The Cayman Islands government has neither the resources, nor the information available to properly manage an increasingly complex “hybrid” healthcare system for its resident population, Auditor General Sue Winspear concluded in a report made public Friday.
Ms. Winspear’s office also noted in a secondary public interest evaluation released along with her healthcare system audit that private sector healthcare system users were increasingly shouldering more of the territory’s overall health costs within the past five years.
Total health-related expenditures in the Cayman Islands increased by nearly 26 percent between 2010 and 2015, the report stated, for both private and public system users.
The private sector’s share of the estimated $269 million in healthcare expenditures during 2015 was about $131.2 million, up from $95.7 million during the government’s 2010/11 financial year – a 37 percent increase. Meanwhile, public sector health costs went up as well, from $118.4 million in 2010/11 to $137.8 million in 2015, an increase of about 16 percent.
The report found that the average per person annual spend on healthcare in Cayman during 2015 was about $4,454, up from $3,857 in 2010/11.
While costs increased significantly, Ms. Winspear’s report concluded that government could not show much for that increase.
“The government does not have the resources or the information required to manage the health system effectively, and neither the Legislative Assembly nor the public can be confident that high quality healthcare is being delivered, or value for money being achieved,” the report concluded.
Part of the difficulty in obtaining crucial data on healthcare services is that Cayman currently uses a “hybrid” care model where public health, school health services, ambulances, district clinics and indigent care (now provided for about 1,200 people) are delivered by the government-owned Health Services Authority. However, nearly all direct healthcare services – whether they are accessed through public or private providers – are paid either through health insurance arrangements or out-of-pocket if the person is not insured.
Government regulates both private and public healthcare services via a labyrinthine cluster of 30-odd laws, but little information is available on healthcare or regulatory outcomes, auditors found.
“The performance of the Cayman Islands health system is not known and accountability to the Legislative Assembly and the public cannot be rendered,” Ms. Winspear reported.
For example, in the public sector, the Health Services Authority’s Cerner computer system and the Cayman Islands National Insurance Company’s claims system capture most information regarding health expenditures, patient outcomes and vital statistics. Some of that data is available to the government Ministry of Health, but it is not currently being used for performance management, auditors found.
“And, except in the case of public health surveillance, relatively little performance-based information is sought from, or provided by, the private sector,” the audit noted.
Health problems ‘concealed’
In addition to significant gaps in information about the state of Cayman’s general health, the very nature of the island territory’s population may be serving to “conceal” serious health problems, auditors opined.
At a glance, Cayman’s 60,000-plus population is relatively healthy, with life expectancies over age 80, a low infant mortality rate and low rates of mortality from chronic diseases when compared to the rest of the world.
Auditors note, however, that in 2015, the Cayman Islands government estimated 43 percent of the islands’ total population was non-Caymanian – largely expatriates who had moved here from other countries to work.
“Most of the expatriates tend to live in the Cayman Islands only during the healthiest years of their life,” auditors wrote, adding that non-Caymanians could not come to work here if medical tests showed they were in poor health or had a communicable disease.
Data provided by the 2010 Census in Cayman showed “a significantly higher rate of disease in the Caymanian population than in the non-Caymanian population.” Diabetes rates among Caymanians were 3.1 times higher than for non-Caymanians, the occurrence of heart conditions 5.7 times higher and cancer rates 2.7 times higher.
“[Current] health statistics … risk distorting the apparent performance of the health system,” the audit report found.
In another area of concern, some patients were being placed at risk due to certain situations where health services practitioners are falling through the cracks in government’s regulatory net, auditors found.
For instance, the government’s mental health treatment and substance abuse centers (The Counselling Centre and Caribbean Haven) have qualified practitioners who are providing counselling and therapy for patients, but who are not registered with the various local medical professional regulatory boards and councils.
In some cases, registration fees paid to those professional regulatory bodies may be waived for government employees. If the fees aren’t paid, the professional councils do not register the healthcare providers. In other cases, the health practitioners may not have achieved the minimum number of hours required to obtain full registration required in the U.S. if they were trained there. Once they have received the requisite hours, those individuals can then be registered with the appropriate local council.
“The risk that this poses is two-fold; first, the facilities are not being inspected and certified for an appropriate healthcare environment; and second, the practitioners who work in them are not subject to the same requirements as other registered healthcare practitioners,” the audit found.
In addition, several Cayman Islands residential care homes for seniors, and adults and children with disabilities are not being inspected as required, leading to further potential patient risk, auditors found.
Both public and private sector healthcare professionals told auditors of serious concerns regarding government’s “capacity shortages” in a number of health regulatory areas.
The Health Insurance Commission, for instance, has the same number of inspectors now (three) as it had when it began operations in 2004, during a period when the local healthcare industry has grown significantly. Auditors noted the commission has attempted to find some creative ways around the lack of staff, including the recently proposed creation of a “certificate of compliance” for all employers. That certificate would require all companies to submit proof of health insurance with work permit applications.
“Nevertheless, the reality is that enforcement of compliance with the Health Insurance Law and regulations has suffered and the risk of some employees and their dependents being uninsured has increased,” Ms. Winspear’s report stated.
The government reports that 94 percent of all Cayman residents maintain health insurance, up from about 87 percent in 2010. However, the commission noted it largely depends on proactive complaints about healthcare coverage not being provided before investigating a specific matter.
In the past two years, the Health Insurance Commission has imposed administrative fines in nine cases ($1,000 each) for employers who failed to continue health insurance coverage and one $5,000 fine for an insurance company that did not report certain information as required to the commission. Another nine cases of healthcare coverage non-compliance went before the local courts during that time, auditors found.
“What appears to be a relatively small number of fines imposed by either the Health Insurance Commission or the courts must be interpreted in light of the fact that [the commission] does not have the resources to go into the field and carry out inspections of employers,” the audit noted. “Several officials and practitioners we interviewed believed that neither the administrative fines imposed by the commission, nor the fines imposed by the courts are sufficiently punitive to encourage compliance.”
Again, auditors noted monthly reports given to the government Health Ministry do not have enough information to allow the ministry to track the extent of non-compliance with local healthcare laws and regulations.
While the legal framework for governing the healthcare system is mostly adequate, even if it is not always enforced well in practice, there were some concerns expressed by auditors regarding the suitability of local health laws as well. The 1979 Pharmacy Law, still the active legislation for governing the operation of Cayman’s public and private sector drug distributors, was the best example of this issue.
There are currently no legislated regulations in Cayman for pharmacies. A 2010 standard of practice was developed by the local Pharmacy Council, but those standards are entirely voluntary.
Drug distribution is also somewhat of a hodgepodge, according to auditors. “There are no shared pharmacy information systems to ensure that patients are not receiving multiple prescriptions from different physicians and obtaining the drugs from multiple pharmacies,” the auditor’s public interest report noted.
In one case noted during the audit, a prescribed drug was issued by a pharmacy with no information written in English on the label.
Revised pharmacy legislation was approved by the Legislative Assembly in 1991, but was never brought into force. Since then, another Pharmacy Law has been drafted, but no vote on it has occurred.