It took a while, but many people have awoken to just how extensive the Government’s proposed health financing reforms are — the recent Patients 1st meeting had an attendance that was essentially twice that of the consultation organised by the Ministry of Health a few weeks earlier.And last week’s panel organised by Age Concern was standing room only, with late arrivals being turned away. On the whole, this is positive, although it might be in the ministry’s best interests to extend the deadline for submissions — scheduled to close on Sunday — to allow people more time to consider and comment on what is being proposed. Any healthcare reform is complex and there are no easy answers. And it is critically important to get it right. Once Bermuda sets off on one path, it will be nearly impossible to change course. Thus, proposing a longer consultation period is not a delaying tactic, but a plea to take the time needed for a lasting solution. Having said that, the consultation has been misguided on two counts. The first is that attempting to restructure the financing of healthcare without a comprehensive effort to reduce the costs of the system treats the symptoms of the problem, not the causes. The second has been to make the big decisions — the move away from multiple insurers to a single insurer and the increase in the cost and the benefits of the Standard Health Benefit — before the consultation. That means that the public and the system’s stakeholders have been reduced to debating the details of the plan, not the principles themselves.It can be argued that that is the elected government’s right, but if the Government wants support from the public and if it wants this to be politically popular, it would do well to engage more deeply in designing a system that benefits all. One of the problems has been that debates on healthcare have all too often resembled a circular firing squad, with the Government, the Bermuda Hospitals Board, the physicians, the allied health professionals, the insurance companies and the patients — when they all too rarely have a place in the discussion — all taking shots at each other while refusing to take responsibility for their own actions. The Bermuda Health Council was supposed to end this, acting as an honest broker, but it has instead become just another participant in the argument. So an honest discussion is desperately needed. Blaming greedy doctors or greedy insurers is not the way to get there. That does not mean that answers cannot be found. Before getting into how to pay for it, the whole system of health needs to be examined. Fundamental questions about whether healthcare is a right, whether there is a basic level of care that all people should have and what constitutes a reasonable expectation for speed of delivery and quality of service need to be answered. As ever with cost, there is a Bermuda premium to be paid. Bermuda is more expensive than most other jurisdictions and this will be as true for those who deliver healthcare as it is for those who deliver legal or computer services. The same costs of living apply to the hospital and to doctors’ offices as they do to everyone else. But there are ways of reducing costs. The first, as proposed in the recent BermudaFirst report, is to move away from a “fee for services” model to an outcome-based or value-based system. What this means is that physicians and other health providers receive incentives for successful services. It also means that fees for services are essentially standardised; at present, there is little transparency on price and because of the nature of mandated insurance through employers, little awareness of the cost of procedures or an incentive on the part of the patient to manage their own costs. Indeed, customers will often base their judgment on price on their co-pay, which has as much to do with what insurance policy a patient has as it does with the price charged by the medical provider. Having said that, moving to an outcomes-based system does require changes in approach. It may work well only when the central provider — whether that is a medical system or a sole insurer — can control what services may be offered and at what price. The same is true for utilisation. This is important because of the way health services are delivered through insurance. If a grocer sells more apples, the cost of apples does not increase, but because insurance recovers this year’s expenditures by increasing next year’s premiums, increases in the use of services drives up costs for everyone.But it is virtually impossible to manage utilisation when health providers believe they have a right to offer whatever services they wish and patients believe they have a right to whatever medical tools they want. Thus, when former One Bermuda Alliance health minister Jeanne Atherden tried to raise the age requirement and lower the frequency for “healthy and asymptomatic” women needing to have mammograms, the cost savings for the health system would have been enormous. More importantly, scientific research supported the move — the benefits of women having mammograms before the age of 50 were relatively negligible while the cost reduction would have helped to make healthcare more affordable for all. But that did not stop an uproar from breaking out — so much so that the minister was forced to back off. So the problem is that patients often want treatments and diagnostic tools that they do not need. And doctors are all too willing to provide them. After all, no one really knows what they cost, or can relate this to the increase in their health insurance premiums the next year. So some form of control is needed to manage utilisation, and then to show why it is benefiting the overall population, not just in terms of cost but in terms of overall health.One of the drivers of high costs in the system is the misuse of acute-care services in the hospital for what are either chronic problems or non-emergency problems that could be resolved by a general practitioner — if one was available on the weekends or overnight. Making it easier for well-regulated urgent care centres to open and operate so they can deliver services that are available only at the hospital otherwise would be a start, as would making it easier for the elderly to live in affordable care homes or to remain at home with suitable care. Finally, and this is the holy grail for health, much more needs to be done to encourage wellness and prevention. This is no secret. Bermuda’s stratospheric levels of diabetes, kidney failure, amputations, obesity, hypertension and heart disease are largely preventable, not just through medication but through lifestyle changes, including improved diets and moderate exercise. But our existing health system does little to encourage healthy living and even less to incentivise patients (through lower insurance premiums) or doctors (by rewarding them for preventing disease instead of curing it). Revenue from the sugar tax was supposed to be used for a public health campaign that turned people away from sugar and towards healthier, sugar-free diets. But little has been done. Ring-fencing revenue from the sugar tax and other duties — on alcohol and tobacco, for example — and using these funds to support healthy lifestyles in schools, medical facilities and other institutions would be a start.At the same time, insurance companies need to find a way to reward individuals or groups who follow healthy lifestyles and medical professionals who encourage wellness and prevent problems from occurring — instead of being rewarded for solving problems that have already occurred. Short of the economy miraculously improving — that is the real solution to the healthcare crisis — only this kind of systemic approach to preventive medicine can stop the surge in prices while making healthcare more accessible.