Medical Association Oppose Pre-Certification

October 6, 2014

The Bermuda Medical Doctors’ Association [BMDA] said they “note with some dismay the Request for Information published by the Ministry of Health,” adding they are “steadfast in its opposition of the implementation of pre-certification, and this has been made clear at every step of the consultation process.”

USlegal.com defines pre-certification as the process of obtaining eligibility, certification or authorization and collecting information from the health plan prior to selected ambulatory procedures and services

“We remain opposed to the implementation of pre-certification. We are, however, committed to making healthcare costs sustainable,” said the BMDA.

The BMDA said pre-certification “can delay access to treatment” and “will add to the costs of the system – every person in Bermuda will pay for the implementation of pre-certification.”

When asked for their position on the matter, the Bermuda Health Council [BHeC] said, “The RFI for pre-certification was issued by the Ministry of Health, Seniors and Environment. As a Quango under the Ministry, the Health Council defers comment on the matter to the Ministry, which is the appropriate authority.”

Ministry’s Previous Comments On Pre-Certification

Last week, the Ministry of Health, Seniors and Environment said they are “seeking information and creative ideas for solutions to implement, manage and operate a system to provide pre-certification of diagnostic medical testing for Bermuda’s healthcare system.”

“Bermuda has a higher rate of utilization of advanced imaging equipment than most OECD countries,” explained the Minister of Health, Seniors and Environment Jeanne Atherden. “Some procedures present risk to patients and their use should be minimized.

“Increased use of medical imaging has led to concerns globally about the impact of cumulative radiation exposure on individuals and public health. In addition, the utilization increases have had a significant impact on the cost of healthcare in Bermuda.

“As a result, we are seeking a centralized utilization management agency, contracted by the Health Insurance Department [HID], which will pre‐certify all eligible diagnostic imaging and clinical laboratory procedures. Public and private payers will be required to adhere to HID’s pre‐approvals for their insurance plans.

The statement from Government noted that, “Pre‐certification is planned to apply to select medical imaging procedures [e.g. MRI, CT scans, Echocardiography, etc.]; and to specific clinical laboratory test orders and orders with a cumulative value above $300.

“Orders by specialists and diagnostic testing for emergencies will not have to be pre‐certified. Self‐referrals will be subject to pre‐certification.”

Full Statement from the Bermuda Medical Doctors’ Association

“The Bermuda Medical Doctors’ Association [BMDA] note with some dismay the Request for Information published by the Ministry of Health last week. The BMDA has been steadfast in its opposition of the implementation of Pre-Certification, and this has been made clear at every step of the consultation process.

“The Ministry was very involved in a Symposium last year at which experts from the Caribbean and the United States [both jurisdictions in which pre-certification exists] encouraged Bermuda not to proceed with pre-certification. The reasons given echoed very strongly with the objections from local physicians:

  • Pre-certification does not change physician behaviour – instead, it encourages physicians merely to write what is needed on forms so that the body pre-certifying is obliged to approve the investigation and the test can be arranged. It does not improve clinical judgement.
  • Pre-certification can delay access to treatment – the argument is often given that emergencies will be exempt. This may be true if a patient presents to the ER, but there are situations outside of the Emergency Room which require fast responses by the physician, and waiting for pre-certification is not appropriate. Indeed, this may even drive up costs as primary care physicians [GPs] will be forced to send patients to the ER just to get the required testing done. There are cases when even a 24 hour delay could be extremely detrimental to the health of the patient.
  • Pre-certification will add to the costs of the system – every person in Bermuda will pay for the implementation of pre-certification – from an increase in expense by the government in order to facilitate this, in an increase in expenses by the insurance companies in order to be able to implement this, and by an increase in cost from the physician’s offices as they will require more administrative staff in order to be able to process requests.
  • The biggest single driver to changing behaviour in the Cayman Islands was the implementation of guidelines, not the implementation of pre-certification. Supporting physicians with guidelines that aid them in providing the best level of care for their patients is much more effective at reducing costs than adding another level of bureaucracy and cost that is pre-certification.

“We were then strongly encouraged to put our alternatives for pre-certification forward to the Ministry. A committee of dedicated physicians from across the physician community worked for 6 months to produce a report, which was presented to the Health Minister in July of 2014, and which will be published for the general public imminently.

“This report details 20 recommendations that the physician community believe will drive costs down. Indeed, this report was so well received by the Bermuda Health Council [BHeC] that the BMDA and BHeC are already working on implementing some of the measures.

“The primary focus of the report deals with the largest drivers in increasing cost in the health system since 2004 – namely the Bermuda Hospitals Board and Overseas Care. However, the BMDA felt it was vital that we took a holistic look at the healthcare system in its entirety, and as such the report specifically aims to address issues across the entire spectrum of healthcare, including community-based care.

“The BMDA is committed to improving the quality of healthcare provision to the whole population of Bermuda. We remain opposed to the implementation of pre-certification.

“We are, however, committed to making healthcare costs sustainable. We have worked diligently to produce our report on containing costs and we will continue to collaborate with the BHEC in implementing those recommendations that contain costs while ensuring proper care for patients.”

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  1. Evie says:

    Why do we need this? Who is really pushing for this? Who will benefit from this? Things that make you say Mmmm

    Did anyone see 60 minutes that is why Heath care is so high all about $$$$$ SMDH this is truly a wicked world how much money is enough

    • Kunta says:

      SHUT DE WHOLE ISLAND DOWN !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

    • Annie says:

      I worked for an insurance company and they have been pushing for this for YEARS. However, they have a valid point-Bermuda’s healthcare costs are out of control.

      One of the main problems I saw working in health insurance was the nonchalant way physicians ordered diagnostic tests, oblivious to the costs. In the U.S. if you go to a physician for, let’s say, an infected hangnail the doctor isn’t allowed to send you off for blood tests on all and sundry plus an MRI-they are only allowed to send you for tests that related to that particular ailment (e.g. a skin culture). In Bermuda, physicians often do this-sometimes at a patient’s request. The doctor will say “While you’re here, let’s send you off for some blood work” or whatever else the patient asks for and will proceed to tick a million boxes on the lab form with NO idea of how much those tests cost-with many costing hundreds of dollars each. Most times the test will come back perfectly fine which appeases the patient but at what cost? Don’t even get me started on hypochondriacs who request and receive any test they want with no necessity whatsoever-who pays for that? All of us.

      Of course preventative medicine is important but sometimes the physicians go overboard in ordering tests. Furthermore, there ARE some physicians who know full well how lucrative labs are and so have attached labs to their practices, where they then direct the patient for a bunch of unneeded tests, bill the insurance companies and generate a ton of revenue. If you go to the doctor for something minor like a mild rash on one’s hand, why test the every organ in the patient’s body just for the sake of it? If the person has a raging rash that covers their entire body and a cause isn’t found and it doesn’t respond to treatment, fine, but in most cases they are ordered at the get-go with no valid reason. If people have to pay for these tests out of pocket, they’ll pass…but if they have insurance they don’t think twice about receiving unnecessary tests because they never see the bills-and then complain when their premiums go up.

      It’s hard for the ordinary citizen to understand this and I’ll probably get bashed but lab costs are WAY out of control in this country. When you have individual tests that cost four, five, six hundred dollars that are ordered for NO legitimate reason, of course it will drive health care costs and insurance premiums sky high. I wrote a letter to the editor years ago warning that this would eventually happen and that this needed to be controlled by physicians or government would step in and put the controls in for them…and here we are.

  2. The Minister added, “Pre-certification will promote the delivery of quality healthcare in a cost effective manner, improve standardization in the ordering of diagnostic tests, and reduce unnecessary utilization of and duplication in diagnostic testing [both medical imaging and clinical laboratory tests].”
    The statement from Government concluded by saying, “Pre‐certification is planned to apply to select medical imaging procedures [e.g. MRI, CT scans, Echocardiography, etc.]; and to specific clinical laboratory test orders and orders with a cumulative value above $300. Orders by specialists and diagnostic testing for emergencies will not have to be pre‐certified. Self‐referrals will be subject to pre‐certification.”
    I believe the Minister has been / made things quite clear. I may add Medical care here in Bermuda is expensive and we aren’t as fortunate as some others e.g. them in Canada. Our Govt. needs money; so whether you want to be a part of the solution or the problem it’s your choice.

    • Shadow Minister Ms. Wilson: She had spoken out after the Health Minister Jeanne Atherden said that the move would lead to improve “standardisation” in the ordering of diagnostic tests and reduce the unnecessary use of and duplication in both medical imaging and clinical laboratory tests.
      Ms Wilson said that “diagnostic imaging amounted to less than two per cent of Island healthcare costs and said that changes in other areas could ease the financial burden without risking patient health — including allowing larger international insurance firms into the Bermuda market to increase competition and lower costs.” If we were to permit more Insurance companies to set up business here in Bermuda then where would the money go that is paid to them for their services? It certainly wouldn’t be staying on Island helping us get out of debt. Yes the debt that the former Govt.(of which Ms. Wilson was part of) left us ALL in :-( Sad yes, but true!

    • Allspice says:

      What are you on about?
      This is a professional body providing their professional opinion to a debate that has not taken place in front of the public. Their argument is rational and a productive contribution to the debate backed by professional experience. So in fact the BMDA is being part of the solution by behaving like sane members of a democratic society.
      You should be grateful.

  3. Archie says:

    I disagree with this statement. I am not a doctor but I do know about precertification and I believe the BMDA is only protecting the interests of doctors and not the patients.
    There are too many people who abuse the system and it that abuse that is pushing up costs – costs that the patients have to bear.
    A lot of doctors in this country run businesses so it is in their interests to ensure that they refer for more and more MRIs, Cat scans, blood tests etc etc. That is not putting the patient first, it is putting their business interests first and – again – it leads to increased costs that are – again – borne by the patient, hitting the ordinary man in the street in his pocket at a time when everyone is struggling.
    The people must must must understand this …..

  4. Double D says:

    Well then lower your prices you Doctors, Specialists and Dentists!

    I hope any Government places caps on the prices you charge for treatment. Getting rich off of your patients is immoral and needs to end.

    For instance one filling should not cost $400 as mine did last month!

    That is absolute robbery and should be addressed immediately.

    And on top of that I would like to see evidence from the Caribbean and US jusrisdictions in which pre-certfication has increased health care costs and resulted in ‘death by delay.’

    Show us the evidence of your claims and why these jurisdictions introduced pre-certification while you think it would be detrimental to Bermuda.

    You can shout and scream all you want, but without evidence it looks like to many that you Doctors, Specialists and Dentists just want to continue overcharging your patients who you are entrusted to keep healthy by stating such without the facts to back up your claims.

    • Rhonda says:

      The only people in the usa subjected to pre certification are poor people on government subsidies, its a way for the private company to milk government. Give it one year to see all the executive insurance plans exempt from this intrusion. It will become an added benefit for those who can afford.

  5. Truth is killin' me... says:

    When are Doctors, Lawyers, Dentists etc. going to start feeling the pain like the average Joe Blow Bermudian. I don’t see their rates going down anytime soon!

    • Openyoureye says:

      Truth is killin’me – well with pre-certification the cost to visit your doctor is only going to increase. what you have to say about that?

  6. LaVerne Furbert says:

    “Other than economically, Bermuda’s demographic population is as different from many of the compared countries, e.g., Iceland, Germany, Hungary, Luxembourg, Czech Republic, etc., as is night from day.”

    • Politricks says:

      Huh?

      Didn’t the Ministry and the Doctor’s Association both mention the Caribbean and USA as comparables in terms of policy?

      The Caribbean jurisdiction makes more sense in terms of comparables.

      Suprised that a Union stalwart is so keen on protecting the Doctor’s right to charge their patients so much money. Very strange position indeed.

      But then again you are the same Union stalwart that defended a certain Doctor’s firing of two employees that sought to be unionized.

      Guess your opinion depends on what way the wind is blowing.

      • LaVerne Furbert says:

        Politricks, obviously you haven’t read the article in its entirety. Go back and read and get back to me. This has nothing to do with the “Doctor’s right to charge their patients so much money”.

        What doctor fired two employees because they sought to be unionised? Get your facts right, because you’re wrong on this one, again.

        • Politricks says:

          Read it again.

          Still see no reference to the countries in the above article you listed in your original post. Please enlighten. I see references to the Caribbean and the US, however.

          If you need a reminder I suggest you Google the incident about the two Doctor employees seeking to be unionized. The story was printed sometime in September 2013 and you defended the decision to fire the workers because of who the doctor was/is within that same article. Strange your defending given your desire for anyone who desires to become unionized is allowed to do so. Strange indeed.

          Liek I said wind must be out the east today.

          • LaVerne Furbert says:

            They were not fired for trying to join the Union.

  7. Family Man says:

    There has to be a way to reduce the incentive to pad the system with unnecessary tests. Either get an independent second opinion for all non-emergency tests, or prohibit doctors from benefiting, directly or indirectly, in labs, pharmacies or diagnostic centres.

    If I’m a doctor and I own a diagnostic testing lab, I’m going to have an incentive to send my patients to my own lab for frequent multiple tests, not all of which may be necessary. But insurance pays, so why not?

    • Rhonda says:

      Even if these companies are legally separated, they are one in every other way, just look at banks, Realtors, and the insurance industry all one.

    • Openyoureye says:

      Family Man – private labs are less expensive for the same test than the hospital (KEMH). Fact!

      • LaVerne Furbert says:

        Ditto to that. The private lab(s) who use MRI and CT Scans charge much less than the hospital.

        • 32n64w says:

          Good to see you are 100% in support of privitisation! Just think about how much can be saved if we spread this same approach around to all aspects of the Government. Hopefully you’ll relay the same opinion to the BPSU, BIU, BUT, etc. so they can similarly embrace the concept. Well done!

        • LiarLiar says:

          Exactly Ms. Furbert!

          The private sector provides the same services as the public sector but at a with much more efficiency and at a lower cost.

          As the poster above notes I am overjoyed that a Union loyalist such as yourself sees the benefits of privatization and hope you relay the message within your organization.

  8. Chris Famous says:

    So the OBA knows more about healthcare than the Doctors do?

    • gmsgms says:

      In all fairness to those trained in health care, can it also be assumed they are expert in the business of healthcare? Treating a patient is one skill that takes much training and experience. Managing an industry, especially one with thousands of involved individuals and a myriad of business and political challenges, is not a skill that can be assumed to be in the quiver of medical professionals. It may well be for some, but most likely not for all.

    • Politricks says:

      Guess the USA and Caribbean Governments also know more about healthcare as their local Doctors as well?

    • Jon says:

      No… That was the whole point of the RFI.

  9. watching says:

    Only one insurance company is pushing for this…
    what are the real reasons?

  10. Common Sense says:

    It appears that Double D did not even bother to read the release from the Doctors Association.

    When the Ministry of Health was directly involved in a Symposium last year at which experts were brought in from both the U.S. and the Caribbean by the Symposium organizers/Government with the express purpose of promoting the introduction of pre-certification, these experts encouraged Bermuda NOT to proceed with pre-certification and gave their reasons for this recommendation.

    Surely, this Symposium (not open to the public) was recorded or videotaped. Can the Symposium organizers please release these recommendations now so we can all hear and see what the experts recommended?

    It has been suggested that our local insurance companies fully support pre-certification. There is good reason to believe that it is supported by one, and only one insurance company and this company has a direct interest in seeing it implemented. If that is not the case can we have someone from the other insurance companies make their position clear as the Doctors have done?

    Can we also be advised what the Bermuda Health Council’s position was on the issue of pre-certification. Did they vote to support it? Or did they vote against it?

    The alarm bells should be ringing loud and clear if our doctors, the majority of our insurance companies, the BHeC, and even the experts brought in to “sell” pre-certification are all against its introduction.

    We the public have a right to know the truth and the facts.

    • Double D says:

      The overseas experts were local pyhsicians who have a vested bottom dollar interest in ridding pre-certification from their respective jurisdictions.

      All I ask is for the Doctor’s to provide the proof that pre-certification is as bad as they say it is. Provide the cost increases and the ‘death by delay’ examples. Given the size and populations of the Caribbean and USA regions it shouldn’t be that hard to conjure up some examples of the negatives they speak of. And if so bad why hasn’t those respective Governments done away with pre-certification after experiencing the negatives of their legislative requirements. These are also facts that the public should be made aware pf as well.

      And if the local doctors are committed to reducing healthcare costs in Bermuda then they need to take the next step by lowering their fees. Especially for specialists who charge outrageous prices no matter the length or depth of the visit.

      You ask if the BHeC suports it then in the next sentence claim they are against it.

      It appears that you did not read the Ministry’s release which it states that:

      “Pre‐certification is planned to apply to select medical imaging procedures [e.g. MRI, CT scans, Echocardiography, etc.]; and to specific clinical laboratory test orders and orders with a cumulative value above $300.

      “Orders by specialists and diagnostic testing for emergencies will not have to be pre‐certified. Self‐referrals will be subject to pre‐certification.”

  11. clearasmud says:

    If the government are concerned about increased exposure to radiation then why is there a monetary limit as opposed to an exposure limit? It the government wants to reduce the cost of services then the way to do that is to provide the services and remove the profit motive. More state supported services would bring down prices to a competetive level. No one other than my physician should be involved in my health care decisions. I do not believe that precertification will bring down the cost of health care because when you factor in the ongoing cost for the pre-certification system all you are doing is transfering cost!

    • Rhonda says:

      Transferring the cost from a business man we don’t like to one the oba does like, just my opinion.

    • Allspice says:

      I agree that you and your physician should be the ones to make these decisions however we can’t afford state supported services. That party, if it was ever possible, is certainly not happening now. In fact state support is just transferring cost … to the tax payers … so we would still pay for it and pay and pay.

      • clearasmud says:

        You say we would still end up paying for state supported care. But given the argument is that we are already paying for it would it not be better to pay less. Again I say the only way to pay less is to remove the profit motive! If you know a better way I am all ears!

    • Gone Girl says:

      There seems to be a lot of talk about this, but not clear enough dissemination of the issue. Clearasmud is right that a very good way to reduce costs is to reduce the profit motive. But you are very wrong if you think your physician is interested in decreasing tbese costs. In Bermuda, the physician profits very heftily when bloodwork and imaging are done in their clinic, which is why they opened them in the first place…it’s a business, and a profitable one. You are the consumer…you pay for these services indirectly with your insurance premiums…and statistics from WHO and health economists worldwide show that physicians order more than they know they should 65% of the time due to things like financial incentives to do more, or fear of being sued for doing too little. What better incentive is there to do more than when you take home a profit from every test you order? Precertification will not stop you from getting the healthcare you need. It will likely be a defined set of treatment algorithms that say if you are investigating this problem tests A-F are helpful, but x,y,z are not related. Simple. Good for everyone. Except the people who lose an easy profit from unnecessary test. I believe you are hearing from them already.

  12. Rhonda says:

    I can see the doctors and patients, having to decided, do you want to wait for pre certification, or go see the specialists, or go to the emergency room.

  13. Rhonda says:

    Are we on the dawn of seeing mergers between GP’s and specialist office, even if it is just on paper.

  14. Jeremy Deacon says:

    Last time I looked, health care contributed almost three times as much to the GDP as tourism.
    Now there has to be something wrong with that, doesn’t there?

  15. Xaxa says:

    Dear OBA,
    The docs say “NO”. The public says “I trust my doc”. What else do you need to carry out your own agenda regardless of what the people say like you did with immigration and the referendum on gaming? just go ahead anyway. that’s your track record innit? and I’m NOT even a fan of the PLP. Sheesh already!

  16. Fisherman says:

    The doctors want to continue to give unnecessary tests so they can make mucho $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$.
    Why not insist on pre certification involving non threatening life situations? If could reduce healthcare costs.The old PLP/UBP let healthcare costs spiral out of control.Now poor people cannot afford it. Kudos to the OBA govt for introducing initiatives to try to bring down costs and at the same time help those in need!

    • S.D. says:

      Doctors have to take some responsibility for these high healthcare costs. They benefit greatly from all the tests and unnecessary procedures.
      My personal pet peeve is when they have you come in just to deliver test results. I can understand if there is a concern, but it is unfair to hold a patient’s results hostage unless they come in. I went to the doctor for a simple blood test and had to pay a $40.00 co-pay. Three days later I called for my results and was told I had to come in. When I came in, I was literally in the office five minutes for the doctor to say everything was fine. Couldn’t I be told that over the phone? To make matters worse, I had to pay ANOTHER $40.00 co-pay that I could ill afford. My OB/GYN does the same thing, only his co-pay is even higher. This is legalized highway robbery in my opinion.

  17. Impressive says:

    Oh, A group of professionals have a viewpoint that that opposes a planned initiative from the OBA Government, wow. I await that attacks on the group’s intelligence and understanding of all things. I await the attacks on the track record of the group. I await the attacks on the educational credentials on the representatives of the group.. Got my popcorn ready

    • Politricks says:

      IB told the PLP that term limits were hampering their business on island. And yet they were enforced along with a hike in payroll tax in the middle of a recession with the latter implemeted with NO consultation whatsoever.

      When the Opposition at the time brough this up they were called racists while IB was called capitalist pigs, part of the Combined Opposition that just wanted to make money off Bdian backs.

      So please stop acting like this is some sort of a precedent for our island’s political scene.

  18. more than enough says:

    This is a business oppurtunity. A chance for someone or some group of individuals to make money, and government wants a slice.
    Of course to achieve these ends, there are plenty sick and dying people and those in need of medical aid to take advantage of.
    I suppose the medical associations stance has not been pre certified.
    Just another brilliant “business” solution presented by none other than the oba.
    Thanks but no thanks.

  19. pebblebeach says:

    What this Government needs to do is tackle Pension reform. It is rather sad when someone works all their life, finally sits down in front of their Pension Administrator and are presented with annuity products and the like that are actuarially (over 99 years) designed so that upon your eventual death, a substantial portion of your hard earned money that you have contributed over your working life is left on the table for the Pension Administrator’s shareholders to pocket. Absolute farce.

    It stands to reason that a person should get every cent of the value of their pension balance over their retirement years irrespective of the annuity product they choose with any unpaid balance going to their beneficiary and not the Pension Administrator’s shareholders.

    Who lives to be 99 years old these days, very few.

  20. S.D. says:

    Doctors have to take some responsibility for these high healthcare costs. They benefit greatly from all the tests and unnecessary procedures.
    My person pet peeve is when they have you come in just to deliver test results. I can understand if there is a concern, but it is unfair to hold a patient’s results hostage unless they come in. I went to the doctor for a simple blood test and had to pay a $40.00 co-pay. Three days later I called for my results and was told I had to come in. When I came in, I was literally in the office five minutes for the doctor to say everything was fine. Couldn’t I be told that over the phone? To make matters worse, I had to pay ANOTHER $40.00 co-pay that I could ill afford. My OB/GYN does the same thing, only his co-pay is even higher. This is legalized highway robbery in my opinion.

    • Openyoureye says:

      S.D – well if pre-certification is approved you would see your co-pay increase from $40 to maybe $50.

      If you feel that government should regulate doctors rate, then we much advocate the same in regards to grocery stores, BELCO, TELCO, plumbers and electricians, Lawyers (hell they charge $500 per hour just to listen to you) etc.
      Were would it END!

  21. Coffee says:

    Classic David vs Goliath , or is it Goliath vs David ?… Oh I dunno . One vexed insurance company against one smooth Doctor . We got to get rid of this colonial way of thinking !

  22. JONO says:

    As a retired healthcare professional, I shall not tolerate any OBA politician attempting to regulate my health care.,. Just bought a ‘green tee shirt’