In Spain, universal healthcare coverage is provided to the vast majority of the population via the country’s National Health System (Sistema Nacional de Salud; SNS). The public SNS is combined with private healthcare, with the two operating together to reach those in need.

“Spain has a universal healthcare system that, thanks to its extensive hospital network, manages to reach 99 per cent of the population,” said a spokesperson for Iris Global, an insurance and assistance provider that forms part of Grupo Santalucía, the eighth largest Spanish insurer. “The public system provides high-quality medical care and can handle any kind of condition, including the most severe ones. Primary care makes up 90 per cent of healthcare, it keeps high standards of care and it is close to the patient, providing prompt assistance and avoiding unnecessary referrals to specialists.

“The private network complements public health by reducing waiting times for specialties and surgical procedures. If somebody needs specialised medical aid – such as a dentist or mental healthcare professional – they can rely on private health systems or insurance.”

ITIJ also spoke with Javier Casquero, who is International Business Director of HM Hospitales, a leading private hospital group at national level. “Patient treatment and patient satisfaction is paramount for any Spanish hospital, regardless if it is private or public,” he said. “The fact that the Spanish health system is a combination of private and public hospitals is an advantage for all, and insurance companies should know that their policyholders, when they go to a public hospital where for medical or resources reasons they cannot be operated on or treated quickly, they have the option to go for high-level private medical providers with competitive prices in accordance with the agreements established between the hospital and the company. This greatly facilitates the assistance and treatment of their insured and therefore the degree of satisfaction is higher. The level of care and medical quality of Spanish hospitals exceeds, in many cases, many hospitals inside and outside the EU.”

Dr Juan José Ríos is Medical Director of Hospital Universitario La Paz, which is part of the public healthcare system in Spain, offering universal healthcare to all residents. “The Spanish healthcare system excels in providing universal, high-quality care,” he said. “Institutions like the Hospital Universitario La Paz are renowned for their ability to manage complex cases, reflecting our commitment to continuous improvement, innovation and patient-centred care.”

Indeed, the high-quality healthcare delivered by both private and public sectors is evidenced by Spain’s low mortality rates from preventable and treatable causes, as well as its low unmet medical needs relating to cost, distance or waiting times, which were reported by only 0.2 per cent of the population in 2019 (State of Health in the EU: Spain Country Health Profile 2021).

Meeting the needs of international patients

Another important element of the Spanish healthcare system is its provision for expats, offering them access to one of the best healthcare systems in the world. A spokesperson for ASISA, a leading health insurance company in Spain with a large network of private hospitals and specialist clinics, spoke to ITIJ about international patients and related challenges. “The proportion of international citizens residing in Spain is significant, while the percentage of temporary residents (persons who spend a period of time in Spain for professional or academic purposes) is a growing trend,” they said.

The private network complements public health by reducing waiting times for specialties and surgical procedures

“International citizens have a variety of needs that are different to those we have grown accustomed to addressing when tending to the needs of traditional clients and users of private healthcare in Spain. At ASISA, we have been working intensively for some years to understand what these needs are and how best to meet them. Language barriers are the most evident issues, not only when it comes to communicating with doctors and sharing patient histories that might span several different countries. They can become insurmountable when a patient is experiencing serious health difficulties, is living in a country where access to his or her support network is not within reach, and the administrative tasks related to authorisations can snowball into an additional trauma.”

Inflation’s impact on insurance

Of course, healthcare systems in Europe and beyond are facing myriad challenges caused by the current fraught economic situation. First came the global financial crisis of 2007–2009, which was deeply damaging for healthcare systems the world over, and then the Covid-19 pandemic, the far-reaching consequences of which continue to impact health systems.

“Nowadays, the public health system is facing challenges related to the collapse of primary care, the saturation of the emergency room, the increase in waiting lists and the general shortage of professionals. These issues affect the entire territory and are becoming endemic,” said Iris Global’s spokesperson.

ASISA’s spokesperson discussed inflation and its impact on insurance: “Inflation is a concern for all sectors in Spain, and has come as a shock to most of the stakeholders in the health industry. Over the last two decades, inflation has not been a relevant factor in the Spanish economy, and its appearance, when we were jostling to recover from the hit taken by the Covid-19 pandemic, has evidenced the weaknesses all organisations carry and need to address, including ASISA. Most of the insurance policy premiums offered in Spain have been affected, and, although in ASISA’s case the impact has been relatively subtle, it has been difficult for us to come to terms with culturally as an organisation.”

According to the 2021 State of Health in the EU report by the European Observatory on Health Systems and Policies, life expectancy in the country is among the highest in Europe, but declined significantly in 2020 due to the impact of the Covid-19 pandemic. Subsequently, the pandemic had ongoing effects and encouraged those in a position to do so to consider private medical insurance. “The pandemic, finally overcome, has caused an increase in awareness of having medical insurance that complements the National Health System, as the waiting lists have been saturated in recent years,” commented Iris Global’s spokesperson. “Travel insurance is also increasing in demand from travellers in order to travel more safely. Nowadays, we are facing a very difficult economic situation due to existing inflation, so the challenge for insurers is being able to mix both health systems and being competitive.”

Iris Global’s spokesperson said that, for the private sector, the challenge is to be able to respond to the fast-growing demand for healthcare. “Depending on the specialty, it can reach an increase of 10 per cent of new demands, making costs more efficient with the same quality standards. The role played by insurers is essential. Due to their specialisation and knowledge in a competitive sector with higher prices, the challenge is responding in an agile and professional way to the request received from our travellers, referring to the most appropriate medical centre in order to be treated accordingly.

“The National Health System (SNS) is necessary since there are specific pathologies which are taken through them (tropical diseases, for example) or those cases that are handled by emergency services. The gap we are having in the post-pandemic era is the increasing demand on the professionals in the SNS.”

Ríos said that despite these challenges, the focus on unwavering patient care remains the priority: “In the face of increasing medical complexity and limited resources, our mission at Hospital Universitario La Paz remains clear: to provide top-tier care for our patients. This entails strategically deploying our resources, making judicious use of technology, and always prioritising interventions that will provide the most value for our patients. Every decision we make is driven by this goal, ensuring that we are continually advancing patient outcomes and care experience.”

Overcoming digital challenges

For hospitals, key challenges relate to the uptake of technology. Ríos told ITIJ: “Despite our strengths, we recognise the need for improvement in harnessing data and leveraging AI [artificial intelligence]. These technologies can not only streamline administrative and clinical processes but also catalyse research, foster innovation, and usher in a new era of personalised medicine.”

Casquero commented: “From our HM international departments, we reiterate that the information about the benefits, co-payments or franchises of the insured in many cases should flow more efficiently and be on digital platforms that are easily accessible.”

Iris Global’s spokesperson agreed that implementing new technologies is key for insurers: “We should be able to respond to our clients more effectively, improving timing in accordance with the needs and challenges of any given medical issue. A service that has been increasingly growing lately is video consultation. More than 20 per cent of requests that we received from our travellers were for this service, and we provide it. The capability of adapting and responding to new demands will mark the continuity of insurers.”

Indeed, Casquero said that digital transformation is the main challenge for hospitals working with insurance companies. “In order to have a more effective and fast insurance service at our hospitals, we need to manage medical assistance authorisations, medical cover and even the payments and invoice management in a more digital manner. Therefore, we believe in technology to innovate and improve the relationship with key insurance players.”

One challenge is achieving a broad, comprehensive and perfectly functional network across the entire territory

Hidden relationship complexities

Reflecting on the key challenges encountered by insurance providers working with hospitals in Spain, ASISA said: “One challenge is achieving a broad, comprehensive and perfectly functional network across the entire territory, including the islands. At first, the partnership appears a perfect fit: the largest source of revenues received by private hospitals comes from private health insurance and, for the insurers, the quality of care offered in Spanish hospitals in relation to the cost is tremendously favourable – especially in comparison with other first world countries. However, a closer look evidences some hidden complexities. The ownership structure and organisation of the private hospitals – which represent approximately 45 per cent of all healthcare institutions across Spain – is largely fragmented.”

Casquero told ITIJ: “Sometimes we find there is a lack of information from insurers on the wide range of services we offer at our hospitals. Data service management is another challenge we face on a daily basis. It is key for us that insurers have the information about the services of our international department and the most complete medical information on the services of the hospitals we offer, so that their insured can easily see the information before going to a hospital. There are seldom forms or systems within the insurance companies that allow more complete information about what a hospital offers. And, in our case, it would make it much easier for insurance companies to improve the copayment or deductible system, since the information we receive at the hospitals is often incomplete.”

Connections are crucial

For ASISA, a robust network of connections has proven key to navigating challenges: “ASISA has cultivated excellent relationships with all private hospitals and healthcare facilities, large and small, across the entire Spanish territory. This has allowed ASISA to lay solid foundations in its relationships so it can offer its clients access to the largest possible network with the freedom to choose amongst the clinicians and healthcare units in the country, including the rural areas and islands (Balearic and Canary Islands); these are popular destinations with great seasonal fluctuations in demand for healthcare,” the spokesperson said. “In addition to fostering robust relationships with all the major hospital groups in the country, ASISA has developed its own network of private health facilities, including clinics, hospitals and two university hospitals.”

Ultimately, strong connections between hospitals and health insurers with a shared goal of excellent patient care is continuing to drive the system forward. Casquero concluded: “We are always grateful for close collaboration with insurance companies and are always open to growing with them, establishing long-term business relationships, and willing to listen to suggestions for improvements to constantly enhance the medical care of their policyholders.”