The right time to repatriate?

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Assistance & Repatriation Review | April 2019

There are multiple choices to be made during the repatriation process, but the decision of when to repatriate a patient is the pivotal consideration. How is this decision made and what happens when involved parties disagree? Christian Northwood finds out

Medical repatriations are rarely simple. The medical assessment involved is rigorous – not only does the patient have to pass several tests in order to be considered fit to fly, but the repatriation itself, whether on a commercial aircraft or air ambulance, requires specialist medical knowledge on behalf of the organising and accompanying teams. 
 
Repatriations can also mean eye-watering costs for those shouldering the bill, which in many cases is the insurer. James Page, Senior Vice-President and Chief Administration Officer at AIG, told ITIJ: “If you’re travelling from Miami to the Caribbean, you may only need US$25,000, because that’s probably what it will cost to get you home. If you’re going from Miami to Sydney, you may need an amount upwards of $125,000.” 
 
With the clock ticking, all sides need to be able to identify where potential disagreements may be and know how to mitigate them as swiftly as possible 
 
And these are from locations that have good infrastructure. If a patient falls ill in a remote location, with a complicated condition, those costs can spiral. The patient’s medical condition and the cost associated with the various options regarding their treatment and repatriation are main considerations in repatriation cases, but other factors can muddy the waters and decisions over the right time to repatriate are not always easy to make.
 
Working together
As you might expect in an often-sensitive situation, with various parties involved who all have a responsibility toward the patient, the stakes are high, and disagreements can occur. However, with the clock ticking, all sides need to be able to identify where potential disagreements might be and know how to mitigate or deal with them as swiftly as possible.
 
AP Companies’ Business Development Manager Natalya Butakova puts the disagreements that are had during the process into two categories, ‘objective’ and ‘subjective’. She explained that objective disagreements occur when: the level of treatment in the home country is lower than in the country of temporary stay; when treating doctors don’t know much about medical transportation guidelines and when and how the patient can be transported; when medical facilities don’t want to release the patient due to financial reasons; when the insurance limit is not sufficient to cover both medical expenses and repatriation costs, but the condition of the patient requires immediate repatriation; and when an air ambulance provider doesn’t accept the patient on board.
HourglassSubjective disagreements can include instances when the patient does not agree with the medical decisions being made. The desire of patients or their families for a swift decision puts pressure on all other parties involved. Like many areas of the insurance sector, Page believes that patient education needs to be worked on to help improve the repatriation experience, and he advises travellers when buying or even not buying that ‘your limits are important’. “The further away from home you’re going,” he said, “the higher level of evacuation coverage you should have.”
 
Insureds can often want to stay put in a facility because it provides the best healthcare, but that may not be medically necessary or cost effective
 
Travellers also need to be more up to speed with what their travel and healthcare policies cover, another issue that improved education may be able to mitigate. Page emphasises: “Like anything else, customers need to read the exclusions in their policy, make sure they understand the conditions and how they apply, and if they have any questions, contact their travel insurer prior to purchase.”
Despite this, Page states that the most common disagreement that an insurer has to deal with is payment, and he agrees with Butakova that patients’ desires can often be a cause of stress for those wanting to treat them in the most efficient way: “When you’re at home and you have a medical situation and you go see a doctor, you might wish to also get a second opinion so that you can gather more information to make a better decision about your care. But for some reason, when people are travelling, they don’t want to hear other options. They don’t want to hear that there are other choices to be made. They often think there’s a single answer: they want what they want, which is usually to go home. But it’s not always that simple.”
However, there does seem to be a reasonably simple method to negate many of these issues.
 
It’s good to talk
It seems almost too obvious, but for every party spoken to for this feature, good communication is one of the key ways to mitigate disagreements and facilitate efficient decision-making with the best outcomes for all. “Communication between the hospital and assistance company is key to the success of the repatriation,” said Eve Jokel, International Director at Luz Saude, the holding company of Hospital da Luz, a network of private hospitals and clinics in Portugal. “The first priority is the clinical situation and decision to repatriate. Secondly, the assistance company must know in advance what conditions are required for the patient to experience a secure discharge and journey to his or her destination. Agreement should be reached between the clinical teams, in consideration of the wishes and consent of the patient and family.”
Nicole Bootsma, Medical Director at Eurocross Assistance in the Netherlands, also believes that being open and taking the time to explain decisions can avoid parties butting heads over issues: “Repatriation requires very specific knowledge, which the treating doctors do not always have; they may feel like they are being controlled. That is why it is important to have a good dialogue.”
 
Good communication is one of the key ways to mitigate disagreements and facilitate efficient decision-making
 
Doctors in hospitals may not have the intimate knowledge of the International Air Transport Association (IATA) fit-to-fly guidelines that are so important in medical repatriations, asserted Bootsma – so fully explaining why decisions need to be made, plus listening to the ground medical staff, helps both medical teams to push in the same direction. On the flip side, ‘good knowledge of the financial details is crucial, like the costs of the hospital abroad, costs of the transport, and so forth’, when it comes to understanding the motivations of an insurer.
 
Page points to a different factor that he believes is key to a successful medical repatriation: providing the insured with options. “If any of the three parties are not completely aligned on the path forward,” he explained, “the solution is found by providing options or choices.” Insureds may want to stay put in a facility because it provides the best healthcare, but that may not be medically necessary or cost effective for the insurer. On the other hand, a patient may want to be repatriated home immediately, but the care they’re receiving is more than adequate. “In such a case,” said Page, “the treating physicians should give them options and we, as an insurance or assistance company, should give them options. While none of the options presented may include what they consider their optimal choice, they at least have an opportunity to select the next best thing.” 
Bootsma added that keeping the patient in the loop also makes the decision-making process smoother: “It is very important to manage the expectations of the patient and the patient’s family about the repatriation process by informing them, listening to their wishes and discussing the different steps.”
 
Patients need to be given the impression that ‘they are being managed under a co-ordinated effort
 
At the same time, Jokel explained that patients need to be given the impression that ‘they are being managed under a co-ordinated effort’ and should be shielded away from any of the disagreements the other parties may be having. “The client should never be placed in a position where they need to tell the hospital what the plans are for collection or inform the assistance company about what information the hospital will deliver and when,” she said, explaining that she has seen a position develop several times where the client is in the middle of the co-ordination ‘as a result of assistance companies’ struggle to co-ordinate with hospitals, either due to language issues, experience with repatriation, inadequate response time or resistance, from the inpatient service or treating physician’. This situation creates a great deal more pressure and stress for the patient and their family, creating a negative experience that can ultimately affect the entire repatriation process.
 
Time is of the essence
So, keeping all these factors in mind, when is the best time to repatriate? It likely won’t surprise regular readers of ITIJ that the answer is, basically: it’s complicated. As Butakova puts bluntly, ‘there is no unique answer to this question’.
Instead, every case is evaluated on its own factors, and although experience and knowledge help to make decisions, each case is a unique balancing act. As well as constant discussions and evaluations from attending medical staff, insurers, air ambulance staff and assistance companies, Butakova also points out that there is a further legal angle to take into account. “There are certain rules, especially for air travel, established by the responsible authorities,” she said. “The most important reference in this field is the Medical Manual issued by IATA. There are also a certain number of local documents – Air travel and transportation of patients, written by the DoctorsDanish Aeronautical Medical Association, for example. These documents describe situations and give recommendations regarding timing and air transportation options.”
 
Bootsma also finds that technical hurdles can often change when and how a repatriation takes place, and these have to be taken into consideration – along with most patients’ desire to be home as soon as possible. “Except for the medical condition of the patient, when and how a repatriation will take place can depend on the possibilities of commercial flights (for example, stretcher possibilities), medical clearance of the airline and the policy condition of the insurance company (for example, whether an air ambulance is covered),” Bootsma explained. There is also the issue of working out where the patient is going to end up, and making sure that there is a hospital bed available for them when they arrive – often a challenge if the decision to repatriate has had to be made swiftly.
 
Technical hurdles can often change when and how a repatriation takes place, and these have to be taken into consideration
 
Page argues that medical repatriation should happen ‘when the patient is able to travel in the least obtrusive way’. For AIG, he told ITIJ, the ideal optimum time is when a patient is able to travel on their own in a safe way. However, patients are always put first, and if this is simply not possible – whether due to the patient’s condition or the lack of amenities at the attending hospital – AIG moves to acquire a medical escort. “We weigh what is best for the patient first,” he said. “After that, cost might become a factor, if there are multiple options that are all equal from the patient-safety standpoint.”
With no medical repatriation being the same, no matter how much preparation is feasible, there are always going to be curveballs, but that should not stop companies from striving to prepare as much as they can. As Bootsma asserts: “There is always a space for improvement, and the only way to improve is to take lessons and experience from each and every case, and understand what the best plan of action is and why.”