Medical Tourism Requires Accountability

Medical tourism in the Bahamas is now official, according to reports in recent business news articles.

The possible advantages to the Bahamian economy are welcomed. The immediate advantages to medical tourism companies here are: a tax-free income, and a more relaxed regulatory environment.

According to a recent news report, “the costly and onerous regulatory requirement in the company’s home country, related to a medicine or treatment, …can be avoided by setting up shop in the Bahamas.” (Dr. David Allen Jr, The Tribune, August 11, 2010)

There is nothing inherently wrong with a tax-free income which enhances profit. Avoiding “costly and onerous regulatory requirements” refers to other issues, like regulatory requirements abroad making it more expensive for the healthcare provider to operate. Arguably, however, these requirements ensure better standards of care for the patient. Effective regulation and medical protocols not only protect the patient’s life, but they also protect the doctor from professional negligence charges.

One likes to believe that the primary objective of a healthcare company is quality service and positive patient outcomes. After all, providers are in the business of improving your health. But a company locating in the Bahamas intends to enhance the profit aspect of the business, because regulatory environment requirements are less, and the track record shows that such requirements as may exist here are not enforced.

Patient Protection Rights
Take  for instance the Hospitals and Health Care Facilities Board, which has been in existence since 1998. The Board has a duty to investigate complaints into the management, diagnosis, and treatment of a patient in any licensed private healthcare facility.  It seems in the last 10 years or so, the Board has received one complaint- a hospital fatality that occurred in April 2002, which it has refused to investigate.

Then Minister of Health, Dr. Marcus Bethel, directed the 2004 Board to investigate, and replaced half of those Board members. The 2006 Board decided to form a panel to carry out the investigation, but this did not happen. In 2008  Minister of Health Dr. Hubert Minnis, at a public meeting, promised the complaint would be investigated, but no investigation has taken place. In 2008, The chairman of the Hospitals Board, (as reported in the Tribune, May 2008), publicly stated that the Board would not investigate any complaint, because it did not “want to be bothered with that detailed level of work.” 

The Board’s 2008 report to Parliament complained lengthily about being pressured to investigate a complaint the Board did not want to investigate - this, notwithstanding the directives of two ministers of health, and advice to the Board from the Attorney General’s Office. The chairman of the Board, (in 2004 and 2008) was also a director and officer of the hospital company where the April 2002 fatality occurred.

[To its credit, the private hospital where the April 2002 fatality occurred, has now obtained JCI accreditation, meaning it meets certain hospital standards set in the US. This is a significant step in the right direction.]

Despite the Board’s statutory duty, it answers no correspondence on the subject of the April 2002 fatality, and takes no phone calls. It also wants Parliament to amend its legislation to reduce its oversight responsibility. Therefore, patients cannot count on the Hospitals Board to address systems failures in Bahamian hospitals.

An earlier article on this website, “When is a hospital a Hospital?” addresses how systems failure issues can arise under the current legislative regime governing local hospitals.

Hospital Board members are also political appointees, who are paid fees. The Board is supposed to submit to Parliament annual reports of its work. Annual usually means every year. In its 12-year existence, the Board has submitted only two reports to Parliament.

Considering the self-proclaimed unwillingness of this Board to act, it’s time that the political hacks on this Board are replaced by dedicated individuals who care about patient safety. It would be wise to do this before the unfortunate glare of international spotlight shines on the Bahamas, as a result of a systems failure injuring or causing the death of a medical tourist.

A petition urging the government to take steps to create an effective Board, for both private and public patients, can be found on the BPA website.

But even if hospitals do not suffer a system failure, what about discipline and accountability within the medical profession itself?

The Medical Council
There is a Bahamas Medical Council,(MC) established by the Medical Act of 1974. The Medical Council has one main purpose: to licence and discipline its members in the public interest, and in doing so, preserve the reputation of the medical profession.

Well, the Medical Council chairman (in a newspaper interview in September 2008) stated that a complaint to the Medical Council in reference to the April 2002 fatality was being actively pursued, as a “landmark” case: Landmark, because it is the only complaint in its history since 1974, that the Medical Council has claimed it will process. So far, this promise has proved illusory.

The first, and so far the only, meeting of the Medical Disciplinary Committee of April 2009, (seven years after the April 2002 fatality) was never followed up. The process appears to have been de-railed by the Medical Council chairman’s foray into electoral politics, leaving behind unfilled promises.

However, the Elizabeth bye-election ended more than six months ago, and the Medical Council has yet to resume its disciplinary process, in spite of correspondence and phone calls to that office on the subject.

In truth, there is another reason for not continuing the disciplinary process. And this is because an investigation of all the doctors concerned in the April 2002 fatality is legally impossible. One of the doctors concerned has an injunction preventing the Medical Council from investigating him. The doctor’s lawyers obtained this injunction ex-parte before a judge in 2008. That judge’s daughter worked with the attorneys making the application.

The Medical Council is represented in this case by the Attorney-General’s office. Interestingly, the council may be the only professional statutory body in the Bahamas represented in a professional disciplinary matter by the AG.

Under the Medical Act, doctors should pay a $200  fee for renewal of their annual licence to practice. It may be that this annual fee is not sufficient, or not sufficiently collected, for the Medical Council to retain its own lawyers. In that case the Medical Act and its regulations need to be amended so the Medical Council can retain its own counsel to represent or defend it. 

The word “defend” however, is used loosely in this particular case. The case against the Medical Council has been only part heard, and the AG’s office has not obtained another court date to get a judicial decision on the doctor’s complaint against the Medical Council, nor to have the injunction discharged. So the  injunction remains in place, and the council licenses a doctor whom they cannot investigate. The doctor may well be the only professional in the Bahamas with legalized immunity from professional investigation.

Thus the inactivity of the AG’s office, allows the Medical Council a reason for not investigating its members. The ethical and professional issues raised by the April 2002 fatality remain outstanding and the Medical Council can continue to license all the doctors concerned.

In reality, the whole situation can be resolved by the Medical Council retaining its own attorneys, having the injunction discharged, and carrying out its duty to investigate its members. Will the Medical Council rise to the occasion?

What will be the reaction of the international press when a medical tourist misadventure turns the spotlight on our Medical Council’s response to its oversight duties? 

The Public Interest
Complaints to the Hospitals Board and the Medical Council are purely public interest complaints: that is, they should result in correcting defects in a hospital, or taking remedial measures against an unfit doctor.  In that regard, the Medical Act needs to be amended. The objective should be to protect the public from further medical misadventures on that account.

Complaints to these statutory bodies are seldom made, because they cannot result in any compensation to the victim of medical malpractice, and as we see from the above case history, circumstances are such that the Hospitals Board and the Medical Council do not function as they should.

Compensating the Victim
Compensation is only available if a patient files a legal action in the civil court against the doctors or hospital involved, and succeeds in proving liability and damages. In this jurisdiction, the level of awards for personal injuries or fatality is low.

So apart from the lower regulatory oversight cost factor, doctor’s professional insurance costs here are also less, because our law does not allow for the extreme awards made in the US. This will be another surprise for the American medical tourist.

Professional Insurance
Payout on medical claims here is also less, because medical evidence to support the claim can only be obtained from abroad, at an up-front and significant cost to the injured patient. Without this medical evidence the claim cannot proceed. If it does proceed, the medical facility/doctor, may claim (unjustifiably) a reduction in damages payable, on the basis that insurance will not cover the damages claim. There is no obligation here for medical providers to maintain adequate insurance coverage.

The healthcare regime currently operating in the Bahamas means the overall impact of a  medical misadventure, both physically and financially, will fall on the patient, his/her family members or survivors.

The cost savings of medical treatment in the Bahamas are a worthy consideration for medical companies: lack of regulatory effectiveness = lack of accountability = savings on operating costs = greater profits.

Financial accounts for publicly traded medical companies are properly audited and good profit ratings are posted regularly in the press. But we also need effective oversight bodies reviewing avoidable deaths and injuries, ensuring the fitness of healthcare facilities and the doctors who practice in them.

JCI accreditation is a significant step in the right direction, but the statutory licensing body likewise needs to carry out is functions, which it could more readily do with information provided by the JCI.  Effective regulatory oversight of both healthcare facilities and physicians has to be a priority for any government.

Medical tourism offers the Bahamas an opportunity to expand the economy and raise employment levels, which cannot be dismissed. But economic benefits have to be balanced by effective provision for the welfare and safety of the patients, the same people expected to generate these economic benefits. The risk to patients is not an acceptable basis for endorsing lower cost (read “un-regulated”) healthcare.

For a number of patients treated here, it is already too late to address these issues. For future patients, both local and tourist, the time to address these issues is now.

Comments

[interested]

What a mess. A mess from every aspect.

It seems clear that there are no conflict of interest laws, no funding for government agencies, doctors in cahoots with attorneys, attorneys in cahoots with politicians, and politicians in cahoots with doctors.

And judges in cahoots with all of above. The perfect circle. Scary.

[john Lloyd]

My Name is John Lloyd my family is originally from the Bahamas. I work with an organization the INTERNATINAL BOARD OF MEDICINE AND SURGERY. We are Global Advocates for patient safety. Safety starts with the individual physician. We must police ourselves in the arena of professional accountability and integrity. IBMS provides a plattform where every physician can register and become accountable and transparent. Because of lack of oversight many negligent physiscians continue to put patients at risk. Together we will make a difference.
john@ibms.us