Video: Minister Moniz On Healthcare Reform

Good morning everyone; and welcome to today’s symposium.

I’d like to start by thanking you for joining us today; for giving up a large part of your Saturday to dedicate time to examining Bermuda’s health system needs.

As health professionals, I appreciate the central role you have in providing the country’s healthcare, so I want to open by stressing how much I value what you do.

I, and my technical teams, understand your stresses, your long hours, the challenges you face daily and the burden you carry in caring for your patients – the people of Bermuda. And I want to make sure that we work collaboratively to find ways to overcome the challenges our health system faces. Because, ultimately, I know we all want the same thing: “healthy people in healthy communities.”

The purpose of bringing everyone together in this forum is to share knowledge and experiences about healthcare, so they may guide us as we develop initiatives to improve quality and efficiency for everyone. I know I have much to learn from you, and I look forward to hearing the day’s presenters and the discussions that will follow.

But before we do that, I want to lay out what I have come to see as some of the key health system priorities and share with you the broad strategic direction that I believe is needed for our health system. There is much scope for improvement, and hearing about the experience in other countries will hopefully help to develop solutions that we can consider locally. But first, I’d like to share with you some of my thoughts on where we are and where we need to go.

Clearly, we are all here because we care about people. We care about patients, about families, about our community. These common values drive people like us to serve the public – to give of ourselves for the benefit of others. Which is why the vision of the Ministry of Health and Environment is so very applicable to the vision I have for Bermuda’s health system. Simply: “healthy people in healthy communities”. That is what we are here for.

But, as we know, visions are easy to have and difficult to achieve. For this reason, I want to make sure that we don’t waste time reinventing any wheels. We know what we want: good patient outcomes, efficiently delivered care, and an engaged, collaborative healthcare community. Now we just need to do it. Should be easy, right…?

Maybe not, but one way we can make it a little easier is to pick up good work that has already been done. And listen attentively to the views of key stakeholders, like yourselves, in elaborating that work further.

In this regard, I see today as an important part of a series of discussions to identify and prioritize Bermuda’s pressing health system needs; and I’m very much looking forward to your take on these issues today and in the coming months.

Significantly, as we move forward to develop solutions together and make plans for implementing those solutions, I’m very keen that the work done by many of the “Task Groups” under the previously proposed National Health Plan provide a guiding foundation.

Indeed, the mission that I agree our health system must have is that it should do everything in its means “to assure the conditions to enable the human capacity to adapt and cope in achieving optimal health and quality of life.”

I won’t disguise that this was the mission of the Health Plan, and it remains as meaningful today as ever.

Significantly, however, it is vital that we stress the need for sustainability. In 2012 our health system cost $678 million dollars. We spent $10,562 dollars per person on health, making us the second most expensive health system in the world. But we are not getting value for this level of investment.

Yes, we get a lot of healthcare – and pay dearly for it – but it’s evident that we have to pull together to get a better bang for our buck. Last year, thankfully, health costs flattened for the first time in decades. There were many reasons for it, but it’s vital that we maintain the trend.

Indeed, sustainability is more important today than ever, because our economy simply cannot take any increases in health spending. Despite last year’s flattening, health costs consumed a larger proportion of our GDP, which is an important reminder that we haven’t bent the cost curve yet.

It also highlights why the Health Plan’s definition of sustainability must remain our target, as it provides a common framework; namely, we must aim to achieve: “health spending growth in line with inflation, and a health system resourced to be affordable to the economy, payors, providers, employers, individuals and families.”

Yes – sustainability is the key.

Because while it is clearly about cost containment, it is not only about costs. We have to do the best we can with what we’ve got. No one can say that $10,500 per person is not enough.

But we need to spend it better. We need to avoid duplication, target our resources, and focus on the quality of patient care, rather than the quantity.

It has been said, and proven, that quality care is the most effective care, because it doesn’t over treat, over prescribe or leave patients waiting, guessing or without care.

Good quality is about delivering the right care, at the right time, and in the right setting – and doing it in a compassionate and dignified manner. This can only be achieved where there is collaboration, mutual respect, accountability and trust.

For these reasons, some of the things we must achieve as a health system require a formidably difficult balancing act.

The new hospital wing will open later this year, and we have to make sure we right-size the hospital. We’ll have a smaller emergency department; we have to ensure it’s used appropriately.

We’ll have to find suitable ways to provide for patients in need of continuing care and alternative levels of care. Social cases don’t fare well in an acute setting – medically, it can sometimes be the worst place for them. But, unfortunately, many of our families struggle to find a way out.

Our health system can leave even the most willing families to flounder when caring for a chronically ill loved one. And though there clearly are some instances of neglectful families, most of us know that even with the best will in the world, an ordinary family is simply not able to keep an elderly, diabetic, amputee with Alzheimer’s and a heart condition out of the hospital for very long stretches. Such patients are resigned to a revolving door because our current system is not able to meet their healthcare needs outside the hospital setting.

This is something we must fix; and we can only fix it together.

We all talk about the ‘elephant in the room’ and in our health sector it is often synonymous with the hospital. But, in fact, anyone who sits on the front line of healthcare knows that the real elephant in Bermuda’s health system is chronic non-communicable disease and the ageing of our population.
If we want to fix healthcare, we’ll need to find ways to manage these better.

But when we talk about managing better, don’t mistake this with a simplistic notion of utilization management. It isn’t only about the way we “use” services. It’s about the way we care for patients.

When the patient is at the centre of medical decisions – rather than convenience or the bottom line – we’ll be better placed to manage their care more humanely; and in so doing, we’ll make more rational choices about medical necessity and medical appropriateness. This is what will help us control costs: better patient care, not rationing care.

Within the Ministry we are actively moving in the direction of focusing on improved management of patient care. The Department of Health’s “Beyond Wellness Medical Clinic” focuses on un- and under-insured patients with chronic conditions, because we know that a small investment to help these patients manage their conditions, will keep them in better health and out of the hospital.

The Health Insurance Department now has a Clinical Case Manager, and we’ll be piloting focused initiatives with the most chronic patients to improve their health outcomes by ensuring their care is better coordinated.

In addition, of course, everyone is aware that we have been considering pre-certification as a mechanisms to reduce utilization. This is an idea that can’t be ruled out, as there is no magic bullet and we have to tackle the problem on many different fronts. I’m aware of the disparate views on this initiative and today’s discussions will help to inform how we ultimately move forward.

I have to also mention that, despite Bermuda’s small size, our health system is incredibly complex, fragmented and, at times, difficult for patients and healthcare providers to navigate. But we are too small to afford – or justify – the fragmentation in our system. We all have an obligation to be more efficient. For this we need more collaboration and simplicity. More pulling together. Less self-interest; and more focus on the long-term benefit of patients and the country.

This year’s budget has been an extraordinarily difficult one. Given the state of government finances and the fiscal space we’re constrained by, we had to make some very tough decisions. There simply were no palatable options, and the lack of funds forced us to have to scale back on government subsidies. This had a knock on effect on the standard hospital benefit, its coverage and premium. But, in my view, this must be seen as a temporary fix while we find longer-term solutions to our systemic challenges.

In this context, I can outline what we’ve come to see as some of the health system priorities that need addressing. I would be interested to hear if these reflect your experience, and what else needs to be prioritized.

First, we need to change our approach to chronic non-communicable diseases and other determinants of health. If we keep doing the same thing, we’ll get the same result. We just can’t afford it anymore.
We need a strategic, joined-up approach to long-term care. Our population is ageing and some of the most vulnerable patients have care needs that far exceed the system’s current capacity.

With the new hospital wing opening, and the financial commitments this brings for the country as a whole, right-sizing the hospital is essential to the system’s survival. So we have to ensure that the healthcare dollars we do spend on hospitalization are spent locally wherever possible, and that healthcare providers and the public have confidence in local services, so that overseas transfers are focused on cases that need care which is genuinely not available here.

Further, we must, as a matter of priority, address the fragmentation in our health system and work collaboratively to find solutions and help patients achieve the best quality of life within their reach. Working in silos will never achieve this. Care needs to be coordinated and managed by the appropriate health professionals, or else we’re stuck with that revolving door – and the previously mentioned elephants. For this we need a shared strategic vision and a road map to reform.

In addition, we have to fundamentally change the way our health system is structured. We’re stuck in a 1970s model built around acute care. But 21st century population health needs and medical knowledge demand that we place much more focus on primary care, health maintenance and primary and secondary prevention. This requires reforming our basic health package.

Working out how to do these things won’t be easy, and I don’t pretend to have all the answers. But I know that, together, we can find them. I know that you have a myriad of solutions to offer. And I know that we cannot fix these problems without you.

For these reasons, I hope you will support the pursuit of that singular vision for “healthy people in healthy communities”.

The values underpinning this vision, I believe, help to provide a foundation to direct policy decisions and programme development. I have talked about them throughout but let me list them here for clarity. I believe the values that need to drive healthcare reforms are the pursuit of quality, sustainability, accountability, protection of the most vulnerable, and collaboration.

If we are not driven by these values, our efforts will be in vain; because no matter how noble or well-intentioned they may be, if we operate in silos, we will fail our patients.

Since becoming Minister of Health and Environment, I have been impressed by the extent to which there is a shared desire to focus on patient care and quality outcomes. But I have been equally surprised at the apparent paucity of collaboration that occurs at times, and is glaringly obvious when things go wrong.

There is a saying that is highly appropriate in the health sector: “If you want to go fast, go alone. But if you want to go far, go together.”

We have a long way to go, folks. I’d very much like us to go together. Thank you.

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