In recent weeks, there have been some press discussions about rising medical inflation, and health insurance providers have signalled a likely increase in premium payments. Currently, only an estimated 15 per cent of Jamaicans are covered by health insurance leaving about 85 per cent without any form of health insurance.

Many of the 15 per cent with health insurance are under insured or have plans with such high co-payments or deductibles that it leaves them vulnerable in the face of major illness or emergencies. For yet another insured segment, the insurance companies require them to pay out of pocket and “claim back”. In essence, those with limited means often cannot access care for high-cost medical services even during emergencies because they lack the resources for pre-payment. Many patients are also indirectly encouraged to delay or decline care because of fear of exceeding their lifetime maximum benefit, which frankly is low for many patients in the context of advances in health-care diagnostic and treatment options driven by significant innovations in medicine over the past 25 years. By declining or delaying care to save their policy for “a rainy day”, many patients face major complications despite having health insurance. Health insurance providers are often unavailable after hours, weekends, or holidays to provide pre-authorisation for major procedures and services to further compound the problem. Given these issues, we can estimate that less than five per cent of our population are adequately insured to guarantee health security when needed. A rise in premiums will not improve access, and it will further shrink the pool of the insured and deny access to many more. Therefore, we believe that the debate about medical inflation and premium hikes misses the big picture in this context. We believe that for a low resource nation like ours, our discussion should focus on creative mechanisms and strategies to improve access to ensure inclusive healthcare, especially in the post-pandemic period.

How can we improve access post-pandemic?

The pandemic has altered the way citizens across many nations gain access to care and, in some cases, has created enough shift to influence medical cost trends by altering price and utilisation. We expect that post-pandemic the response of health systems to lessons learned from the pandemic will, in the short run, inflate the cost-of-service delivery. At the same time, many lessons learned from the pandemic, if properly deployed, should lead to changes in consumer behaviour and more efficient technology-driven operational models that would, in some instances, deflate the cost of care. Forward-thinking and progressive health systems worldwide are already redesigning and re-imagining their infrastructure, capacity, and processes to create a more robust and more resilient ecosystem to withstand external shocks from future pandemics or other potentially catastrophic events. This redesign expectedly will bring inflationary pressures on health care in the short to medium term but will lead to significant and sustained cost savings in the long term.

1. Investments in digital health care to enhance the patient relationship and cost-effective utilisation

The pandemic has greatly accelerated improvements in digital health so that providers can deliver appropriate care to patients safely without geographical barriers or the risk of contracting COVID. Innovative health systems worldwide are fine-tuning “digital front door” mobile apps that connect them to their patients, strengthening portals and intensifying the use of customer relationship management (CRM) tools. Virtual care, artificial intelligence and analytics not only improve the patient experience and create regular touch points with patients, but also expand access and capacity. In the post-pandemic era, we expect these digital investments in the patient relationship to expand consumers’ access to care, increasing utilisation cost-effectively and affordably in 2022.

2. Optimising cost of care in best-of-class facilities

Insurers and payers have been aggressively nudging patients toward lower-cost sites of care over the past few years using multiple mechanisms without regard to quality measures. This has often resulted in patients “shopping around for lowest cost care,” often at the expense of quality and outcomes, sometimes to their detriment. Sometimes, uninformed patients end up comparing apples to oranges. If we told you that Airline A could get you to Miami for $300 but has crashed a few times in the past year with lives lost, but Airline B can get you to Miami for $400 and has done so safely for many years with no crash, your decision would be a no brainer. The same will apply if you know that pilots for Airline B have 20 years’ experience each while pilots for Airline A have an average of five years’ experience. What would your decision be? Let that sink in, and next time you decide about your health care utilisation or pressured by a payer to take the lowest cost option without regard for quality or outcome, think further about that. Many studies have shown that the approach that seeks the lowest cost care may financially benefit the payer in the short run but is flawed as the cost of care is affected by many not easily comparable inputs. Most experts now agree that the best measure of value in healthcare is the patient outcome, which is reflective of the quality, access, speed of care, best practices, skills, and infrastructure of a facility. Rather than compare the “cost” of a given service between non-identical service providers with differing standards of care and patient outcomes, we should focus on the long-term savings from better patient outcomes and overall improvement in population health as measured using a standard quality matrix. A healthier population results in a healthier workforce and improvement in national productivity and gross domestic product.

3. Cost reduction through new ways of work

In the post-pandemic era, we can reduce costs by embracing new ways of work with a shift to remote work for some healthcare employees. Health systems are also starting to rethink their real estate spending too. According to PricewaterhouseCoopers (PwC) Health Research Institute, health systems could significantly cut costs by adjusting the real estate requirement for non-clinical services and, where appropriate, encouraging work-from-home options and reconsidering the allocation of space between business functions that typically do not generate revenue or involved directly with patient care.

4. Improve efficiency through process automation and cloud technology

Health systems can seek to increase efficiency to reduce costs using proven technology-based solutions. Cloud services are also becoming increasingly desirable since they allow employees to work remotely and reduce health organisations’ physical space and fixed assets.

Next week we will continue by looking at group purchasing agreements to reduce medical costs; reduced importation of medical equipment and mobility of skilled workforce, and concessions to healthcare facilities.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Correspondence to info@caribbeanheart.com or call 876-906-2107