PLP: Pre-Certification Is Potentially Dangerous
[Updated] “Notwithstanding the urgent need to reduce healthcare costs, with diagnostic imaging only amounting to less than 2% of health care costs, the OBA plan to move forward with pre-certification is an unnecessary and potentially dangerous practice,” Shadow Health Minister Kim Wilson said.
Ms. Wilson added,”Forcing patients to wait for permission for medical diagnostic tests ordered by their physician while a separate body determines whether it should be performed creates added potential risks.”
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.
Ministry’s Previous Comments On Pre-certification
Earlier this 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.”
Opposition’s Comments On Pre-certification
Kim Wilson said, “Notwithstanding the urgent need to reduce healthcare costs, with diagnostic imaging only amounting to less than 2% of health care costs, the OBA plan to move forward with pre-certification is an unnecessary and potentially dangerous practice.
“Forcing patients to wait for permission for medical diagnostic tests ordered by their physician while a separate body determines whether it should be performed creates added potential risks.
“The added layer of bureaucracy being proposed by the OBA will likely result in delays in patients receiving the treatment being recommended by their physicians; physicians who have repeatedly objected to the OBA proposal.
“There are many other ways in which heath care cost can be reduced, ways that would not interfere with patient safety.
“With the hospital representing the single largest item relating to Heath care costs, surely a prudent Government would look there first to eliminate areas of waste and unnecessary spending as opposed to concentrating their efforts on an area which will see little savings whilst at the same time interfering with the health and wellbeing of Bermudians.
“A Progressive Labour Party Government would look to the manner in which local insurance companies are operating with respect to all matters affecting Heath costs.
“As we all know, competition drives down the cost of goods and services and as such considerations ought to be given to allow the introduction of larger international insurance companies which could not only drive down costs but could also prove the difference between life and death.
Ms. Wilson concluded, “HealthCare in Bermuda is expensive and costs must be cut, but not at the risk of patient’s lives.”
Update 2.52pm: Health Minister Jeanne Atherden’s Response
Minister Atherden said, “I am disappointed by the tone of the Shadow Minister’s comments, as both the press release issued on behalf of the Ministry and the detailed RFI specify that testing ordered by specialist and diagnostic testing for emergencies will not be subject to pre-certification. Clearly the intent of pre-certification is not to put Bermudian lives at risk – the intent is to reduce the cost of healthcare while still ensuring quality outcomes for Bermudians.
“I would also like to remind everyone that we are not relying only on pre-certification. We have made information available to physicians on their utilization so that they can compare their data with the average. Once we have received the responses to the RFI we can review the impact of our other efforts to reduce utilization, and determine the cost/benefit of taking the next step of issuing a Request for Proposals for a pre-certification system.
“Finally, the total cost that diagnostic imaging and lab testing adds to the healthcare system is significant. In 2013, the healthcare system cost Bermuda $678 million and more than $47 million of that was spent on diagnostic imaging and lab testing. If we can reduce utilization by as little as 10%, we could save the system over $4 million each year.”
“As we all know, competition drives down the cost of goods and services and as such considerations ought to be given to allow the introduction of larger international insurance companies which could not only drive down costs but could also prove the difference between life and death.
Now we agree on that point how do you suggest the Government get the “ball rolling” in the right direction when there’s obviously a shortage of funds?
Ms. Wilson concluded, “HealthCare in Bermuda is expensive and costs must be cut, but not at the risk of patient’s lives.”
That is true Ms. Wilson, not at the risk of a patient’s life
May I add this overlooked fact, large insurance companies will be taking more $ out of our economy where it’s needed (or do I need to mention “who’s in dire straits?”)
That’s what they said about the HSBC BOB purchase and look at the great “benefits” we are getting from them
I hope that’s a joke! Bermudians now pay large amounts of money in banking fees for mediocre service, provided most often by someone who is struggling with English on the other side of the world… I used to actually make money from the fact that the Bank of Bermuda paid interest on all my cash!
kekep an eye on EB’s clinic
Seriously?
Nobody here thinks that having a panel of accountants make decisions about individual health care is a crazy idea?
Everybody here wants to see their doctor be cut out of the decision process?
Good luck with that.
It isn’t going to be a panel of accountants. Grow up and discuss it like an adult.
Do you really think that it would be a bunch of accountants reviewing the recommendation?
Get off the radio show and come back to reality.
This smells like de Dead Peasant Insurance Scheme!!!!!!!!!!!!!!!!!!
De O.B.A/ubp are de new breed of de Oligarchy, a bunch of business men who are driven by GREED at de expense of human concern.
Just a few more years to get these DREAMERS out then de new Govt. will have to undo all de legislative F!@# ups these clowns are implementing !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
So, like the Republicans did with Obamacare, the PLP is now claiming that this approach to reducing healthcare costs is akin to ‘death panels’ which will cause teh deaths of an untold number of Bermudians.
“Sarah Palin said that if the healthcare bill became law, people like her disabled son would “have to stand in front of Obama’s ‘death panel’ so his bureaucrats [could] decide, based on a subjective judgment of their ‘level of productivity in society,’ whether they are worthy of health care.”
Thought the PLP was all about Pres. Obama and against the GOP? Strange considering most of their arguments are aligned with the elephant as opposed to the donkey of US politics.
I would like to hear much more information about how it will work before I start to spread fear amongst the population with claims of ‘death panels’ and the like.
What cost cutting measures do the PLP approve of, because since their time in Opposition they have vehemently fought any method sought to reduce costs across the board. Not one solution has been brought by the Opposition to stem the increases of health care in this island. The Party of No (to reducing the costs of living).
The HUGE difference between Obamacare and what we have here is that insurers have to insure you even if you have a pre-existing condition. Secondly, Sarah Palin didn’t/never knows what she’s talking about, because that’s not the process of Obamacare, but that was scare tatics to scare Americans into not supporting the Affordable Care Act.
Ironically, this scare tatic is not a rumour, but what they actually plan to do here in Bermuda!
The insurers were against Obamacare, but our insurers are for this pre-certification. That ought to make us look again harder at the FACTS.
I would like to challenge the statement made by Tough Love who states, “our insurers are for pre-certification”.
I have excellent reason to believe that this statement is almost completely untrue. I have heard from insiders within the insurance companies in Bermuda that they are against pre-certification and have stated so to the people who are in Government, but there is one single insurance company pushing for pre-certification because they have a financial interest in doing so. That same insurance company is close to the reigns of power so they probably hold more sway than all the other local insurance companies combined.
If “tough love” is so sure that our insurance companies are all for pre-certification then please name them, and let’s see if an official spokesman for each insurance company will publicly state that they are for it.
Can we also hear what our doctors have to say about pre-certification. Have they made their views known to government and to the public at large? Have the members of our medical profession been given an opportunity to state their views, and if so what are they? Surely they should have some say in what we need to do moving forward.
Interesting comment, however, if you look at the BHeC document that produced the recommendations on pre-certification there was representatives there from all private insurers as well as the health insurance department, physicians and charity health groups. So how can 1 insurance company be pushing this through when they were only 1 representative on the committee???
The headline should be changed: PLP is potentially dangerous.
potentially ?
A battle over profits for providers and profits for insurers. Patients get stuck in the middle.
Health insurance provision should be proived by a mutual non-profit insurer. It is unethical to deny care for profit. And it is unethical to administer harmful radiation for the sake of profit. OMG!
No insurer can deny you coverage they are contracted to provide you and any non-profit healthcare provider will also be employing likewise cost containing restraints, so know your coverage contract. There is just no insurer in this world, whether private, public, non-profit…, that can provide every person full unlimited healthcare coverage, it would just cost far too much money for them and would be unaffordable for us.
So among the Oppositions suggestions for reducing healthcare costs are the running of the hospital… the new and really expensive one they commissioned to be built, that will definitely see a rise in cost. and to invit international insurance in to our market… let’s look a this one a little closer.
Should we invite the big internationals in to our local insurance market, you can be assured of a couple of things; in order to bring the cost down they will outsource as much service as possible, meaning next to no jobs will be brought in and as they their prices will able to lower with a larger market support behind them, we will see our local medical insurance companies struggle to compete and may even cut their losses on the medical insurance product, so more jobs will be lost. Additional, as these are foreign companies, the profit they would make would be going overseas, and more money would be bleeding from our economy. Local insurance is one of the big job providers in our local market, one of the few industries here that hasn’t shed too many jobs in this economy, can we afford to force them into a situation where they will have to shed more
jobs we can’t afford to lose.
We need to cut our healthcare costs for sure, but we must also carefully look at the question of what we are willing to pay for those cuts and overuse of diagnostic imaging is a fairly easy area. The question we should be focusing on is can they keep these pre-cert turn around time to a day or 2? Also remember, the pre-cert isn’t for all diagnostic imaging.
“A Progressive Labour Party Government would look to the manner in which local insurance companies are operating with respect to all matters affecting Heath costs.
“As we all know, competition drives down the cost of goods and services and as such considerations ought to be given to allow the introduction of larger international insurance companies”
OK……………..
1) PLP allowed, you could even say encouraged the increased cost of healthcare under their watch.
2) THe PLP want to open up healthcare to Large international Insurers.
So the local insurers who employ thousands of Bermudians would end up out of work AND more dollars would leave the island !!!!
PLP are so full of good intentions, but abject failures at understanding implications of their actions.
You just lost my respect Wilson.
I glossed right over that.
Strange that the PLP is advocating for more foreign insurers to enter the market, despite their calls for less foreigners, less IB and the fact that they will compete with locally born and bred businesses who employ numerous Bermudians throughout their ranks.
Seems to be a Party of two minds at this point.
One thing is true though is that healthcare costs are outrageous in Bermuda and need to be tamed. Just the other day I was charged almost $400 for a filling that took less than an hour to do!
I find it funny with this latest release that they say the OBA is anti-Bermudian and all for foreign business coming in to take our money and jobs… And they propose to have big international insurance to do just that.
They say whatever fits at that point in time that they think will make them popular, in order to win votes and POWER.
They don’t give a damn all they give is lipservice.
Indeed an extremely hypocritical statement for anyone to make in reference to resolving our financial “woes”
“What we can do is to live our lives as best we can with purpose, and love, and joy. We can use each day to show those who are closest to us how much we care about them and treat others with kindness and respect that we wish for ourselves. We can learn from our mistakes and grow from our failures. And we can strive at all costs to make a better world so that someday, if we are blessed with the chance to look back on our time here, we can know that we spent it well; that we made a difference; that our fleeting presence had a lasting impact on the lives of other human beings.”
– Barack Obama
“Although Bermuda spent more than $50 million on local diagnostic testing last year, representing seven percent of total spending, it added up to 34 percent of Standard Benefit claims, she said — and represented a rise of 25 percent over 2011’s figures.”
Firstly, it is not 2% as Ms. Wilson claims and closer to 8% of total healthcare related costs which has been confirmed by doctors on island and can be found within the same article as the figures presented in my first paragraph. Secondly, as noted in the paragraph above the Government is seeking to reduce its healthcare costs with these tests now accounting for over 1/3 of the Standard Benefit claims which is paid by the…take a guess.
So I understand the approach and the reason for it, but would like to hear more on how it will be implemented, before forming an opinion. Information like the process of the pre-certification, members of the committee and the standard turnaround times for decisions to be made are essential for a informed opinion to be made. And I know Ms. Wilson knows this as well which can be evidenced by the insertion of the word “POTENTIALLY” before dangerous in her opinion.
I am agree with you on this, the crux to this is going to be entirely on the implementation and turn around, and this should be where focus is directed. Mis-information and mis-representation could become far more dangerous for us than Pre-cert.
So when you do something to reduce healthcare costs, the PLP says “oh, that’s only 2%. That’s not much. Don’t bother doing that”.
But then next week they will be saying “Ohmigod. Healthcare costs are too high. DO SOMETHING”.
Sorry, hit dislike in error. Small screen, large fingers…..
The PLP created this problem so you uneducated people should all wake up, shut up, and grow up. Thank your own stupid government for forcing our whole island into this crap life!
This sounds like “The case for killing granny”….
everyone agrees, including Ms. Wilson and the PLP that health care costs have to come down, but if these diagnostic costs are only 2% of the budget then why are the OBA so focused on this being the main way to do so. In my opinion it is to target Dr Brown and his facilities.
What they need to focus on is the specialists who charge $500 for a introductory visit (as a copay!!!). GP fees are generally fine, but try going to the Dermatologist, or urologist and you are paying exorbitant fees just to get in the door. These are the services that are barriers to seniors and the poor getting proper medical care and are grossly overpriced.
This is exactly why the PLP can’t manage budgets. If you do five things each saving 2%, you save 10%. You have to start somewhere.
The level of commentary is just asinine.
Yes of course.
It is all about Dr. Brown. It always is.
The sheer fact that a man that is a 1%er that will have more money than you and I will ever see in our lifetimes and properties in some of the most expensive jurisdictions in the world has convinced some that he is a perpetual victim is completely laughable and says alot about your rational thinking process.
The Bermuda Medical Doctor’s Association stated their opposition. Not just your beloved Dr. Brown. Within the same article it was stated that:
“These currently represent 40 percent of all standard benefit claims and 8.5 percent of total health costs in Bermuda.”
Not the 2% that Ms. Wilson stated in the above article. And again as I noted it is the fact that more than 1/3 of the standard benefit payments (paid by the Govt/taxpayer)are going towards these procedures. So it appears that is the crux of the matter.
SO how do you propose to do that without creating an environment whereby future required specialists don’t want to work in Bermuda as they can make more elsewhere ?
My thoughts on your point…..
Perhaps the “Specialists” can provide a business case as to why their cost are so high as part of a discussion to try and make care more affordable.
Perhaps the specialists can make a suggestion on how we can cut the costs, afterall they are the ones in the business.
1. When Minister Moniz was the Minister of Health he spoke at the a symposium on healthcare costs in February where he indicated to the physicians that pre-certification was being examined as one of many different avenues for controlling the costs and that other items will be rolled out as well for cost containment of healthcare. So, let’s remember that this is not the only item that is being worked on to assist in stabilizing healthcare costs. The government also rolled out the pharmacy updates in February – how many of you are demanding the generic that is supposed to be dispensed now instead of the brands to help control costs??? I am… but are you?
2. In reference to Ms. Wilson indicating to bring in foreign insurance companies, that doesn’t work for Bermuda for a variety of reasons (least being the number of local jobs that would go by-by as a result) but the fact is, is that the standard hospital benefits and pricing for it are set by the BHB and BHeC every year and as such local insurance companies don’t get a say in the pricing but are instructed that if the test is a standard hosptial benefit item then it has to be paid, regardless of whether it is appropriate or not at the price set by BHB or BHeC (depending on if in hospital or in private facility), or if the patient just had 5 of the same MRI’s in the last two months or not… That is contributing in a large way to costs escalating – duplication of services, which pre-cert will assist in curbing as whatever company gets the contract for it can inform the doctor that the patient just had that test done on x date at x facility.
3 – If you read the documents out for the tender, you will see that there are stipulations in place for medical emergencies – and really most items done on an outpatient basis aren’t true medical emergencies, we may like to have our MRI done on the same day that it was ordered, but it’s not an emergency, you can wait a couple of days… Heck, people in Canada wait up to 6 months for an MRI…
Pre-cert is not a death trap, it is used in one form or another in a number of western countries, including those that have private and publicly funded medical care.
I for one will be thankful to find out that yes the test that was ordered by my local doctor is meeting best practices for medical care, because right now we have a LOT of quacks in Bermuda who have no sweet clue how to practice medicine and would never be granted a license to work in the US or Canada – mind you we have some good doctors too, but unfortunately it’s the quacks that are most dangerous.
I think that you have really missed the point. It is not necessarily the delays that will now be put in place before elective investigations can be arranged, it is the distinct possibility that the test will be refused by an entity that has not seen the patient. This may well result in a patient suffering or dying. Only time will tell. Whichever way the numbers game is played, there is simply no doubt that KEMH and overseas hospitals consume the majority of the healthcare budget and local insurers make millions every year off the back of Bermuda residents, with their massively inflated premiums.
The eye of Sauron should be turned towards the Paget atrium.
Good thing we spent half a billion on a wing down there I guess…
Please read the tender document. This does apply to KEMH outpatient services that are not true medical emergencies as well, so it will help decrease costs at KEMH and in the private facilities. There is also an appeal provision in it should an item be denied that the physician can appeal it with providing the adequate clinical documentation and there are guidelines in the tender for turn around times as well on getting the responses back to the patient, doctor and insurer on it. Many doctors are ordering ct and MRI’s when an old fashioned ultrasound or xray will do just as good of a job in getting the same diagnosis at a fraction of the cost.
And who will pay for the extra administration involved in this?
I can see the medics refusing to comply with pre-certification, if it ever comes to fruition, which i very much doubt.
Diagnostic tests might only be 2% of the budget but the tests are quite expensive and many times unnecessary, with more than a few medical professionals not prescribing the correct diagnostic procedure.
The modalities listed in the article (MRI,CT, Echocardiology) only one acutally emits any radiation which just goes to show how much is NOT understood about each technology.
MRI is very expensive and also very much a money making procedure for the facility. It’s a very large issue in the states because the trend has been an increase of unnecessary expensive testing because the reimbursement rate is much higher. The game then becomes between how much insurance providers are willing to pay and not having to pay because of pre-authorization.
I find it interesting that the OBA trolls now run Bernews comments. It doesn’t seem to matter if a PLP member actually says anything intelligent or legitimate, certain posters read PLP and “everyone loses their minds!”
In the case of the young girl with the rare brain tumor, her doctor ordered a series of tests trying to find out what was wrong with her and he found it early. If this young girl would have gone through the precertification process who knows how long it would have taken for a decision to be made to allow the tests, IF they were allowed at all.
If insurers suspect a GP of abusing tests, surely there are ways to detect it without the danger of losing people while waiting to get through red tape!
If a physician feels to him /herself that the M.R.I is an emergency then it will be done A.S.A.P. In other words, no-one will have to wait months before having a M.R.I Get the fact first Tough Love
47/678 = 7%.
As usual the PLP can’t do math.
If we are looking to reduce health care costs surely we should be looking to see if doctors have a financial interest in ordering expensive tests, and in prescribing drugs and treatments. One such test is an MRI. If we have doctors in private practice ordering MRI’s for their patients when they own the MRI equipment and therefore directly profit from such tests, or when they are prescribing drugs and medications and they own the pharmacy dispensing them, then what we have is a system that is rife for exploitation.
Yes and this is in the tender as well, that if a physician has a business interest in a private facility for labs or diagnostic testing such as MRI, CT or ultrasound then they have to pre-certify to prove medical necessity to try and avoid the doctor from profiting from patients that don’t really need the test. There are way to many private facilities in Bermuda that give a very nice profit to the physicians that own them, and not everything ordered is medically appropriate for the patient.
It’s good to see that Alicia agrees with my point of view regarding not allowing physicians to benefit financially from ordering tests such as MRI’s or dispensing drugs when they own either the testing equipment or the pharmacy, but I take issue with her assertion that the insurance companies have all endorsed pre-certification. This is patently untrue and I challenge her to name the insurance companies that support pre-certification. This should be really easy to do, if true. Let’s see the names of their companies, but don’t hold your breath because you may find that there is only one. Can we also hear directly from the doctors themselves, or someone on their behalf? Have they made any recommendations to Government, and if so what are they?
Someone is being careless with the truth and we, the public, have a right to know exactly who is making these decisions on our behalf.
Please reread my statement on the insurance companies. I never indicated that they all supported it, I outlined that as each insurance company had a seat on the committee for this that it isn’t not possible that only one insurance company got this pushed through out of a multiple of people at the table, including the other insurance companies, charity health groups and doctors.
“as both the press release issued on behalf of the Ministry and the detailed RFI specify that testing ordered by specialist and diagnostic testing for emergencies will not be subject to pre-certification.”
If that’s the case then what’s the issue again?
For the past couple years hasn’t one of Bermuda’s leading health insurers been bragging of huge first quarter, half, 3rd quarter, etc. profits totaling in the multi-millions? Now there’s a cry of poverty that there’s no cash for use of health care services that was boasted on front pages when Bermuda received the testing equipment & was told how it all will help save lives. Now we’re to put our lives at risk by having to wait for a 2nd referral by a 3rd party (who isn’t as familiar with the personal details of my condition just a quick look at a couple papers) just to get access to this very same test equipment. Having contributed a couple hundred dollars a week for years into my insurance am I to now have to wait for 3rd party permission to use the services I have paid into for decades?
This argument will be settled after the first lawsuit, cause of death delay..
Healthcare costs and procedures are presently largely unregulated and that is one of the problems. A doctor/dentist/whoever can charge whatever they like. The insurance company will pay for the scheduled cost but anything above is paid by the patient. What needs to happen is for Government to mandate what a doctor/dentist/whoever can charge for each procedure etc.
There is also a perception that there is a cartel at work. Patient goes to Dr. A. Dr. A says not sure what is the problem, I’ll refer you to this specialist; then that specialist thinks you have ** and need to go to that specialist and so it goes on. Less people = less income so to solve that the patient is referred over and again. Don’t believe it? Your dentist retires and a new person takes over. Suddenly you need lots of replacement fillings. Paid for by insurance in the main, but not needed and guess who pays? The list goes on.
Actually, BHeC already does this for medicine. There is a list of codes on their website with pricing and for those codes that is all that they can charge you. In terms of lab work, if one private lab charges you a copay and the one down the street doesn’t, then the one charging you the copay won’t be in business very often. The problem with the copays is for the general doctors office visit or procedures that they do in their office.
Under the PLP healthcare costs went through the roof. Now our seniors are having a hard time,even not getting coverage!
I went to my doctor for a growth in my neck. Doctor sent me to specialist for precertification ( First available visit was in 3 months) as well as a visit with the surgeon who couldn’t ascertain what he should do without a catscan, after six months. Here I am a year later still awaiting a catscan that nobody wants to request. The lump in my neck is growing more. I had to pay three people for consultation only to be back at square one because of precertification. IMO. This process makes doctors uncomfortable and hesitant. I believe my doctor has my best interest at heart and I trust him. It’s bad enough that your physician is hands off during your hospital stay. This is very intrusive and undermines the level of care a person chooses for themselves. How is it cost cutting when you have to include along with your doctor, a specialist and a surgeon? What kick backs are the OBA receiving for this move?
I appreciate the Health Ministry’s concern about over-radiation to patients and agree that too many expensive diagnostic procedures have been requested by doctors. I wondered if some doctors lack confidence in their diagnostic abilities or if they are overusing the diagnostic technologies as backup to avoid potential malpractice suits. Could it be a requirement for doctors’ insurers?
I think people need to take back responsibility for their health care and be prepared to question their doctors. It is always advisable to get a second opinion AFTER a diagnosis from your own doctor if it is a serious illness. Isn’t that what we do for other major investments. I don’t see how mandated pre-certification is helpful. Who benefits financially? Who is disadvantaged?