Managing Overseas Care in TCI- the NHIP Experience Dr. Hamlet Nation Medical Advisor / Medical Officer

OVERVIEW Background The Referral Process Provider Management Patient Care and Experience Medical Claims Policies and Organizational Framework

Background- Health in TCI The Turks &Caicos Islands has a population of 31,458 (39%TC Islanders, 35% Haitian, 26 % others) 2012 Census Healthcare is delivered at the Primary healthcare level (TCIG/Private) 8 TCIG centers/6 private centers* Including Psychiatry) Secondary healthcare 2 Centers (30 beds 2 NICU, 2 HDU, 2 L&D) ability to increase by 100% Treatment Abroad Program (TAP) for Tertiary and Specialized Care

Background-TCI Hospitals TCI Hospitals emerged from a 25 year contract between TCIG & InterHealth Canada The first Public Private Partnership (PPP) involving the construction and operation of full service hospitals in the Region. There are 2 facilities operated with approximately 180 multi-disciplinary clinical staff. 5 diamond accreditation since 2012, highest rating by Accreditation Canada

Background-TCI Hospitals

Background-TCI Hospitals Services Resident Specialists; Radiology, Internal Medicine, Obstetrics and Gynecology, General Pediatrics/ Neonatology, General Surgery, Orthopedics, Maxilo-Facial Surgery, Family Medicine, Nephrology, Emergency Medicine, Anesthesiology Visiting Specialists (monthly) Medical Oncology, Urology Visiting Specialists (every 3 months) Ophthalmology, Neurology, Plastic Surgery, Otorhinolaryngology (ENT)

Background-NHIP Emerged in 2010 as one of the pillars of the Health Sector Renewal Policy NHIP has 25,340 registered clients Manages local pharmacy / providers and TAP benefits Processes Medical Claims for both Local and TAP care Coverage for 81% of Population ***

What does this mean to us? We spend NHIBs money… We manage interactions with beneficiaries We manage interactions with providers

Treatment Abroad Program (TAP) Since 04/10 to 07/15 total of 3,473 referrals through TAP 10-15% of all referrals Urgent Over Ninety-six percent (96%) of all cases are treated regionally sent to the Jamaica, Dominican Republic and the Bahamas. Process 500/month claims for TAP

Referral Process Urgent TCI Hospital Medical Officer NHIP Overseas Provider Non Urgent Referrals Doctors Chief Medical Services Joint Referrals Meeting (TCIG, NHIP, TCI Hosp) NHIP Overseas Provider

Referral Process -NHIP Functions of NHIP Provide approval for care based on the benefit package Contact Overseas Provider for appointments and acceptance Transfer medical information/ images (before and after treatment) Arrange transportation (air ambulance, charter, commercial) Prepare treatment agreements for Patients/ Providers Process claims for patients and providers Follow up patient who are overseas

TAP Services

COST FOR TAP FINANCIAL YEARS 2010 – 2015

COST FOR TAP FINANCIAL YEARS 2010 – 2015 Services FY 2010/2011 FY 2011/2012 FY 2012/2013 FY 2013/2014 FY 2014/2015 Medical $6,947,674.88 $7,469.508.30 $9,173,837.97 $8,769,876.52 $8,091,905.58 Subsistence $155,386.89 $328,647.44 $448,335.00 $645,825.00 $694,500.00 Travel $663,740.15 $327,506.68 $1,462,840.97 $2,364,328.68 $2,356,660.68 TOTAL $7,766,801.92 $8,125,662.42 $11,085,013.94 $11,780,030.20 $11,143,066.26

TAP Expenditure

Provider Management NHIP via TAP has over 200 major medical providers, 6 Hospitals, 10 Majors transport providers and we process over 9000 claims /month Providers in 3 majors countries ( 1 Spanish Speaking) Use of a Third Party Administrator TPA

Provider Management-Lessons Learnt Establish a Preferred Provider List Frequent opportunities for engagement with the providers (surveys on relationship NHIP) Establish standardized requirements (documentation, indemnity, etc.) Limited benefit in using (TPA) services Provider Audits Communication Protocol

Provider Consultations

Patient Care and Experience; Lessons Learnt Personalized care (case managers) Provide on the ground assistance for patients traveling overseas Daily subsistence ( allows for your patient to be more independent ) Selection of providers with concierge services Purchasing Private vs Public Care

Patient Care and Experience; Lessons Learnt Patient assessment forms/ Staff and facilities Follow up visits reduction through bringing the overseas provider on island Cultural sensitivity /Immigration Comparable clinical outcomes/standards**

Medical Claims NHIP Processes 500/month claims for TAP ( transport, subsistence, medical claims) Varied standards of claim submission ( paper based, codes) Timeliness of claims submission ( 30 days to 1 years) Use of Letters of Guarantee (LOG) Prompt pay discount (15-20%) Provider Contracts

Policies and Organizational Framework Purchasing care regionally – Policy implemented in 2011 Building staff capacity – Operations Department Training & Participation Information Technology platform

Strategic Vision 2015 & Beyond Standards, Efficiency and Quality in Service