[Reprinted: Jamaica Observer, 10-25-2020]
What can the Government do to unlock the potentials in the sector?
The nexus between health care and economic development is well established and there is no question the Government has a significant role to play in unlocking the immense opportunities in the health care sector.
The role of the Ministry of Health and Wellness will need to be redefined to emphasize its role as an enabler of good quality health care for all Jamaicans anchored on best medical evidence and advances in diagnostic and therapeutic techniques.
The Ministry of Health and Wellness should act as a catalyst for health sector development with the understanding that good quality health care should not be hindered by the constrictions of tradition and orthodoxy. We are now in the 21st century with unbounded innovation and limitless digital transformation that has been particularly impactful in the health care sector globally.
More creativity and determinism would be required to embrace societal evolution in health care delivery over the past 50 years and to recognise that health care in modern parlance must extend from the confines “public health clinics and facilities” to include technology and knowledge-based health care innovations and applications in the private space.
Technology is now a key component of driving efficiency and quality in health care. High level knowledge, skill and intellectual capital are now pre-requisites for optimal health care in any society. Access to capital and a global labour market of highly skilled health care workers are absolute necessities to drive modern health care, quality, and outcomes.
Global health care workforce of interest in developing our health systems and capacity are not limited to health care specialists like doctors and nurses but include experts in health care support systems like health care administration, health care accounts/finance, health informatics and IT, biomedical engineering, etc.
It is wrong to pretend that we can continue to view health care in a one-dimensional way as we have done for 50 years. Unless a significantly higher proportion of Government revenue is allocated to health care, it is difficult to see how the Government, bedeviled with competing needs, can fund the type of health care that citizens deserve without enabling the environment to unlock private capital into the health care ecosystem and expanding the economic potential within the sector to create new jobs and downstream support services. Health care intersects with multiple sectors of the economy and so the ministry that is charged with managing health care for Jamaica must recognise these intersections and be in the vanguard of promoting relationships and partnerships that ensure the cohesion in policy making that is necessary to attract a highly skilled health care industry workforce to enhance knowledge transfer, develop internal capacity and promote advances in health care development, access, quality and outcomes in the island.
The Government must create the enabling environment to unleash the opportunities in the health care ecosystem that drive quality health care and economic development. In today’s column, we will explore emerging areas of development in the health care sector that present current opportunities for our island.
Enhance Telemedicine/Virtual Care and Remote Patient Monitoring
At the Heart Institute of the Caribbean (HIC), we launched our HIC Telemedicine and Virtual Care programme in 2006, long before the virtual revolution necessitated by the global pandemic. The HIC Telemedicine platform is enabled by Net Medical New Mexico, USA, a global leader in Telemedicine. The benefits of telemedical care in bridging access gaps in care is well documented but inadequately utilised.
The novel coronavirus pandemic has led to a resurgence of telemedicine and virtual care services globally and in Jamaica has seen the emergence of several telehealth start-ups attempting to capitalise on the opportunity created by the crisis. Lockdown and social distancing rules have also forced patients to explore virtual consultations, some for the first time.
Even though the Heart Institute of the Caribbean has offered telemedicine consultations for nearly 15 years, adoption had been slow and utilisation weak, until the pandemic hit. Patients have experienced virtual care and appreciate it as a viable alternative. Recent surveys by Sage Growth Partners and Black Book Market Research show more than 60 per cent of respondents want their health care providers to offer more, not less telehealth options after the novel coronavirus pandemic. This is a potential health care investment opportunity but must be done on a regional level to scale because of the small size of the local market.
In the past six months, a few commercial telemedicine service providers have become more visible in Jamaica. Notable ones include MDLink founded by physician and entrepreneur, Dr Che Bowen. In a Jamaica Observer article of May 21, 2020, Dr Bowen was reported as stating that 10,000 Jamaican citizens and 200 doctors had registered on the MD Link platform to access and provide services respectively, with 85 per cent registering within the three weeks prior to the report, obviously spurred by the lockdowns announced in response to the novel coronavirus pandemic.
In another article of September 27, 2020, it was reported that MDLink had launched a COVID-screening app that could be used for pre-test risk assessment. This is a tool that may be useful in public-private partnership (PPP) arrangements as part of an islandwide COVID-19 management. Another emerging telemedicine provider is eDocine, which is reported to be the brainchild of Vilakis Innovations, a Jamaican technology company.
Creative use of telemedicine will unburden the public health, outpatient facilities and doctor’s clinics; cut down absences from work occasioned by minor ailment; and increase productivity. Remote patient monitoring is also an emerging area of health care delivery that is best suited for developing countries with a limited pool of experts. With properly structured remote patient monitoring services, just like virtual care and telemedicine, many patients may not need to leave the comfort of their homes in the various parishes to get to Kingston or Montego Bay for routine visits with health care providers. For many patients, hypertension and diabetes, for example, can be effectively managed with remote patient monitoring. This is cost-effective and expands the reach of specialists to remote locations.
Expand care through capitation arrangements with the private sector providers
Less than 15 per cent of the Jamaican population has health care insurance coverage. Within this number is a large pool of Government employees, whose health care insurance protection is limited and offers inadequate coverage for critical services. New models for financing health care must be explored. Capitation arrangements with a network of providers is one such model that presents an exciting opportunity to expand access to care for citizens. Capitation is a payment plan to health care service providers that guarantees a set amount for each enrolled person assigned to a practice for a specified period, whether that person seeks care or not.
Capitation payments are made to providers in advance in anticipation of care to be provided to enrollees. Capitation arrangements are in varying forms and may include a listing of services that would be provided to enrollees at no additional cost. The amount of capitation payment is based on the average expected health care utilisation of that patient, with payment for patients generally varying by age and health status.
Capitation arrangements provide significant cost saving to the group, guarantee access to best in-class facilities, while at the same time providing reliable revenue streams to practices. A key difference between traditional health insurance and capitation arrangements is that capitation arrangements usually will require no additional payments from the patients for covered services, and so this approach reduces the financial stress on the patients without devaluing the quality of care.
Rather than paying hefty premiums to insurance companies for limited coverage and utilisation by enrollees because of the financial pressure of the often-high, co-pay requirements, Government should explore alternative arrangements like capitation models directly negotiated with health care providers without the middle man and associated costs. Capitation models are widely utilised in many countries, including the USA, UK and Canada, and offer incentives to governments to utilise taxpayer funds properly and judiciously, for corporations to control costs and manage health care budgets, for practices to manage care properly, focusing on prevention to keep costs manageable and allowing patients open access without limitation or financial burden.
Rather than continue with the status quo which has been sub-optimal, we suggest that the Government does a pilot with a few thousand employees and compare the utilisation, patient satisfaction, and cost-benefit analysis of the capitation model with that of traditional health insurance as currently provided.
Expand sources for PPEs to the supply chain
We have highlighted this in prior articles, but this bears further mention. The rapid escalation of the novel coronavirus pandemic has exposed gaps in the global health care supply chain. Considering disruptions in supply chain, response strategies must include an evaluation of the need to manufacture essential medical goods and supplies locally to serve the local market. This is particularly relevant with respect to low-value, single use, protective and personal equipment (PPE) items, like gloves, gowns, shoe covers and facemasks.
Over the past 10 years, there has been a massive growth in the global trade for PPE largely due to rising demand from developing countries and aging populations in many countries. While exports of PPE from traditional locations like France, Germany, Belgium, UK and USA have increased by 45 per cent since 2008, exports of PPE from non-traditional locations, like China, Mexico, Malaysia and Costa Rica, have increased by more than 100 per cent over the same period.
The demand for PPE has gone into an overdrive since the novel coronavirus pandemic. While our market may be relatively small, single-use disposable products like face masks, gloves, gowns, etc are expected to remain in high demand and can sustain the local manufacturing base with good opportunities for export to regional and global markets. We believe that this is both necessary and potentially attractive as an investment opportunity for interested investors, if an enabling environment is provided by the Government. A local manufacturing base protects the Jamaican public from external shocks, due to supply chain disruptions, as seen in the early phase of the pandemic.
In our last column, the reference to “Island Dialysis” is an error and should have referred to Sunshine Dialysis founded and led by Dr Lilieth Johnson-Whittaker for more than 25 years.
Dr Whittaker is a pioneer in dialysis care in Jamaica and through her Sunshine Dialysis has done a commendable job in making dialysis services available to patients in Jamaica in several parishes, including Kingston, Montego Bay, and Mandeville. The error is regretted.
Our series will continue next week when we will address the need for a national stockpile, human capital development, digitisation, and capital access for health care development.
About the authors: Dr Ernest Madu, MD, FACC, and Dr Paul Edwards, MD, FACC are Consultant Cardiologists at Heart Institute of the Caribbean (HIC) and HIC Heart Hospital, Kingston, Jamaica