Bermuda Health Strategy SymposiumBermuda Underwater Exploration Institute

16th Jan 2016 . 8:30am - 12:00pm

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8:30 am Breakfast and Registration9:00 am Opening Remarks Chairman, Bermuda Medical Council Master of Ceremonies - Dr George Shaw9:05 am Feature Address and Formal OpeningBermuda Health Strategy Minister of Health, Seniors and EnvironmentHon Jeanne J Atherden CA, CPA, JP, MP9:20 am Bermuda Health Action Plan Acting CEO, Bermuda Health CouncilTawanna Wedderburn9:30 am Reducing Chronic Non-communicable Diseases Dr Cheryl Peek-Ball9:40 am Quality and sustainability through modernization and innovation Chief of Staff, BHBDr Michael Weitekamp9:50 am Insurance coverage access initiatives Clinical Care Manager Consultant, HIDDiana Liacos10:00 am Care Quality initiatives Acting CEO, Bermuda Health CouncilTawanna Wedderburn10:10 am Questions and Comments (about initiatives) Chairman, Bermuda Medical Council Master of Ceremonies - Dr George Shaw10:30 am BREAK10:45 am Panel Session:• Provider perspectives on cost savings Chief of General & Family Medicine, KEMHDr Fiona Ross• Insurance perspectives on quality/costs Executive Vice President, Group Insurance, ArgusMichelle Jackson• NGOs perspectives on care and affordability Executive Director, The Family CentreMartha Dismont• Public health and health promotion perspectives Director, Department of HealthDavid Kendell11:00 am Panel discussion Chairman, Bermuda Medical CouncilModerator - Dr George Shaw11:50 am Closing remarks and next steps Minister of Health, Seniors and EnvironmentHon Jeanne J Atherden JP, MP, CA, CPA12:00 pm Lunch on participant's own: 10% discount offered at Harbourfront Restaurant3

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BERMUDAHEALTHREFORMSTRATEGY2014‐ 2019FromVisiontoAction

The Hon. Jeanne J. Atherden, CA, CPA, JP, MP

16th January 2016

OurVision:“HealthyPeopleinHealthyCommunities”

FromVisiontoAction

Vision • Health Reform Strategy

Action • Health Action Plan(s)

Results • Measured outcomes

ComplementaryStrategiestotacklevarioushealthsystemcomponents

Health Reform Strategy

DOH Strategic Plan

Bermuda Health Action

Plan

BHB Modernization

Plan

Well BermudaPAHO/MOH

Biennial Work Plan

Mental Health Plan

BMDA Cost Containment

Plan

Ageing Plan

HealthReformStrategy

What

WhyHow

Healthsystemcomponents

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BermudaHealthStrategyOverview

VISIONHealthy People in Healthy

Communities

MISSIONTo provide affordable and sustainable healthcare for

all Bermuda residents

COREVALUESQuality

Equity

Sustainability

GOALS14 health sector goals address

specific deficiencies in the health system that lead to high cost and

poor value

REFORM

FocusonQuality

Right Care

Right Time

Right Setting

Best Value

The14GoalsoftheReformStrategy

EquitableAccess

QualityStandards

Sustainability&Efficiency

• 1. Access to basic insurance• 2. Smarter basic coverage• 3. Affordable contributions• 4. Appropriate overseas care

• 5. Pay for quality• 6. Electronic health record• 7. Address Long Term Care• 8. Standards of care

• 9. Financing efficiency• 10. Regulate health technology• 11. More health promotion• 12. Coordinate healthcare delivery• 13. Tackle NDCs• 14. Subsidize the vulnerable

GovernanceStructure

Lead Agencies

Develop Action Plans Consult stakeholders Implement initiatives

Bermuda Health Council

Coordinates Action Plan Development Assures Consultation Drives Strategy

Ministry of Health, Seniors and Environment

Sets Strategy & Approves Action Plans Communicates Updates & Progress

THANKYOU

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Bermuda Health Action Plan 2014 - 2019

Tawanna WedderburnActing Chief Executive Officer

16th January 2016Presentation for Bermuda Health Strategy Symposium

Overview

About the Action Plan

1. Quality Care

2. Collaboration

Action Plan Goals

Capacity Building

Systems Strengthening

Disease Control & Prevention

About the Action Plan – Quality Care

Chronic kidney disease

Asthma

Diabetes

Hypertension

Heart disease

Other NCDs

About the Action Plan ‐ Collaboration

Residents

Providers

&

Professionals

Health Agencies

Regulators Solution

Action Plan Goals

Systems strengthening

Disease control & prevention

Capacity building

Goal # 1 – Capacity Building

System strengthening

Disease control & prevention

Capacity building

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Capacity building

Strengthen and develop human resources (5 actions)

• Maintaining independence as we age (BHB, ADS)

Long‐term care

• Medical workforce planning (OCMO)

• Enhancing registration and complaints handling (OCMO)

Health Professionals

• Enhancing business practices and facility standards (BHeC)

Health Providers

Goal #2 – Systems strengthening

Systems strengthening

Disease control & prevention

Capacity building

Systems strengthening

Improving infrastructure and technology to support quality care (5 actions)

•Financing reforms to achieve insurance coverage for all (BHeC)

•Screening using evidence based clinical guidelines (BHeC)

Care Access

•Ensuring appropriate referrals and testing (BHeC)

•Managing health system planning and technology (BHeC)

•Monitoring population health and implementing UPI (OCMO/BHeC)

Health technology

Goal #3 – Disease Control & Prevention

System strengthening

Disease control & prevention

Capacity building

Disease control & prevention

Effective disease control (10 actions)

Chronic disease registers (OCMO)

Diabetes education (BHB)

Obesity and diabetes rates (DOH)

Disease control & prevention

Effective disease control (10 actions)

Monitoring CKD to prevent progression to ESRD (OCMO/BHeC)

Adding benefits to promote wellness (HID)

Improving access to quality, specialty medical care (BHB)

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Disease control & prevention

Effective disease control (10 actions)

Post‐acute care programmes (HID)

Primary care pilot (HID)

Reducing NCD risk factors (OCMO/DOH)

Reducing risk factors associated with violence and injuries (DOH)

Summary

Systems strengthening

Disease control & prevention

Capacity building

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Symposium opportunity

Office of CMO Vision:  bird’s eye view and from the trees

PAHO‐WHO priorities and guidance

Office of Chief Medical Office– focus areas

Additional recommendations

Overview

Confirm we all have the same Vision 

Answer relevant Question(s):  • What are we trying to achieve in the health system?

• What changes are required?

• Are wewilling to make the necessary changes?

• Who’s best positioned to lead the changes?

• What is my role/contribution in the process of change?

Symposium opportunities

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Bermuda’s Vision: Healthy people in healthy communities

Bermuda’s “…first concerted effort to create a joined-up approach to the promotion of health on our island, and to create a shared vision for health promoters across all sectors.”Well Bermuda: National Health Promotion Strategy, Dept of Health, 2008, 2nd edition.

• 3 Themes: Healthy People, Families and Communities

• 18 health goals, many objectives

• Approx. 40 Well Bermudacommunity partners with Action Plans

Cradle to grave positive health outcomes:   low rates of avoidable health complications across life span

Equal access to high quality primary health care

Financial risk protection Optimal social outcomes:  eliminate poverty, economic 

stability and opportunity, high education rates, full employment, strong family structures, social cohesion, social justice…

(supported by family‐friendly  policies addressing the social determinants of health)

Safe, health‐promoting environments

Healthy people in healthy communities

International Guidance:  World Health Organization 

• NCDs well understood; vast body of knowledge and experience exists to guide steps

• Refers to UN declaration on NCD’s (2012) and urgent need for multi-sectorial policies and plans

• Endorsed by World Health Assembly (2013): roadmap to progress on 9 global NCD targets by 2025

Governments must :• Set NCD targets• Develop multi-sectorial plans to

reduce exposure to risk factors• Measure results

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“Enjoyment of the highest attainable level of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” (WHO constitution, 1948)

Universal Health Coverage (UHC):2005WHO member states endorsed UHC as central goal in order to guarantee access to necessary services while providing protection against financial risk 

2012 UN General Assembly adopted resolution emphasizing governments’ responsibility to “urgently and significantly scale up efforts to accelerate…transition towards universal access to affordable and quality health‐care services.” 

Must:  expand priority services, include more people (esp low‐income) and reduce out‐of‐pocket payments

UHC is “single most powerful concept that public health has to offer” (Margaret Chan, WHO Director‐General) 

International Guidance…Health for Development

International guidance 

NCD Control…5 priority strategies

Forum of Key Stakeholders on NCDs: Advancing the NCD agenda in the Caribbean, Barbados, June 2015 • Universal access to health

• Universal health coverage

• Appropriate human resources for population needs

• Sustainable financing of health system

• Enabling environments 

• Health‐promoting public policies

• Multi‐sectorial , collaborative problem‐solving

• Political will

International Guidance (requirements for  “Healthy people in healthy communities”)

5 Functional Areas:

1‐ Registration and Regulation of healthcare professionals and healthcare facilities

2‐ Drugs and Pharmaceutical product control– controlled drug monitoring & reporting

3‐ Epidemiology & Surveillance Unit‐ outbreak prevention and control, research, community assessment 

4‐ Statutory functions‐ Customs, Burials, SMB, Ex‐officio role on BHB, BMC, BHeC

5‐ Public health focal point for international communications, reporting (PAHO‐WHO, IHR Focal Point) and public health leadership

Office of the Chief Medical Officer

Assure competent health work force (enhancing registration criteria and health workforce planning)

Advocate for health‐promoting policies

o Collaborate with Health Promotion Office  (focus on NCD Risk Factor reduction)

Collaboration with providers to assure high clinical care quality and standards in community  (adoption of evidence‐based clinical guidelines where possible)

Strengthen Surveillance of NCDs  (creation of NCD registers)

OFFICE of CMO focus on NCDs

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1‐ Completed STEPS to a Well Bermuda survey 2014—results  disseminated 2015, consultation with stakeholders  on actions to reduce NCD risk factors, and to increase surveillance

2‐ Development of NCD Registers–Priority: Diabetes, Hypertension, Heart Disease, Chronic Kidney Disease 

3‐ Health Workforce Planning Project—identify  appropriate 

types and numbers of professionals for future needs of community

Lines of Action underway(chronological listing)

STEPS survey data summary‐sampleGo to health.gov.bm

Overweight orobese

Not meetingrecommendedconsumption of

fruits andvegetables

Not meetingrecommendedlevels of physical

activity

Raised BP(including those

on meds)

Self‐reportedhypertension

Three or moreselected risk

factors

Total 74.6% 81.9% 27.1% 33.4% 33.0% 42.0%

Male 79.1% 85.4% 20.2% 32.3% 32.0% 43.7%

Female 69.6% 78.0% 33.7% 34.6% 35.0% 40.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

“The significant problems we have cannot be handled at the same level of thinking we were at when we created them!”  

(Albert Einstein)

1‐ Bipartisan commitment to health goals and strategy and to long‐term action

2‐More vigorous collaborative problem‐solving (establish multi‐disciplinary working groups)

3‐Leverage worldwide experiences and guidance from international public health authorities

4‐ Engage healthcare providers more completely (esp Bermuda Medical Doctors Association and BNA)

5‐ Engage the public fully:  personal responsibility for health and advocacy for access to health

6‐ Embrace change, try things without fear of failure and assume “humble posture of learning”

Additional RecommendationsThank you!

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Quality & Sustainability Through Modernization 

and Innovation

Bermuda Health Strategy Symposium

16th January 2016Michael R Weitekamp MD, MHA, FACP

Chief of Staff 

Bermuda Hospitals Board

By Way of Background

BHB serves as a critical medical and social safety net for Bermuda, each year providing more complex and uncompensated care 24/7

BHB is also a robust component of the economy in its own right, as well as a key component of the enabling infrastructure supporting Bermuda’s international business and tourism

By necessity and strategic intent the current scope of services exceeds legislative mandate of Hospitals Act 1970, but would cause significant disruption and potential harm to the community if curtailed abruptly with no alternatives in place

Healthcare spend is determined by the volume & intensity of services & price  

Cost are exacerbated by unwarranted duplication, volume‐based incentives, fragmentation, administrative inefficiency & limited regulation

By Way of Background

90 acute care beds should be more than adequate for population of 65,000

Yet beds are filled too often with patients who have preventable illness and trauma, unstable social supports, psychiatric co‐morbidity, are hospitalized as the default venue, or some combination of all the above

Similar challenge exists at MWI ‐ too often admission is a default and/or discharges are significantly delayed due to a lack of available social, behavioral or forensic resources within the community 

Unnecessary hospitalization is bad for your health – risking rapid de‐conditioning, hospital acquired conditions such as infection, adverse drug reactions or falls, and immune suppression contributing to secondary illness after discharge

By Way of Background

Unnecessary hospitalization is also bad for the economy, as the hospital is the most expensive venue in the continuum of healthcare services

When viewed through a holistic lens of population wellness, the opportunity costs of acute healthcare expenditures are enormous 

Healthcare competes for resources with education and health literacy, socio‐economic security, programmes to influence behavioral choices, infrastructure and the environment

YET SIMPLY TAKING MONEY OUT OF BHB WITHOUT SOLVING THE SYSTEMATIC ISSUES WILL ONLY DESTABILIZE THE SYSTEM

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Concentration of Healthcare Spending in the US Population, 2012

21.0%

49.5%

65.2%

75.0%81.7%

97.3%

2.7%

0%

20%

40%

60%

80%

100%

Top1% Top5% Top10% Top15% Top20% Top50% Bottom50%

PercentofPopulation,RankedbyHealthCareSpending

NOTE: Dollar amounts in parentheses are the mean annual expenses per person in each percentile. Population is the civilian noninstitutionalized population, including those without any healthcare spending. Healthcare spending is total payments from all sources (including direct payments from individuals and families, private insurance, Medicare, Medicaid, and miscellaneous other sources) to hospitals, physicians, other providers (including dental care), and pharmacies; health insurance premiums are not included. 

SOURCE: Kaiser Family Foundation calculations using data from U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey (MEPS), Household Component, 2010 and 2012 Health Care Transformation Task  Force Report

Percent o

f Total H

ealthcare Spending

($97,859) ($43,038 ($28,452) ($12,951) (≥$829) (<$829)

Bermuda Hospitals Board Commitment

BHB is working diligently to modernize and improve safety, quality and efficiency of acute care services and can also assist Bermuda in rationalizing the use of overseas providers, but this requires time, fiscal stability, political will and regulatory assistance 

BHB is well positioned in terms of governance, facilities and expertise to continuously evolve in support of secondary prevention/chronic disease management, as well as coordinating key elements of post‐acute, long‐term and palliative care

Partnering with government on well‐designed primary prevention strategies can have tremendous ROI – both from the prospective of a healthy and productive society as well as a responsive & financially sustainable healthcare system

Thank you

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Health Strategy SymposiumJanuary 16,2016

Diana Liacos, MSN,NP Clinical Care Manager Consultant

Vision Statement: To provide accessible health benefits for residents of

Bermuda

Mission Statement: We will deliver health benefit products with:

◦ Participant focus◦ Consistency and fairness◦ Stakeholder collaboration

◦ Coordination of affordable benefits◦ Prudent fiscal & operational management

focus on cost containment, accessibility and quality of care encompasses care coordination, efficient use of services,

promotion of healthy lifestyle choices, and improved disease management.

Initiatives to develop partnerships to engage customers, collaborate with stakeholders, and enhance population health.

Recognition of multiple issues in healthcare system Care management/nurse case management Person centric Proactive process Collaboration

•Identification•Stratification•prioritization

Highest impact

• Tailored to meet individual need

• Engages customer in care planning process.

• Ensures coordination of care

• Evidence-based practices

interventions

•Systematic measurements

•Testing•Analysis

Evaluation / effectiveness

•Aligns to support improvements in care management

•Rewards consumer and provider in participation

•Establishes accountability

Payment/financing 5-10%

20-40%

Healthy active

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Targeting individuals most likely to benefit from the intervention.Comprehensive assessment of the patient’s health conditions, treatments, behaviors, risks, supports, resources, values, and preferences Evidence-based care planning in accordance to patient’s goals and priorities and routine monitoring to meet the patient’s health-related needs and preferences. Promotion and coaching of patients’ and family caregivers’ in self-care .Coordination and communication among the patient and the care team.Facilitation of the transitions from the hospital to post acute care and referral to community resources. Specially trained nurse case manager that builds rapport with face to face contact with patient and collaborative relationship w/physician.

Re-evaluation of benefits to improve basic coverage Collaborations

Discharge planning Overseas referrals Chronic disease and long term care Case management software with patient engaging platform

Benefit Changes: HIP and FutureCarePromotes Quality of Care and LifeEnhances System Sustainability

Personal Home Care Services

Increased Number of Specialist Visits & Reimbursement Rates

Wellness Benefit

Youth Coverage (birth to age 21) - HIP Only

Overseas Preferred Provider Network

When an individual reaches their optimum level of wellness, everyone benefits including: The individual Their support system The health care delivery

system The reimbursement source

CMSA, 2013

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Insurance Perspective on Quality/Costs

Michelle Jackson

EVP, Group Insurance

The Argus Group

Health Strategy Symposium: January 2016Agenda

1. The Role of Health Insurance

2. The Costs of Non-communicable Chronic Disease (“NCDs”)

3. Stakeholder Interests

1. What is the Role of Health Insurance?

Insurance companies serve the community by collecting premiums and paying medical claims on behalf of their customers.

Premium = Claims + Administration Cost and Profit

2. Costs of NCDs

% of Population % of Resources

1% 30%

10% 72%

50% 97%

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2. Costs of NCDs

1. Patients and providers often do not know the costs of care.

2. Treating chronic disease accounts for 86 percent of health care costs in the USA (Center for Disease Control and Prevention).

• Cardiovascular disease, Type 2 Diabetes, many cancers, kidney disease are among the most common, costly and preventable

• Example: $200,000 annually for one person on haemodialysis in Bermuda

3. Insurance payment model is “fee for service.” We pay for volume not value.

3. Stakeholder Interests

What can be done?

1. Initiatives focused on health literacy and empowerment

2. Non-communicable disease management (all stakeholders)

3. Payment reform

1/18/2016

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Care Quality Initiatives: Unlocking the regulatory puzzle

Tawanna Wedderburn Acting Chief Executive Officer 16th January 2016 Presentation for Bermuda Health Strategy Symposium

Overview

Clinical Care

Care delivery

Health Technology

System Improvements

CARE DELIVERY

HEALTH TECHNOLOGY

SYSTEM IMPROVEMENTS

CLINICAL CARE

Clinical Care

CLINICAL CARE

Action #1 Adopt Clinical Guidelines

Background: 2014/15 Corporate Plan collaborate with

the medical community to agree on one set of international guidelines to be applied locally and develop mechanisms to enforce adherence

Reviewed international guidelines and encouraged adoption of USPSTF

Symposium: May 2015 planned Symposium to

engage physicians and highlight the importance of evidence based screenings

Implement: Engaged BMDA, BMC, BHB, and

community practices to encourage use of guidelines

Radiology reports given to patients with advice included

Physicians discuss appropriate screening with patients

Some have adopted USPSTF guidelines

Action #2 – Early management of CKD

Held collaborative meeting in June 2015 Nephrologists, CMO, and BHeC

Developed 4 lines of action Collaborate with providers Enhance public & patient education Encourage early identification of disease Improve data collection and reporting – chronic kidney disease register

Implementation Clinical care guidelines presented to physicians Increase in referrals to nephrologists GFR reporting is being considered Reviewing SHB coverage for care Dept. of Health and Health Promotion Office are being engaged Follow up meetings planned for CKD control and prevention

1/18/2016

2

Care Delivery

Action #3 – Registering health businesses

Action #3 – Registering health businesses

Sept 2015

Voluntary registration

begins

Nov 2015

Application processing

Jan 2016

Registered businesses will be

published

Health Technology

Action #4 – Health Technology Reviews

Enable health system planning via collaboration:

Health Council

Monitor entry

Application and fee

DOH

Monitor operation

Equipment maintenance/inspections

Health Technology

Completed pilot of high risk medical equipment (2)

Developed and refined procedures and processes

Working towards implementing legislation

1/18/2016

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Action #5 – Unique Patient Identifier

2014/15 Corporate Plan Alleviate information flow problems Protect patient confidentiality Provide basis for shared electronic health system

Extensive stakeholder consultation Department of Social Insurance (DOSI) Transport Control Department (TCD) Bermuda Hospitals Board (BHB) Health Service Providers Local Health Insurers (HID, Argus, Colonial, BF&M, GEHI) Registry General Parliamentary Registry Department of Immigration

Site visits & demonstrations

System improvements

Action #6 – Health Financing Reform

Health expenditure per person (PPP adjusted (USD))

$6,993

Health Financing Reform

Disease Total # of claims # of local

claims

# of overseas

claims

Local claims

variance

Overseas

claims

variance

Combined local and

overseas claims

variance

Asthma 21,736 9,925 11,811 $213 $147 $246

Chronic Kidney

Disease

23,864 12,524 11,340 $512 $154 $411

Diabetes 94,836 34,392 60,444 -$14 $301 $-31

Heart disease 10,848 7,154 3,694 $131 $104 $360

Hypertension 142,664 58,237 84,427 $28 $365 $21

Number of claims 2,220,264 1,554,549 1,625,652

Health Financing Reform

Reviewing and researching

Preliminary discussions completed

Working group to be established

Consultation to begin soon

Renewing the commitment to focus on: Quality Achieving coverage for all residents Increasing access to mental health, primary and preventive care

Summary

CARE DELIVERY

HEALTH TECHNOLOGY

SYSTEM IMPROVEMENTS

CLINICAL CARE