Medical Association of The Bahamas (MAB) President Dr. Sy Pierre says the MAB is "totally against any independent provider association being the primary instrument through which National Health Insurance (NHI) is funneled to provide universal healthcare (UHC) for the citizens and legal residents of The Bahamas".
The question of the independent provider association (IPA) was raised when the National Congress of Trade Unions (NCTU), which was accidentally misrepresented in a press statement as the Trade Union Congress, and the Bahamas Independent Provider Association (BIPA) released a statement supporting NHI. The statement claims that the NCTU-BIPA partnership covered 80 percent of the unionized workers and 70 percent of the medical care professionals in The Bahamas.
Pierre said the MAB did not sign onto a BIPA agreement "for the simple reason that, in our opinion, it is not in the best interests of the Bahamian people, the Bahamian providers and stakeholders and therefore not in the best interest of our country".

Response
Pierre's critical response to BIPA was lengthy and precise. That critique began with the assertion that BIPA would marginalize those providers who did not sign onto it.
He added, "BIPA may go bankrupt due to poor management, then where does that leave our patients? Who then is responsible for the potential millions of lost public money?"
With respect to the negotiation of contracts, Pierre contended that there is no need to have an IPA negotiate contracts, remuneration, etc., because a properly drafted fee schedule would guide remuneration.
"Also, this role can be played by a neutral, existing umbrella organization, such as the MAB or the United Healthcare Reform Alliance (UHRA)," he added.

Model
Pierre also addressed the issue of the stand-alone home care or medical home model.
"These are not required for primary care in The Bahamas, as a patient never visits more than one primary care physician at a time. For example, when a patient goes to see a primary care physician there is usually a diagnostic work-up. If referral (e.g. endocrinology) is required, this will occur days to weeks later, and if further referral (e.g. ENT surgeon) is needed, this will require even more time.
"In addition, Nassau is 21 by seven miles; if a referral is required, there is no great distance to travel for a referral. In the case of the Family Islands, again, the referral process will take weeks and not occur within the same time frame as the primary care visit. Hence, the referral visit will require time and travel in any event, even if the primary care physician and specialist were located in the same building," he said.

IPA
Pierre also noted that an IPA is a North American term for an association of independent physicians and other healthcare providers that contract with the IPA to provide services to health insurance organizations on a negotiated per capita rate, flat retainer fee or negotiated fee-for-service.
"Again, if a group of providers decides to form an IPA, that is entirely their decision. However, an IPA is not required nor should be mandated in any form to negotiate terms with the government. Again, what is the cost for the IPA to provide this service? This is another service duplication as this function can be served by umbrella organizations such as the Medical Association," he said.
And on the assertion that an IPA is needed to properly manage the delivery of healthcare, Pierre poses the question, "If the most well-run and highest ranked healthcare facilities in the world e.g. the Cleveland Clinic, the Mayo Clinic, have been able to streamline their operations and provide excellent care without the need of an IPA, why do we need one here?"
He suggested that it might be better for the government to send its managers for training at these institutions in order for them to become better equipped to manage the country's public health system.

System
In the statement, BIPA asserts that the IPA undertakes major functions for independent medical practices required to meet the standards of practice and benchmarks for care and diseases delivered in both the managed care and value based arena. BIPA says that, by using an administrative staff of its own, the IPA organizes the delivery of care.
Said Pierre, "At one stroke, a privately owned, for profit entity, is seeking to usurp the authorities of the Medical Association of The Bahamas, the NHI secretariat, the Medical Council, etc. Why create another paid layer of administration? Who are they answerable to? How does this reduce the costs of healthcare?"
And he said "a provider-owned, private, for-profit, managed care company supporting physician shareholders" contracting directly with the NHI public insurer is not only "not in the best interests of the public, it would be ripe for graft, and the conflict of interest issues would be infinite".

Network
And BIPA asserted in its statement that in order to finance and deliver care, an IPA maintains a fully integrated provider network that includes primary care providers, specialists, hospitals, allied health providers and healthcare facilities.
"Why is a provider network a good idea? That may mean something in large countries where junior doctors need a foot in the door and patients need guidelines in how to choose someone - culture and demographics are different here. Also, be very careful of structuring things in ways that potentially prevent doctors from participation. As long as they are willing to provide NHI service, they don't have to be a part of anything. They work for the pre-contracted fee and deal directly with the NHIA," Pierre said.
With respect to the BIPA proposal for a so-called "independent care services" to enter contracts for a defined population of beneficiaries, Pierre said, "This is a politically correct way of intending to start a new physician-owned insurance company - is that what we have here?"
The BIPA statement promotes introducing an IPA to provide services for the beneficiaries of an NHI public sector insurance plan, but Pierre pointed out that the National Health Insurance Authority (NHIA) is already in the process of establishing a national health insurer.
"For the IPA to attempt to provide this service would result in duplication of an existing service, add costs to an already costly venture - by adding another layer of bureaucracy with regards to provider remuneration - and put more public money into a privately run organization with questionable oversight and conflict of interest issues," he said.

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