2

0
1
6
NATIONAL HEALTH ACCOUNTS REPORT
Bermuda health system finance and expenditure for fiscal year 2014-2015
National Health Accounts Report 2016
Bermuda health system finance and expenditure for fiscal year 2014-2015

Contact us:
If you would like any further information about the Bermuda Health Council, or if you would like to bring a healthcare matter to
our attention, we look forward to hearing from you.

Mailing Address:
PO Box HM 3381
Hamilton HM PX
Bermuda

Street Address:
Sterling House, 3rd Floor
16 Wesley Street
Hamilton HM11
Bermuda

Phone: 292-6420
Fax: 292-8067
Email: healthcouncil@bhec.bm
Website:www.bhec.bm

Published by:
Bermuda Health Council (February 2017)
Copyright 2017 Bermuda Health Council

Reference as:
Bermuda Health Council (2017) National Health Accounts Report 2016: Bermuda health system finance and expenditure for fiscal
year 2014-2015. Bermuda Health Council: Bermuda.

Printed by:
Bermuda Health Council
 Acknowledgements

The 2016 National Health Accounts Report is the product of a collaboration between the Bermuda
Health Council and various external stakeholders both local and international. This report would not
have been completed without the contributions and support of the Accountant Generals Department,
Bank of N T Butterfield, Bermuda Cancer and Health Centre, Bermuda Diabetes Association, Bermuda
Heart Foundation, Bermuda Hopsitals Board, Bermuda Life Insurance Company (Argus), BF&M Life
Insurance Company, Colonial Medical Insurance Company, Department of Social Insurance, Department
of Statistics, Government Employees Health Insurance Scheme, Health Insurance Department, HSBC
Bermuda, Ministry of Health and Seniors, Lady Cubitt Compassionate Association (LCCA) and PALS.
Additionally, appreciation is due to peer reviewers who provided scholarly advice and guidance: Collin
Anderson, Jennifer Attride-Stirling, Laquita Burrows, Howard Cimring, Peter Heller, Stanley Lalta, Lorraine
Lipschutz and Brian McLeod.
 NHAReport2016

BermudaHealthCouncil

NationalHealthAccountsReport2016:
Bermudahealthsystemfinanceandexpenditureforfiscalyearending31stMarch2015

1|P a g e

 NHAReport2016

TableofContents
ReportHighlights...........................................................................................................................3

Section1Introduction..................................................................................................................5

Section2HealthSystemFinanceandExpenditure.......................................................................7
2.1HealthSystemOverview...............................................................................................................7
2.2HealthSystemFinance:PublicandPrivateSector.......................................................................7
2.3HealthSystemExpenditure:PublicandPrivateSectors..............................................................11

Section3HealthCostsinContext................................................................................................16

Section4Discussion....................................................................................................................22

Appendix......................................................................................................................................24

2|P a g e

HIGHLIGHTS: HEALTH SYSTEM FINANCE AND EXPENDITURE

The following is an overview of Bermudas health system finance and expenditure for fiscal year ending 31st March 2015

PUBLIC SECTOR FINANCING PRIVATE SECTOR FINANCING

28.5% 71.5%

Total
Per Capita
Health System
Health System
Expenditure
Expenditure
$11,102 $685,829,000
0.8% 1.1%

PUBLIC SECTOR EXPENDITURE

43.9% 3.8% 2.1%

PATIENT SUBSIDIES MINISTRY OF
DEPARTMENT
& HEALTH AND
OF HEALTH
HOSPITAL SENIORS
GRANTS

PRIVATE SECTOR EXPENDITURE

9.5% 10.2% 11%

6.4% HEALTH 13%
INSURANCE LOCAL OTHER CARE &
PRESCRIPTIONS ADMINISTRATION OVERSEAS CARE APPLIANCES
PRACTITIONERS
 HIGHLIGHTS: HEALTH IN CONTEXT
The following provides a snapshot of the health systems and access to care in Canada, Bermuda, Jamaica, USA, Switzerland and Portugal.

Canada: Universal coverage is available to all documented residents through their province and territory; however, about 2/3 of all residents opt
to have private insurance coverage for additional supplemental benefits through a group policy. In 2013, approximately 90% of private insurance
premiums were paid through group policies.1
Jamaica: Until 2008, public health facilities had user fees which acted as a deterrent for over utilization. Abolition of user fees meant improved
access to care as shown by the 10% increase in use of public facilities by the lower income 20% of the population.2

USA: Implementation of the Affordable Care Act has helped to increase access to health coverage. 17.6 million uninsured working adults now
have health coverage and this figure is projected to increase to 24 million by 2018.1
Portugal: The National Health System offers coverage to all residents without a copayment for the majority of health care services within a
national network. Residents can expect to pay a copayment for care provided outside of the nationally covered network of providers.4
Switzerland: Public sector funding is provided through taxation, social insurance contributions and mandatory statutory health insurance (SHI)
premiums. SHI coverage is universal and residents are legally required to purchase it within three months of arrival in Switzerland. Coverage
applies to the individual, is not provided through employers and dependents require their own policy.1

CANADA5 81.5 BERMUDA6 80.9 JAMAICA7 74.0

10.2% 11.5% 5.4 %

$4,614 $6,915 $476

4.34 5.19 7.44

USA5 78.8 PORTUGAL5 81.2 SWITZERLAND4 83.3

16.9% 8.9% 11.5%
$9,451 $2,631 $6,935
4.57 3.35 3.83

Life expectancy at birth (years) Health expenditure per capita (PPP)(US$) Ratio of working adults to seniors
Health Share of GDP (%)
(2014 or latest data)

1
2015 International Profiles of Health Care Systems. Elias Mossialos, Martin Ward, Robin Osborn and Dana Sarnak
2
Health Financing Profile - Jamaica. Dr Deena Class, Eleonora Cavagnero, Sunil Rajkumar, Katharina Ferl
3
OECD (2015), OECD Reviews of Health Care Quality: Portugal 2015: Raising Standards, OECD
4
stats.OECD.org
5
2010 Bermuda Census Report: Population and Housing
6
World Databank
 NHAReport2016

SECTION1INTRODUCTION
NationalHealthAccountsareaninternationallyacceptedtoolforcollecting,cataloguingandestimatingfinancial
flowsthroughthehealthsystem.Thesereportsprovideasnapshotofthecurrentfinancialpositionofahealthcare
systemandaredesignedtoserveasapolicydevelopmenttoolforimprovingthecapacityofcountriestomanage
theirpublicandprivatehealthsystems.

Eachyear,since2010,theBermudaHealthCouncil1reviewsthefeaturesofBermudashealthsystemtoidentify
services and programs that are operating well and conversely, opportunities for improvement. During that
process,theCouncilconsiderssystemcomponentsthatcanimprovehealthoutcomesrelatedtoefficientuseof
healthresources,understandingofhealthsystem trends,anddynamicsoffinancialflowsthataccompanythe
deliveryandconsumptionofhealthcaregoodsandservices.

Basedonobservationsofhealthsystemchangesovertime,anumberofinitiativesforhealthsystemimprovement
havebeenconceptualized,developedorimplemented.Recentinitiativesinclude:

DevelopingtheBermudaHealthStrategy2andHealthActionPlan3whichdescribehealthsystempriorities
anddetailstheplanforimprovingthequality,equityandsustainabilityofourhealthsystem.
Creating health system reform working groups which encompass a number of initiatives aimed at
improvingaccesstohealthcareandimprovinghealthoutcomesthroughexpansionofmandatedhealth
insurancecoverageandcasemanagementprogrammesfortheuninsuredandunderinsuredpopulation
withnoncommunicablechronicconditions.
Identifyinghealthconditionsthatrequiregreatercollaborationofpublichealthentities.Theneedfor
multidisciplinaryapproachestocareisdemonstratedthroughcurrentlysiloedexpendituresofhealthand
insufficientprogressinenhancingpopulationhealthoutcomes.

Tojustifyprogramsanddriveprioritiesforthefuture,the2016versionoftheNationalHealthAccountsReport
reviewshealthsystemfinanceandexpenditureforthefiscalyearending2015(FYE2015)4.Theprocessofreview
isforgedthroughinputfrommultiplehealthcaredatabases,financialstatements,publicfeedback,andeconomic
information.TheultimategoalofpublicationistosupportahealthierBermudaandasystemthatwillmeetthe
increasinghealthdemandsofpatients.Withdistributionofthisreport,systemanalysts,policymakersandhealth
managerscanbettercollaborateforaprogressivepathforwardtoachievetheshortandlongtermhealthsystem
goals.

Although this report primarily analyses high quality data provided by local sources, it leverages international
sources and builds on OECD5, World Health Organization (WHO), and European Commission guidelines for

1
www.bhec.bm
2
MinistryofHealthandSeniors(2016)BermudaHealthStrategy20142019.GovernmentofBermuda.
3
MinistryofHealthandSeniors(2016)BermudaHealthActionPlan20142019.GovernmentofBermuda.
4
Fiscalyear2015istheperiodbetween1stApril2014and31stMarch2015.
5
OECDstandsforOrganisationforEconomicCooperationandDevelopment,aninternationaleconomicorganizationof34countries.

5|P a g e

 NHAReport2016

developingHealthAccounts.Thisuseoftheglobalframeworkforproducinghealthaccountsbetterallowsfor
regionalcomparisonsandcrosscountryknowledgetransfer.

The2016HealthAccountsisstructuredasfollows:

Section1 Introduction: contextually describes thegoalsoftheNationalHealthAccountsandhowit

helpstoguidethehealthsystem

Section2HealthSystemFinanceandExpenditureinFYE2015:providesananalysisofhealthfinance
andexpenditureinBermudafortheperiod1stApril2014to31stMarch2015

Section3HealthCostsinContext:providesobservationsthatplaceBermudashealthsystemfinance
andexpenditureintocontextwithOECDcountries

Section4Discussion:concludesthereportwithasummaryofthekeyfindingsandidentificationof
commonconcernswiththehealthsystem

6|P a g e

 NHAReport2016

SECTION2HEALTHSYSTEMFINANCEANDEXPENDITURE

2.1HealthSystemOverview
Bermudas health system finance and expenditure is characterised by financial flows to and from public and
privatesectors.Thepublicsectorisfundedbymandatedgovernmenttaxesandduties,whiletheprivatesector
isfundedbymandatoryandvoluntaryhealthinsurance,outofpocketpaymentsandnonprofitsources.Fora
healthsystem,itisimportantthatbothpublicandprivatefundingmechanismsaresustainableandalignwith
healthsectorobjectives.

2.2 HealthSystemFinance:PublicandPrivateSector
Healthcarefinancing,allocatedfromtaxesandduties,isaleadingspendforBermudaspublicsector,almostequal
to servicing the countrys fiscal debt. As future initiatives are developed, it is important to understand how
healthcarefitswithinthelargereconomicprofileofBermudasbudgets.Thecurrenttrendofallocatingmore
than$190Mingovernmentfundsannuallytohealthcarewithinasmalljurisdiction,isanareathatmustbetracked
andreviewedasapotentialeconomicrisk.Additionally,whileBermudasprivatesectorisprimarilyinsurance
based, it is not solely commercial as the government administers health insurance plans and carries the cost
thereof,oftenforhighriskindividuals.

Inmostdevelopedandmiddleincomecountriesgovernmentfundingofhealthcarehasbecomecentraltosocial
policyandhealthcarewithapproximately75%ofhealthcarefinancingmetbypublicsourcesinnearlyallOECD
countries6.InBermuda,thistrendisreversedwiththeprivatesectoraccountingfor72%ofthefinancing(Figure
2.2.1).Between2007and2015,thesourcesoffinancingforthehealthsystemtrendedtowardshigherlevelsof
healthinsurancecoverageandrelativereductionsinoutofpocketspending,bothofwhichareprimarilyprivate
sectorbased.Asagovernmentbecomeslessengagedinthefinancingofhealthcare,thereistheriskofreductions
inthetheoreticalandpracticalgroundsofimprovementsinhealthequityandefficiency.Inmanyjurisdictions,
thesignificantfinancingroleofgovernmentallowsforgreaterprotectionofitspublicfromavoidabledisease,
promotes a costeffective health care system, supports the provision of efficient health services and creates
greateraccesstohealthcareforthelowerincomeandvulnerablepopulations.

Local statistics on the broad scope of healthcare coverage (an estimated 90% of the Bermudian population is
insured7)demonstrateprogresstowarduniversalhealthcoverage.AccordingtotheWorldHealthOrganization,
Universalhealthcoveragemeansthatallpeoplereceivethehealthservicestheyneedwithoutsufferingfinancial
hardshipwhenpayingforthem.Thefullspectrumofessential,qualityhealthservicesshouldbecoveredincluding
healthpromotion,preventionandtreatment,rehabilitationandpalliativecare.8 Duringthereportingperiod,
therewereincreasesinpaymentsforhealthinsurance,greateruseofhealthserviceswithintheacutecaresetting,
andadeclineinoutofpocketpayments.Thesefactorsmayindicatethatcareisdivertedorutilizedwithinthe

6
OECD(2015),HealthataGlance2015:OECDIndicators,OECDPublishing,Paris.
7
DepartmentofStatistics:2010CensusPopulationandHousingReport.
8
http://www.who.int/universal_health_coverage/en/

7|P a g e

 NHAReport2016

highercostacutecaresettinginlieuofhavingservicesdeliveredinfacilitieswhereoutofpocketcontributions
wererequired.

Figure2.2.1SourcesofHealthFinancing:PublicandPrivateSector

PublicSector PrivateSector:HealthInsurance PrivateSector:OutofPocket PrivateSector:NonProfit

4% 4% 4% 4% 1% 1% > 1% >1% 1%
100%
12% > 12% >10% 9%
13%
15% 14% 13% 13%

80%

60% 55% 58% 60% 62%

53% 56%
53% 53% 56%

40%

20%
28% 29% 30% 32% 30% 30% 30% 28%
27%

0%
2007 2008 2009 2010 2011 2012 2013 2014 2015

COMPONENTSOFPUBLICSECTORFINANCING
During FYE 2015, public sector financing represented all funds provided by the Government to public health
servicessuchas:

HealthInsuranceDepartmentforthepublichealthinsuranceplans9andadministrationofpatientsubsidies;
Publichealthpromotionanddiseaseprevention;
PublichealthservicesandprimarycareprovidedthroughtheDepartmentofHealth;
Variousgrantstononprofitorganizations10forhealthrelatedpurposes;and
Healthadministration.

PatientsubsidiesinBermudaarefundedprimarilythroughtaxes.ThesefundsarecollectedintotheGovernments
ConsolidatedFundandusedtoreducemonthlyhealthinsurancepremiumsandoutofpocketcostsforeligible
individuals.Forexample,patientsubsidiesareusedinthesupportofhealthclaimcostsforservicesdeliveredat
the local hospital for individuals aged 65 years and older. These funds are also used in an effort to ensure
comprehensivecareandaccesstoasetoflocalhospitalprovidedservicesfortheyouthandlowincomepersons

9
FutureCareandtheHealthInsurancePlan(HIP)areBermudastwoaffordable,openenrolmenthealthinsuranceplansprovidedbytheHealthInsurance
DepartmentoftheMoH.FutureCareisavailableonlytopersonsaged65andover.HIPisavailabletoanyadult.
10
Priorto2011,thefinancingofgovernmentgrantswereincludedinprivatesectorfinancing.

8|P a g e

 NHAReport2016

particularly those without access to coverage through an employer. During FYE 2015, patient subsidies
accountedfor56.8%11 ofpublicsectorfinancingwhichrepresenteda4.3%decreaseinsubsidiesfromFYE2014
($115.5 million to $110.5 million). The reduction in patient subsidies did not indicate a decrease in need for
services, but rather a redetermination of how subsidy funds will be allocated and under what conditions. In
Bermuda, discussions on the equitable use of broad patient subsidies continue as alternative models such as
premiumsubsidies,ormeanstestingforsubsidization,havebeenimplementedinvariousjurisdictionsglobally.
With changing profiles and aging of Bermudas resident population, revenue generated for the health system
throughtaxationshouldbereconsideredastheprimarymeansofsubsidycontribution.

COMPONENTSOFPRIVATESECTORFINANCING
DuringFYE2015,privatesectorfinancingaccountedfor$491millioncomparedto$195millioninthepublicsector.
WhilethechangeinprivatesectorfinancingbetweenFYE2014andFYE2015wasminimal(1.1%),thepublicsector
financing decreased by 6.2%, likely a result of a 28.4% decrease in Ministry of Health and Seniors financing
(AppendixA.2).

DuringFYE2015,privatesectorfinancingrepresentedallfundsprovidedbytheprivatesectortofundhealth
servicessuchas:

Healthinsurancepremiums
Outofpocketpaymentstoproviders
Charitabledonations

HealthInsurancePremiums
Healthinsuranceistheprimarypayorofhealthcareontheislandandoverseas.Foreverydollarspentthrough
publicfunds,therearemorethantwoandahalfdollarsbeinglocallyfinancedthroughvoluntaryorcompulsory
healthinsurancepurchase12.Figure2.2.2showstherelativesizeofBermudashealthsystemspublicandprivate
sectorsassourcesoffundingovertime.Asnoted,theprivatesectorfinancinghasincreasedandiscurrently2.5
timeslargerthanpublicfinancingofhealthservices.

Healthinsuranceincludesfinancingofhealthcareusinginsurancepremiumsthrough:

Threeprivatehealthinsurancecompanies
Twopublicinsuranceplans
ThreeApprovedSchemes
MutualReinsuranceFund(MRF)

Asignificantportionofthepremiumspaidarecompulsoryfromemployees(includingselfemployedpersons)and
employers13.ThiscompulsoryportionofhealthinsuranceiscalledtheStandardHealthBenefit(SHB)whichisthe

11
$110.5millioninMoHsubsidiesasapercentageofthe$194.6millionintotalpublicsectorfinancing.
12
Themajorityofhealthinsurancepremiumsarepaidthroughcompulsoryhealthinsurancepurchase.BasedontheOECD,Eurostat,WHO(2011),ASystem
ofHealthAccounts,OECDPublishing.,itshouldthereforebeclassifiedasprivatesectorfinancing.
13
TheHealthInsuranceAct1970mandatesemployerstoprovideatleasttheStandardHealthBenefit(SHB)insuranceforemployeesandtheirnonemployed
spousesandtopay50%ofitspremium(FYE2015FullSHBPremium=$301.85).

9|P a g e

 NHAReport2016

minimumpackageofbenefitsincludedinalllocalhealthinsurancepolicies.Thispackagecoversthemajorityof
localhospitalservices,andsomediagnosticimagingandhomemedicalservicesprovidedoutsideofthehospital.
Thespecificservicesincludedinthispackageandthebusinessesapprovedtoprovidetheseservicesaredefined
byGovernmentregulationandapprovedbytheBermudaHealthCouncilonanannualbasis.

Adjustments in SHB services are based on introducing cost effective interventions into the system that will
improvepopulationhealthandimproveshortandlongtermaffordabilityofhealthcare.Themonthlycostofthis
packageisreferredtoastheStandardPremiumRate(SPR).InFYE2015,theSPRwas$301.85,adecreaseof7.4%
from FYE 2014s SPR of $325.84. As services provided within the SHB are covered by insurance without an
associatedoutofpocketpayment,itisimportanttocontinuouslymonitortheutilizationoftheseservicesand
theirimpactonpremiumcosts.Attheendofeachfiscalyear,anactuarialreportispublishedthatdescribesthe
spendonSHBservicesduringtheprioryear.

FinancingthroughhealthinsuranceinFYE2015was$425millionwhichwas26%higherthan$414.6millioninFYE
2014.

IndividualoutofpocketandNonProfit(Charitable)financingcomponents

BetweenFYE2014andFYE2015,therewasa9.3%decreaseintheoutofpocketpaymentsfrom$66.4millionto
$60.8million,whichfactoredcriticallyintothe1%decreaseprivatesectortotalhealthsystemfinancing.

Individualoutofpocketfinancingincludesanyfundspaidbytheindividualforgoodsandservicesnototherwise
covered,including:

copayments(uninsuredportionofhealthrelatedbill)
selffinancingamountsforuninsuredindividuals
fulloutofpocketpaymentstopractitionersandprovidersfornoncoveredhealthrelatedservices

Asoutofpocketfinancingdecreased,donationstothehealthsystemincreased.InFYE2015,fundingthrough
nonprofitsincreasedby5.3%to$5.0millionfrom$4.7millioninFYE2014,howevertheirportionoftotalfunding
remainedat1%.

Nonprofitfinancingincludesdonationsreceivedbynonprofithealthrelatedorganizationswhicharethenused
tocoverhealthcareassociatedcostsforeligibleindividuals14.

14
Achangeinmethodologyforthisitem,togetherwithareclassificationoffinancingreceivedbynonprofitsfromthepublicsector,hasledtoamore
modestnonprofitproportionsinceFYE2011.

10|P a g e

 NHAReport2016

Figure2.2.2PublicandPrivateHealthFinancing(in$m)

900 270%
239% 252%
234%
800 244% 231% 234% 250%
252% 254% 214%
700
200%
600

500
150%
$463 $476 $497 $486 $491
400 $438
$421
$352 100%
300 $330
$305
200
50%
100 $190 $216 $203 $208 $207 $195
$121 $130 $144 $156

0 0%
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Public Private RatioofPrivatetoPublic*

2.3HealthSystemExpenditure:PublicandPrivateSectors
Asabalancetothefinancingofhealth,totalhealthsystemexpenditureforFYE2015was$685.8million(Appendix
A.1).Healthsystemexpenditure,likehealthsystemfinancing,isgroupedintopublicandprivatesectors(Figure
2.3.1).PublicsectorexpenditurecapturesthespendinGovernmentfundedand/oroperatedentities,namelythe
MinistryofHealthandSeniorsandtheBermudaHospitalsBoard(BHB)15.

PrivatesectorexpenditurecapturesthespendinnonGovernmentrelatedcategories:prescriptiondrugs,health
insuranceadministrationexpenses,localhealthproviders,overseascareandmedicalappliances.

AlthoughexpendituretoBHBcomesfrombothpublicandprivatesector,themajorityofpublic.fundingispaidtotheBHBthereforeithasbeenclassified
15

asapublicexpenditure.

11|P a g e

 NHAReport2016

Figure2.3.1PublicandPrivateHealthExpenditure(in$m)

800 120%

108% 120%
109% 101% 100% 104% 101%
700 100%
110% 98%
100%
600

$353 $353
500 $339 $342 $344 80%
$326
$315
400
$245 60%
$240
300 $224

40%

200
$340 $337 $352 $340 $342
$302
$251 $262 20%
100 $203 $220

0 0%
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Public Private RatioofPrivatetoPublic*

InFYE2015,publicandprivatesectorexpenditureoccupiednearlyequalportionsoftotalhealthexpenditureat
$342millionand$344millionrespectively.Thisrepresentsa0.3%increaseinpublicsectorexpenditureand2.4%
decreaseinprivate,whencomparedtoFYE2014.

Figure2.3.2showsadetailedbreakdownofpublicandprivatesectorexpenditurewithanexplanationofwhatis
includedineachcategoryofexpenditure.

12|P a g e

 NHAReport2016

Figure2.3.2ComponentsofHealthExpenditure

BermudaHospitalsBoard MinistryofHealthandSeniors OverseasCare

LocalPractitioners PrescriptionDrugs Other
Administration

7% 7% 7% 7% 7% 8% 8% 9% 10% 9%
9% 8% 8% 9% 9% 9% 9% 9%
11% 11%
9% 8% 7% 7% 7% 6% 7% 6%
6% 6%
15% 14% 13% 14% 12%
17% 16% 11% 10%
17%

13% 14% 14% 13% 14% 14% 13%

12% 13% 16%

7% 7% 6% 6% 6% 6%
6% 7%
7% 6%

43% 42% 43% 44% 44% 43% 44%

40% 41% 39%

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

COMPONENTSOFPUBLICSECTOREXPENDITURE
BermudaHospitalsBoard(BHB):expenditureforallinpatientandoutpatientservicesprovidedattheKing
EdwardVIIMemorialHospital,MidAtlanticWellnessInstitute(MWI)andLambFoggoUrgentCareCentre.

Thisexpenditurerepresents43.9%oftotalexpenditure($301.4millionof$685.8million)and88.2%oftotalpublic
expenditure($301.4millionof$341.6million)(AppendixA.4).InFYE2015,oftheBHBs$301.4millioninrevenue,
49.1%wasreceivedthroughpatientsubsidiesandoperatinggrants(includinga$37.5milliongranttoMWI).

Ministry of Health and Seniors: expenditure for all governmentfunded clinics and Department of Health
communityservices.

InFYE2015,$40.2millionofexpenditurewasforthedeliveryofpublichealthservicesthroughtheMinistryof
HealthandSeniors,adecreaseof1.3%fromthepreviousyears$40.7million.

Thiscategoryrepresentsexpenditurefordiagnosingandinvestigatinghealthproblemsandhealthhazardsinthe
largercommunity.MinistryofHealthandSeniorsexpendituresarealsousedtoinform,educate,andempower

13|P a g e

 NHAReport2016

peopleabouthealthissues,especiallyamongstthemostvulnerablepopulations.Thisdecreaseinexpenditure,in
isolationandwhenconsideredwiththedecreaseinpatientsubsidies,canindicateadecreaseinservicesprovided
bytheseentitiesoradecreaseinutilizationoftheseservices.

COMPONENTSOFPRIVATESECTOREXPENDITURE
Overseas care: expenditure for health services and procedures provided to Bermudas residents, outside of
Bermuda.

Overseas care expenditure decreased by 7.2% from $96.3 million in FYE 2014 to $89.4 million in FYE 2015,
representing26%ofprivateexpenditure($89.4millionof$344.3million)and13%oftotalexpenditure($89.4
millionof$685.8million).

Hospitalcareaccountedfor52.3%ofthetotaloverseashealthexpenditureinFYE2015($46.8millionof$89.4
million). The remainder of overseas care spending was for services such as nonhospital health providers,
prescriptiondrugs,diagnosticimagingandlaboratory,andhotelandtransportationcosts.

InFYE2015SHBportabilityceasedwhichleftaportionofthepopulationwithnocoverageforoverseascare.The
decreaseinoverseasexpendituremaybeareflectionofthislegislativechange.Additionally,effortshavebeen
madetoprovidemorespecialistcarelocallyandtoincreaseconfidenceinourhealthsystem;thedecreasein
overseasexpendituremayalsobearesultofthoseinitiatives.

Localpractitioners:expenditureforalllocalphysiciansanddentists.

Thisisthesecondlargestcategoryofprivateexpenditureat10.2%oftotalexpenditureand20.4%ofprivatehealth
expenditures during FYE 2015. Specifically, the expenditure on local physicians declined by 9.5% while
expenditurefordentalpractitionersincreasedby2.2%(AppendixA.4).Expendituresattributedtolocalphysicians
peakedinFYE2012andhavedecreasedannuallythroughFYE2015.

Thedecreasemaybetheresultofresidentsusinghospitalfacilities(expenditureatBHBincreasedinFYE2015)
ratherthanprimaryandsecondarycareoptionsorforgoingcarealtogether.Additionally,withtheincreasein
healthinsurancepremiumsanddecreaseinoutofpocketfinancing,thereareongoingreviewsofcopayments
todeterminetheextenttowhichtheyinfluenceindividualsdecisionsinseekingprimaryandsecondarycare.

Prescriptiondrugs:expenditureforlocallypurchasedprescriptiondrugs.

During FYE 2015 this increased by 3.3% from $42.7 million to $44.1 million although the portion of total
expenditureremainedat6%.

In the United States, increases in prescription drug expenditure in FYE 2015 were attributed to newer more
expensivebranddrugs,higherpricesforexistingdrugsandfewerexpiringpatents16.Aslocalwholesalerssource
the majority of their drugs from the United States, factors affecting drug prices and utilization trends in that
jurisdiction will inevitably be reflected in local drug pricing and procurement. Sourcing drugs from alternate

16
CentersforMedicareandMedicaidServices.

14|P a g e

 NHAReport2016

jurisdictions or in concert with other countries through bulk purchases may provide opportunities for greater
selectionwhenidentifyingthemostcosteffectivedrugoptions.

Healthinsuranceadministration:expenditurerelatedtotheselling,generalandadministrativeexpensesofall
licensed health insurance providers (insurers and approved schemes) including claims processing, payroll and
advertisingcosts,salesexpenses,andinformationtechnologycosts.

InFYE2015,administrationsawadecreaseof2.8%forthefirsttimeinmorethantenyears(AppendixA.4)from
$67millioninFYE2014to$65.1millioninFYE2015.

Other Providers, Services, Appliances and Products: expenditure on local diagnostic imaging, laboratory
services,professionalservicesofawiderangeoflocalhealthproviders(includingbutnotlimitedtospecialised
disease management counsellors, optometrists, allied health professionals and psychologists), immunizations,
andhomehealthcare.

Thisexpenditureincreasedby3.3%.Ofallthecategoriesofexpenditure,demandforanduseoftheseservices
hasincreasedsignificantlyeveryyearsinceFYE2007(AppendixA.4).

15|P a g e

 NHAReport2016

SECTION3HEALTHCOSTSINCONTEXT
AccordingtotheOECDSBOHealthJointNetwork17,overthenext20yearshealthsystemexpenditureispredicted
tocontinuetorisefasterthantheGrossDomesticProduct(GDP)andwilloccupyanincreasingshareofGDPifwe
do not improve existing health policies and utilization of resourcesthis goal is best driven by collaboration
betweenMinistriesofHealthandMinistriesofFinance.WhiletheMinistriesofFinancearetypicallyfocusedon
ensuringbudgetarydiscipline,MinistriesofHealtharetaskedwithensuringgoodpopulationhealthandhealth
systemefficiency.

TheJointNetworkalsoreportsthatdespiteconcernswithincreasingexpenditure,praiseshouldbegivenforthe
associatedincreasesinpositivehealthoutcomes,particularlythe10yearincrease(onaverage)inlifeexpectancy
atbirthsince1970.WhilethistrendisalsotrueforBermuda,therateofincreaseinlifeexpectencyhasbeen
lowerthantheOECDaveragewithahigherrateofincreaseinhealthsystemshareofGDPandhealthexpenditure
percapita.

InFYE2007,percapitahealthsystemexpenditurewas$7,181.ByFYE2013thishadincreasedby57.3%to$11,297
afterwhichitdeclinedby1.7%to$11,102inFYE201518(AppendixA.5).Althoughwehaveseendecreasesintotal
healthexpenditureinFYE2014andFYE2015,itisnoteworthythelongtermimpactthatourdecliningpopulation
ofworkingageadultsandincreasingpopulationofnonworking,uninsuredandunderinsuredindividualscould
haveonhealthsystemcosts.

Additionally,despitethisrecenttrendofdecrease,Bermudaslatestpercapitahealthexpenditureisstillnearly
doubletheOECDaverage($6,915vs$3,740PurchasingPowerParity(PPP)19adjusted).Therearealsosimilar
significantdifferencesreportedinhealthexpenditurewhencomparingBermudatootherislandnations20.Figure
3.1showstrendsinpercapitahealthexpenditure,inPPP$,forBermudaagainsttheOECDaverageforFYE2007
toFYE2015.

17
In2011,theOECDSeniorBudgetandHealthOfficialsJointNetworkwasdevelopedwithrepresentativesfromMinistriesofHealthandFinance,World
HealthOrganization,WorldBankandotherinternationalorganzations,universitiesandthinktanks.OECD(2015)FiscalSustainabilityofHealthSystems:
BridgingHealthandFinancePerspective,OECDPublishing,Pariswasdevelopedasaresultoftheircollaborationtogivetheirviewsandrecommendations
onfiscalsustainability,politicaleconomysroleinbudgetingforhealth,aging,decentralization,costcontaininmentandviewsonrecentfinancialcrisis.
18
Percapitahealthexpendituredecreasedby1.0%fromFYE2013toFYE2014.Itdecreasedby0.8%fromFYE2014toFYE2015.
19
PPPmeansPurchasingPowerParity.PPPadjustmentisatechniquetodeterminetherelativevalue(purchasingpower)ofcurrencies.
20
KPMGReport.(2015).KeyIssuesinHealthcareAnIslandHealthcarePerspective.

16|P a g e

 NHAReport2016

Figure3.1Percapitahealthexpenditure

$7,500

$6,500

$5,500

$4,500

$3,500

$2,500
2007 2008 2009 2010 2011 2012 2013 2014 2015

BermudaPerCapitaHealthExpenditure OECDAveragePerCapitaHealthExpenditure

AnadditionalmeasureofhealthsystemimpactisthroughconsiderationofitsshareofGDP.GDPrepresentsthe
totalcostofgoodsandservicesproducedbythecountry,whichthereforegivesusanideaofhowtheeconomyis
doingoverall.Inotherwords,iftheGDPisincreasing,theeconomyisimproving.ThehealthsystemshareofGDP
tellsushowmuchwearespendingonhealthasaportionofwhatwehavespentoverallwhich,whencompared
toothercountries,givesusanideaofhowfinanciallyefficientourhealthsystemis.

Figure 3.2 indicates the yearoveryear change in the total system expenditure (adjusted for Bermudas
population),thechangeinBermudasnominalGDP,andthehealthsystemsshareofGDP.

17|P a g e

 NHAReport2016

Figure3.2ChangeinHealthExpenditureandNominalGDP

35% 14%
12.05% 12.15% 12.43% 12.16%
30%
10.95% 12%
25% 9.70%
8.03% 11.53%
7.79% 10%
20%
15.78%
15% 8%
9.86% 11.00%
10% 7.43% 7.64%
6.96% 6%
4.77% 6.10%
3.99%
5%
0.20% 0.53% 4%
0%
0.24% 0.96% 1.11%
1.41% 2%
5% 3.37%
3.88% 4.01%

10% 0%
2007 2008 2009 2010 2011 2012 2013 2014 2015

ChangeinPriorYearHealthExpenditure(AdjustedforChangesinPopulationSize)
ChangeinPriorYearNominalGDP
HealthSystemShareofNominalGDP

Between2009and2013therewasasteadytrendofdeclineinthenominalGDP,howeverithasimprovedover
thelasttwoyearswithanincreaseof3.99%in201521.ThisGDPgrowthtranslatestoapercapitaGDPof$96,018
in201522,23.

ThePanAmericanHealthOrganization(PAHO)recommendsthatpublicsectorexpenditureonhealthcarereacha
targetrateof6%ofGDP.During2013,Bermudasaggegratepublicandprivatehealthsystemexpenditureshare
ofGDPpeakedat12.43%,buthassincedeclinedto11.53%in201524.Despitetherecentdecline,Bermudas
spendingon healthstillexceedsthe OECDaverage of8.9%of GDP.Althoughspendingexceedsthat ofother
jurisdictions;asFigure3.3shows,Bermudaslifeexpectancyfrombirthtrailsmanyofthesesamecountries.

21
BermudasGDPcalculationspanscalendaryearsinsteadoffiscalyearsthereforethehealthexpenditureforthefiscalyeariscomparedwiththeGDPof
calendaryear2015.
22
GovernmentofBermuda,DepartmentofStatistics.GrossDomesticProduct2015Highlights.
23
InApril2015,generalinflationratewas1.8%whiletheinflationrateforHealthandPersonalCaresectorwas8.5%(DepartmentofStatisticsConsumer
PriceIndexApril2015)
24
Bermudashealthexpenditureproporationalityisapproximatelyequalbetweenthepublicandprivatesector.

18|P a g e

 NHAReport2016

Figure 3.3 Life expectancy at birth (Y axis) and health expenditure per capita (X axis), 2013 (or latest year
available)

86
ITA FRA AUS CAN
84 ESP JPN
AUT CHE
SWE
ISR ISL LUX
Lifeexpectancyatbirth(yrs)

82 KOR GBR
NZL NLD
GRC SVN BDA
PRT BEL DEU
80 CHL IRL NOR
OECD FIN DNK
EST
78 USA
TUR POL
76 MEX SVK
HUN
LVA
R=0.4537
74

72
1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000
HealthExpenditurepercapita(US$)

Source:OECDHealthData2015

CountriessuchasCanada(CAN),UnitedKingdom(GBR)andPortugal(PRT)havehigherlifeexpectancydespite
spendinglesspercapitainhealthcaredollarsthanBermuda(PPPadjusted25;Figure3.3).

WhilecountriestendtospendmoreonhealthwhenpercapitaGDPishigher(Figure3.4),withtheexceptionof
theUnitedStates,Bermudaspendsmoreonhealththansimilarlyaffluentcountries(Figure3.4and3.5),suchas
Switzerland(CHE),Sweden(SWE),Netherlands(NLD)andFrance(FRA);andlifeexpectancyislowerinBermuda
thaninallfourcountries.

25
InFigures3.2and3.3,HealthexpendituresandGDParePPPadjustedtoenablecomparisonbetweencountries.PPPwasobtainedfromtheUniversityof
PennsylvaniasCenterofInternationalComparisonsofProduction,IncomeandPrices.

19|P a g e

 NHAReport2016

Figure3.4HealthsystemshareofGDP

UnitedStates 16.9%
Switzerland 11.5%
Bermuda 11.5%
Germany 11.1%
Sweden 11.1%
France 11.0%
Netherlands 10.8%
Denmark 10.6%
Belgium 10.4%
Austria 10.3%
Canada 10.2%
Norway 9.9%
UnitedKingdom 9.8%
Finland 9.6%
NewZealand 9.4%
Ireland 9.4%
CostaRica 9.3%
Australia 9.3%
Japan 9.1%
Spain 9.0%
OECDAverage 8.9%
Portugal 8.9%
SouthAfrica 8.8%
Italy 8.8%
Iceland 8.8%
Slovenia 8.4%
Greece 8.2%
Chile 7.8%
CzechRepublic 7.6%
Israel 7.4%
Korea 7.2%
Colombia 7.2%
Luxembourg 7.2%
Hungary 7.0%
SlovakRepublic 7.0%
Lithuania 6.5%
Poland 6.3%
Estonia 6.3%
Brazil 6.2%
Mexico 5.9%
Russia 5.9%
Latvia 5.6%
China 5.6%
Turkey 5.2%
India 4.7%
Indonesia 2.8%
0% 5% 10% 15%

20|P a g e

 NHAReport2016

Figure3.5Totalhealthexpenditurepercapita(Yaxis)andnominalGDPpercapita(Xaxis),2014(orlatestyear
available)

10,000
CHE
9,000 USA

8,000
Totalhealthexpenditurepercapita(PPPadjusted)(US$)

BDA

7,000 FRA SWE

DEU
CAN NLD
6,000 JPN
NZL
IRL
5,000 GBR
ESP
AUT NOR
GRC SVK
4,000 DNK
CZE BEL
HUN SVN ISL
3,000 CHL
AUS
ITA OECD
2,000 FIN
MEX
1,000 POL PRT
LVA ISR
TUR EST KOR

15,000 25,000 35,000 45,000 55,000 65,000
NominalGDPpercapita(US$)

Source:OECDHealthData2015;GDPpercapita,PPP(currentinternational$)

21|P a g e

 NHAReport2016

SECTION4DISCUSSION
DuringFYE2015totalhealthfinancingandexpendituredecreasedby1.1%.Onapercapitabasis,a0.8%decrease
wasseeninexpenditureafteradjustingforthedecreaseinthesizeofBermudaspopulation.However,evenwith
considerationofthechangeinpopulationdemographics,thehealthsystemexperiencedlowerexpendituresfor
thedeliveryofhealthrelatedservices.

Publichealthprogrammebudgetadjustmentsandpolicychangesinpatientsubsidyappropriationsresultedina
6.2%reductioninpublicsectorfinancing($207.4millionto$194.6million).Althoughthesereductionsallowfor
amorefinanciallysustainableandaffordablehealthsystem,thisshouldbealignedwithcommitmentstodisease
preventiondrivenbythesepublicinvestmentsandourlongtermgoalofincreasedaccesstocare26.Subsidies
weredesignedtoassistwithhealthcarecoverageforthosewhoareotherwiseunabletoaffordit;lowincome,
underinsuredsanduninsureds.Similarly,publichealthprogrammesareavailabletoprovideresidentswithlower
costoptionsforcare.Reductionsinthissectoroffinancingrunstheriskofdecreasingaccesstocarewhichcould
becounterproductive27.

Decreaseswerealsoseeninprivatesectorfinancing.Therewasadecreaseinoutofpocketpaymentsby10%
which may have been counterbalanced by the increases in health insurance financing (+2.3%) and charitable
donations (nonprofit financing) (+5.6%). As with decreases in public sector financing, there is support for,
although also concerns with, decreases in private sector financing. Lower outofpocket costs allow some
participantsofthehealthsystemtohavegreaterfinancialflexibilitytobettermanagetheirhealth.However,lower
outofpocketcostscouldalsobetheresultofindividualsdelayingtreatmentorlimitingthepurchaseofneeded
pharmaceuticaltherapies.

Asdrugshavebecomemoreofacriticalcomponentofcurativecare,prescriptiondrugexpenditurewillcontinue
to be reviewed in order to increase our understanding of population access and use of available treatment
interventions.Contextually,pricingpressuresandunstableeconomicconditionshaveledtoaslowdowninthe
pharmaceuticalsegmentglobally28,ashavetighteninggovernmenthealthcarebudgetsand/orreductionsinout
ofpocketexpenditures.Despitethisslowdowninprescriptiondrugexpendituregrowth,itisexpectedthatthe
mainfactorsdrivinghealthcaredemandamongthem,agingpopulations,theriseofchronicdiseases,andthe
advent of innovative and frequently expensive treatments (e.g., for cancer and Hepatitis C) may lead to
increaseddrugspendinginfutureyears.

Theoveralldecreaseinhealthexpenditureislargelyduetothe2.4%decreaseinprivatesectorhealthexpenditure
aspublicsectorhealthexpenditureremainedrelativelyconstant(+0.3%).Despitemarginaldeclinesinfinance
andexpendituresonhealthduringFYE2015,thereremainsapersistentlyhighpercapitaallocationofresources
appropriatedtowardshealthcomparedtoOECDcountries,withoutrelativegainsinlifeexpectancy.Thepotential

26
MinistryofHealthandSeniors(2016)BermudaHealthStrategy20142019andHealthActionPlan.GovernmentofBermuda.
27
Subsidiesprovideassistancetothemostvulnerablepopulations,howeverchildrenandseniorscareissubsidizedregardlessoftheirfinancialstatus.An
indicatorofhowreductionsinsubsidyfundingeffectindividualsunabletoaffordcareisbestreflectedinthechangeinindigentandclinicaldrugsubsidies
asthesesubsisidesareprovidedaslastoptionsubsidiesforthoseconsideredinneedatthepointofcareorservice.
28
Deloitte:2016Globallifesciencesoutlook.

22|P a g e

 NHAReport2016

andevidencebasedimpactofsuchchangesonthehealthstatusandlifeexpectancyofthepopulationshouldbe
furtherexploredthroughbroaderstakeholderdiscussions.

Therelativelyhighexpenditurecanbeattributedtoacombinationoffactors.Theoperationalcostsassociated
withrunninganybusinessinBermudaarerelativelyhigh.Thisdirectlyinfluenceshealthbusinesseswhenthey
setfeestomaintaintheirbusiness.Thisstandardisreflectedinhighlevelsofhealthinsurancecoverageand
subsequently high health insurance premiums. High premiums ultimately affect affordability and can create
disparitiesintheaccesstocare.

Whilsttyinghealthinsurancepremiumstoemploymentbenefitstheemployed,itmakesitdifficultfortheun
employedtogetcoverageorinsomecases,employerswhoareunabletopaytypicalhealthinsurancepremiums,
mayoptforsmaller,lessexpensivehealthinsurancecoveragetherebycreatingthreesegmentsofthepopulation
insured,theunderinsuredandtheuninsured.Withsuchhighcostsofhealthcare,theuninsuredandunder
insured have limited access to the care they require. This disparity combined with the aging population and
increasingprevalenceofchronicdiseases,hascreatedagreaterdemandforqualityandeffectivehealthcareata
costthatisaffordableforall.

Whencomparinghealthsystemexpendituretooutcomes,Bermudahasroomforimprovement.Inlightofthis,
initiativeswereintroducedin2011tocreategreatercosttransparencyandqualityofcaresuchasproviderbased
feedbackintheformofutilizationreports,discussiononbestapproachestoreducingnoncriticalprocedures,
exposure to global clinical guidelines, and generally greater collaboration and consultation between system
stakeholders.TheseactionswereinalignmentwithbroaderprioritiesoftheBermudagovernmentforgreater
longtermhealthsystemsustainability.Furtherimprovementsinhealthsystemplanningweremadeduring2014
as understanding of the health system needs continued to improve, contributing to the development of the
BermudaHealthStrategy20142019andHealthActionPlan.Withclearlyidentifiedgoalsandinitiatives,wecan
usetheinformationinthisreporttomonitorhealthsystemimprovementsandensurehealthsystemchangesare
notattheexpenseofresidentshealth.

ItwillbeacontinuedchallengeforBermudatoidentifyopportunitiestoimproveaccess,quality,andoutcomes
of care delivery while reducing the comparably high resource expectations and requirements of its systems
participants.

23|P a g e

 NHAReport2016

APPENDIX29

AppendixA.1FYE2015BermudaHealthSystemFinanceandExpenditure

HealthFinance InBD$000 %ofTotal HealthExpenditure InBD$000 %ofTotal

ConsolidatedFundMinistryofHealthandSeniors 188,807 27.5% MinistryofHealthandSeniors 14,475 2.1%

ConsolidatedFundDepartmentofSocialInsurance(DOSI)* 4,855 0.7% DepartmentofHealth(DoH) 25,726 3.8%

GrantsfromMinistryofYouth,Families&Sports 901 0.1% BermudaHospitalsBoard(BHB) 301,359 43.9%

PublicSectorSubTotal 194,563 28.4% PublicSectorSubTotal 341,560 49.8%

HealthInsurance 425,516 62.0% LocalPractitionersPhysicians 39,733 5.8%

IndividualOutofPocket 60,761 8.9% LocalPractitionersDentists 30,411 4.4%

DonationstoNonProfitOrganizations 4,989 0.7% OtherHealthProviders,Services&Appliances 75,460 11.0%

PrescriptionDrugs 44,094 6.4%

OverseasCare 89,418 13.0%

HealthInsuranceAdministration 65,153 9.5%

PrivateSectorSubTotal 491,266 71.6% PrivateSectorSubTotal 344,269 50.2%

GrandTotal 685,829 100% GrandTotal 685,829 100%

Sources:BermudasMinistryofFinance,BHB,BermudaHealthCouncil,FYE2015healthinsuranceclaimsreturns,BermudaMonetaryAuthority(BMA),2015statutoryinsurancefinancialreturns,and
thefinancialstatementsofapprovedschemesandleadinghealthsectornonprofitentities.

TheMinistryofHealthandSeniorsfundingincludes$4.4millioncapitalinjectionforFutureCaretosupportitsoperatingexpenses
*TheDOSIfundingisfortheWarVeteransAssociation.

ThisisfromtheunauditedBHBfinancialstatementsandisinclusiveof$37.5millionfortheoperationoftheMidAtlanticWellnessInstitute(MWI).

29
ForadditionaldatafromFYE2004FYE2006pleasevisittheBermudaHealthCouncilswebsite(www.bhec.bm).

24|P a g e

 NHAReport2016

AppendixA.2HealthSystemFinancingFYE2007FYE2015(BD$,'000)

HealthFinanceSector 2007 2008 2009 2010 2011 2012 2013 2014 2015 15vs14 0715 AAGR30

PublicHealthFinancing 129,735 144,056 155,772 190,111 215,886 202,641 208,224 207,409 194,563 6.2% 50.0% 6.2%
MinistryofHealthandSeniors 4,993 3,396 8,505 28,737 35,194 30,250 28,896 29,285 20,975 28.4% 320.1% 40.0%
DepartmentofHealth 24,540 29,463 28,023 29,135 30,508 29,693 30,513 25,298 25,726 1.7% 4.8% 0.6%
Patientsubsidies&OperatingGrants 100,202 111,197 119,244 132,239 150,184 142,699 148,815 152,826 147,862 3.2% 47.6% 5.9%

PrivateHealthFinancing 329,909 352,263 420,532 438,343 463,076 475,801 496,804 485,738 488,933 0.7% 48.2% 6.0%
HealthInsurance 243,755 259,877 323,778 334,893 374,686 379,160 408,602 414,589 423,183 2.0% 73.6% 9.2%
IndividualOutofPocketFinancing 67,707 71,633 74,101 80,103 82,748 90,985 82,736 66,423 60,761 9.3% 10.3% 1.3%
CharitableNonGovt.Organizations 18,447 20,753 22,653 23,347 5,642 5,655 5,466 4,726 4,989 5.3% 73.0% 9.1%

TotalHealthFinancing 459,644 496,319 576,304 628,454 678,962 678,442 705,028 693,147 685,829 1.1% 49.2% 6.2%
Sources:BermudasMinistryofFinance,BHB,BermudaHealthCouncil,FYE2015healthinsuranceclaimsreturns,BermudaMonetaryAuthority(BMA),2015statutoryinsurancefinancialreturns,and
thefinancialstatementsofapprovedschemesandleadinghealthsectornonprofitentities.

Avg
2007 2008 2009 2010 2011 2012 2013 2014 2015
0715
PublicHealthFinancing%ofTotalGovt.Expenditure 13.6% 14.1% 14.0% 16.2% 17.0% 16.3% 16.6% 19.7% 17.6% 16.1%
HealthInsurance%ofTotalHealthSystemFinancing 53.0% 52.4% 56.2% 53.3% 55.2% 55.9% 58.0% 59.8% 62.0% 56.2%
IndividualOutofPocketFinancing%ofTotalHealthSystemFinancing 14.7% 14.4% 12.9% 12.7% 12.2% 13.4% 11.7% 9.6% 8.9% 12.3%
AnnualGrowthinPatientSubsidies&OperatingGrants 8.5% 11.0% 7.2% 10.9% 13.6% 5.0% 4.3% 2.7% 3.2% 5.5%

30
AAGRmeansAverageAnnualGrowthRate.

25|P a g e

 NHAReport2016

AppendixA.3BermudaGovernmentSubsidies(FYE2007FYE2015inBD$,000)
BermudaGovernmentPatient 2007
2007 2008 2009 2010 2011 2012 2013* 2014 2015 15vs14 AAGR
andOtherSubsidies 2015
PatientSubsidies(Legislated)
AgedSubsidy 35,462 41,358 46,877 46,165 55,802 59,798 71,409 70,002 75,251 7.5% 112.2% 14.0%
YouthSubsidy 8,708 9,631 10,176 14,719 16,433 14,638 16,270 18,213 15,990 12.2% 83.6% 10.5%
IndigentSubsidy 7,476 5,176 2,917 5,026 5,894 8,951 4,310 6,265 8,247 31.6% 10.3% 1.3%
TotalPatientSubsidies 51,646 56,165 59,970 65,910 78,129 83,387 91,989 94,480 99,488 5.3% 92.6% 11.6%
OtherSubsidies

(NonLegislated)
CCU/GeriatricSubsidy 11,602 12,673 13,728 13,473 15,188 16,583 10,412 10,000 10,000 0.0% 13.8 1.7%
ClinicalDrugsSubsidy 31
2,522 2,549 2,215 2,368 2,368 2,368 2,368 2,392 1.0% 5.1 0.6%
OtherSubsidies 4,537 5,447 6,830 6,986 6,847 7,391 9,231 8,634 0
32
100% 100% 12.5%
TotalOtherSubsidies 18,661 20,668 22,772 22,828 24,403 23,974 22,011 21,002 12,392 41.0% 33.6% 4.2%
GrandTotal 70,307 76,833 82,742 88,738 102,532 107,360 114,000 115,482 111,880 3.1% 59.1% 7.4%

*2013figuresbasedonrevisedBHBsubsidyfiguresfrom$109,768.

31
TherewasnoClinicalDrugsSubsidyforFYE2012.
32
DialysisprovidedinthehospitalwaspreviouslycapturedunderOthersubsidy.InFYE2015,dialysiswascoveredbysupplementalhealthinsurancethereforeeliminatingtheOtherSubsidyandany
subsidisedindividualswhorequireddialysistreatmentwerecoveredundertheIndigentSubsidy.InFYE2015,$1.4million(17.1%)oftotalIndigentSubsidy($8.2million)wasspentondialysis.

26|P a g e

 NHAReport2016

AppendixA.4HealthSystemExpenditureFYE2007FYE2015(BD$,000)
2007
2007 2008 2009 2010 2011 2012 2013 2014 2015 15vs14 AAGR
2015
PublicSectorHealthExpenditure 219,667 251,317 261,770 314,938 *337,924 336,766 352,287 340,454 341,560 0.3% 55.5% 6.9%
MinistryofHealthandSeniors 32,533 35,859 36,528 47,872 45,800 41,601 42,082 40,718 40,201 1.3% 23.6% 2.9%
Promotion/Prevention/
24,540 29,463 28,023 29,135 30,508 29,693 30,513 27,370 25,726 6.0% 4.8% 0.6%
CurativeCare
GrantsandAdministration 7,993 6,396 8,505 18,737 15,292 11,908 11,569 13,348 14,475 8.4% 81.1% 10.1%
BermudaHospitalsBoard(BHB) 187,134 215,458 225,242 267,066 292,124 295,165 310,838 299,736 301,359 0.5% 61.0% 7.6%

PrivateSectorHealthExpenditure 239,977 245,003 314,534 326,464 339,152 341,676 352,741 352,693 344,269 2.4% 43.5% 5.4%
LocalPractitioners 77,122 76,206 90,123 91,516 87,998 92,648 82,739 73,645 70,144 4.8% 9.0% 1.1%
Physicians 53,110 53,526 61,870 60,826 58,217 59,912 50,621 43,888 39,733 9.5% 25.2% 3.1%
Dentists 24,012 22,680 28,253 30,690 29,781 32,736 32,118 29,757 30,411 2.2% 26.6% 3.3%
OtherProviders,Services,Appliances&
35,795 37,113 54,239 57,422 61,449 59,334 63,878 73,041 75,460 3.3% 110.8% 13.9%
Products
PrescriptionDrugs 36,935 37,121 39,046 41,969 41,847 45,334 43,229 42,694 44,094 3.3% 19.4% 2.4%
OverseasCare 59,074 62,267 90,264 91,384 96,556 89,933 101,151 96,311 89,418 7.2% 51.4% 6.4%
HealthInsuranceAdministration 31,051 32,296 40,863 44,173 51,302 54,427 61,744 67,002 62,820 2.8% 109.8% 13.7%

TotalHealthExpenditure 459,644 496,320 576,304 641,402 *677,076

678,442 705,028 693,147 685,829 1.4% 48.7% 6.1%
Source:TheAccountantGeneral,TheMinistryofFinance,TheBermudaHospitalsBoard,andHealthCouncilannualhealthinsuranceclaimsreturns

Theserevenuesremainunauditedatthetimeofwritingthereportsfortherelevantyear.Thatis,the2014/15figureswerenotauditedintimeforcompletionofthisNationalHealthAccountsReport.
UpdatedfiguresaretypicallyprovidedbyBHBonceavailable;onlytheoriginallyreportedfiguresarereflectedhere.

This item includes additional funding for Future Care medical claims (since FYE 2010); delivery of Ministry of Health and Seniors related services and functions, and grants to charitable, non
governmentalorganizations.ItalsoincludestheHealthInsurancePlanAdministration(forthesubsidyprogrammes,theMRF,FutureCareandHIP),whichwasreportedinearlierNationalHealth
AccountsReportsasaseparateitem.TheDOSIHealthInsurancePlanAdministrationwastransferredfromDOSItoMinistryofHealthandSeniorsinFYE2009.

TherevisedFYE2012healthsystemexpenditureis$664.8million(a2.1%declineoverFYE2011).

27|P a g e

 NHAReport2016

AppendixA.5AnalysisofHealthSystemExpenditureFYE2007FYE2015(BD$,'000)
Avg
AnalysisofExpenditure 2007 2008 2009 2010 2011 2012 2013 2014 2015 15vs14
0715
NationalGovernment
952,606 1,022,899 1,112,193 1,176,834 1,272,651 1,245,741 1,253,712 1,052,497 1,107,031 5.2% 16.2%
CurrentExpenses
TotalHealthExpenditure
459,644 496,320 576,304 641,402 677,076 678,442 705,028 693,147 685,829 1.1%
(THE)(BD$)

EstimatedPopulation 64,009 64,209 64,395 64,566 64,237 64,237 62,408 61,954 61,177 0.3%
PerCapitaHealth
7,181 7,730 8,950 9,934 10,540 10,562 11,297 11,188 11,102 0.8%
Expenditure(BD$)
PublicHealth
219,667 251,317 261,770 314,938 337,924 336,766 352,287 340,454 341,560 0.3%
Expenditure(BD$)
PublicHealthExp%ofNatnl.
23.1% 24.6% 23.5% 26.8% 26.6% 27.0% 28.1% 32.3% 30.9% 33.8%
Govt.Exp
PublicHealthExp%of
4.1% 4.3% 4.3% 5.4% 5.9% 6.1% 6.4% 6.1% 5.8% 54.7%
GDP
PublicHealthExpPer
3,432 3,914 4,065 4,878 5,261 5,243 5,645 5,495 5,529 0.6%
Cap.(BD$)
PublicHealth
47.8% 50.6% 45.4% 49.1% 49.9% 49.6% 50.0% 49.1% 49.8% 4.2%
Expenditureas%ofTHE
BHBExpenditureas%of
40.7% 43.4% 39.1% 41.6% 43.1% 43.5% 44.0% 43.2% 43.9% 7.9%
THE
PrescriptionDrugExp%
8.0% 7.5% 6.8% 6.5% 6.2% 6.7% 6.1% 6.2% 6.4% 19.7%
ofTHE
NominalGDP(BD$) 5,897,374 6,178,691 5,938,934 5,855,331 5,620,380 5,585,410 5,670,093 5,699,992 5,927,652 4.0%
TotalHealthExpshareof
7.8% 8.0% 9.7% 11.0% 12.0% 12.2% 12.7% 12.2% 11.6% 48.4%
GDP(%)
NominalGDPYoY
21.1% 4.8% 3.9% 1.4% 4.0% 3.4% 0.2% 0.5% 4.0% %
GrowthRate(%)
THEYoYGrowthRate(%) 7.8% 8.0% 16.1% 11.3% 5.6% 0.1% 3.9% 1.7% 1.1% 113.6%
Health&PersonalCarePrice
6.8% 6.6% 6.7% 8.1% 7.5% 6.6% 8.3% 6.7% 7.8% 14.7%
Index(%)
OverseasCare%ofTHE 12.9% 12.5% 15.7% 14.2% 14.3% 13.3% 14.3% 13.9% 13.0% 1.4%
Source:DepartmentofStatistics.

ThepopulationfigurewasdeterminedfromBermudasPopulationProjections20102020preparedbytheDepartmentofStatistics.For2011and2012,thepopulationfigurewaskeptthesame
duetotheprojectionofstabilityinthepopulationandthelackofconsistentestimatesduringthetimethereportwasprepared.Priortothepublicationoftheresultsofthe2010census,thepopulation
figuresarefromtheDepartmentofStatistics2006projectionMidYearPopulationProjectionsJuly1,2000toJuly1,2030.

TheGDPisreportedoncalendaryearbasis.

28|P a g e