda spent an average of

$10,562 per person on health.

Visit our website: www.bhec.bm or

follow us on Facebook.

Online

Our website was significantly revamped this year to provide a more accessible and intuitive portal to the Health Council’s reports, articles and more. In addition, online forms were introduced for the public to submit queries and complaints to us, and for health professionals to request being added to our Healthcare Directory. BHeC also maintains a Facebook page where relevant and interesting healthcare information is shared with the public via social media.

Collaboration

BHeC could not deliver its mission and vision without the input of and collaboration with our stakeholders and the community. In 2013-14, these partnerships meant the roll-out of a Home Medical Services benefit, Standards of Practice for Medical Practitioners and better data collection for the National Health Accounts. The Council continues to seek advice and input from all of our stakeholders to identify health system improvements and to address concerns.

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Evaluation

BHeC strives to deliver quality and effective service to our stakeholders. To assess our performance we sought stakeholders’ feedback on how we are doing via an annual online Evaluation Survey. The results for 2013-14 indicated a good level of satisfaction with the Health Council; however, there was room for improvement. In particular the responses indicated additional communication and further transparency on our projects would be welcome. We are grateful for the feedback and will strive to meet this important need.

Figure 6: Quality of information and customer service provided by BHeC

Advice

BHeC consistently provides technical advice to the Ministry of Health and Environment through informal and formal communication means on matters ranging from health system mapping, cost containment and regulated healthcare fees. The Health Council remains an invaluable source of technical expertise and stakeholder engagement to provide the Ministry with evidence based advice to move the health system forward.

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Efficient Operations

Value

The Bermuda Health Council’s mission is to regulate, coordinate and enhance the delivery of health services in Bermuda. In 2013-14, BHeC received the same level of grant from the Ministry of Health and Environment as the previous year, and adopted the Furlough Day agreement between Government and the Unions. In order to deliver on its mission in 2013-14, the Council further streamlined operations and improved efficiency. The Corporate Plan was met despite reduced resources thanks to the commitment and sacrifices of everyone involved. In order to secure essential funding going forward, BHeC obtained a transfer from the Mutual Re-insurance Fund, starting in April 2014. This will enable the Council to be partly funded by its regulatory functions, without adding burden to the Government’s Consolidated Fund.

Team Development

BHeC’s team was able to take advantage of development opportunities in 2013-14 both locally, overseas and online. Overseas and online training provided the Secretariat with the opportunity to strengthen skills and capacity with courses from the World Bank, the American Public Health Association, and the Pan American Health Organization.

In addition, BHeC continued our successful Learning Lunch series to enhance internal capacity and health system knowledge, featuring a variety of topics such as: utilization of emergency room services, the new hospital wing development, and disaster preparedness.

BHeC also maintains membership with the Employee Assistance Program, Bermuda Employers Council, and the Bermuda Hospitals Board Ethics Committee. In addition, we maintain professional membership with the Society for Human Resources Management.

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BHeC is comprised of a Board appointed annually by the Minister responsible for Health, and a Secretariat of eight employed staff. It has operated since 2006 focusing on monitoring all aspects of Bermuda’s health system.

Who We Are

Mrs Jeanne Atherden, ChairmanMrs Simone Barton, Deputy Chairman

Mrs Naz Farrow Ms Alison Hill

Dr Wesley MillerMr Andrew Simons

Ex-Officio Board members are:

Dr Jennifer Attride-Stirling, BHeC CEO, Ex-OfficioMr Anthony Manders, Financial Secretary, Ex-Officio

Mr Kevin Monkman, Permanent Secretary for Health, Ex-OfficioDr Cheryl Peek-Ball, Acting Chief Medical Officer, Ex-Officio

Mrs Venetta Symonds Miss Katura Horton-Perinchief

Mrs Shade Subair Dr Burton Butterfield Mrs Louise Jackson

Appointed Board members from January 2014 are:

Mrs Jeanne Atherden, ChairmanMrs Simone Barton, Deputy Chairman

Mrs Naz Farrow Ms Alison Hill

Dr Wesley MillerMr Andrew Simons

Mrs Venetta SymondsMiss Katura Horton-Perinchief

Mr Richard AmbrosioDr Joanna Sherratt-WyerMrs Jane “Jasen” Moniz

Appointed Board members in 2013 were:

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FINANCIAL STATEMENTS

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