With 60 per cent of the planet’s population, many of its most treasured tourist attractions, more than a mere few of its rapidly expanding economies, plus a rich mix of cultures and customs, the APAC region offers the travel and health insurance industry eye-watering prospects for growth. Last year’s Allied Market Research report on the region posited a compound annual growth rate for the travel insurance sector of 10.1 per cent, reaching an overall value of US$9.87 billion by 2022. Its worth in 2016 was estimated at $5.54 billion.
Making the most of it, however, is not plain sailing for insurers and their healthcare and assistance partners. Lynne Fung, Executive Director, Business Development, at Hong Kong’s Matilda International Hospital – which opened its doors in 1907 – outlines just one of the APAC challenges: “In the past decade, medical costs have been on the rise, particularly in Asia. In 2018, medical cost inflation was estimated to be at eight to nine per cent in Hong Kong, and at 10 per cent for countries such as Singapore, Malaysia and Mainland China.”
Healthcare providers such as hospitals face the challenge of providing quality care and an even better patient experience while managing costs in order to stay competitive in the market and meet the needs of insurers. “Mis-matched supply and demand – an overstretched public system and an under-utilised private hospital sector facing a flood of beds from new facilities – reduces the levels of efficiency that can be achieved in private care and exacerbates the shortage of healthcare workers,” explained Fung. “Initiatives for public-private interfacing have not been that well taken up and, until the money follows patients, there is little chance for sharing the patient load.”
Healthcare providers in Hong Kong, she says, face the same challenge on workforce management as do institutions globally: “There is a worldwide shortage of healthcare professionals, not enough are being trained, some emigrate once trained to look for career opportunities elsewhere, and there are barriers to recruiting from overseas.”
In our part of the world, having somebody on the ground is very, very important
Lay of the land
Eruptions along the region’s political fault lines – Hong Kong and the Korean peninsula, for example – can, and do, shake readings on the travel trends and business graphs. Hong Kong is an attractive choice for Mainland Chinese travellers with the means to buy private care for chronic conditions and check-ups, says Fung, who notes that non-communicable diseases are a significant public health burden in China, which has the additional pressure of an ageing population. But, she fears, ‘the present negative sentiment towards China in Hong Kong, if it continues, will create a reluctance for Mainland people to seek care here’.
Important geo-political factors are highlighted by Tan Chien-Wei, Director of Ulink Assist, which has offices in Singapore, Myanmar, Indonesia and Malaysia. “For example, the number of Chinese tourists going to South Korea for cosmetic surgery has fallen by 40 per cent in the past two years, after a large increase in that traffic, because of worries about political stability in the area and medical care costs.” Some of the clinics have closed because they don’t have Chinese patients any more, he told ITIJ.
“In August, many of our clients were stranded in Hong Kong and unable to return to Singapore because of cancelled flights,” continued Chien-Wei. “We had calls every day from clients with enquiries about their travel policy cover for reimbursements for cancelled flights and consequent accommodation costs.”
Chien-Wei told ITIJ that 95 per cent of the approximately 1,600 cases Ulink Assist handles each year are ‘very, very standard’. The remaining five per cent are ‘exceptional’. “You don’t create an SOP – standard operating procedure – for them, for the exceptional,” he said. “There are times when medical and insurance requirements are very much at odds. This is often not understood. A patient should be evacuated to, say, Singapore. But if the insurer is paying for the evacuation, it could become a very different set of considerations. The insurer might say, ‘why Singapore? Why can’t they be evacuated to Jakarta, which has a sufficient level of care? The policy doesn’t say we’ll bring you back to Singapore’. From a medical point of view, sure, it should be Singapore, but from the policy aspect, it’s different. Feel free to come back to Singapore; it’s just that the insurance company isn’t going to pay for it!”
But are insurers willing to be flexible when a case for an alternative is made? Says Chien-Wei: “If you put a case well, they do listen. You can say, firstly, an evacuation to Singapore is not going to cost a lot more. Secondly, insurers might save costs in the continuation of care; you can get good acute care somewhere else, but aftercare isn’t very good, and the risk of infection might be higher. It’s our job to present the facts in a way that they can say ‘yes’ to us.”
Finding good in-country partners can at times be a challenge for assistance companies, though, he says. “There are good partners, and there are obviously bad ones; or not-so-good partners. In our part of the world, having somebody on the ground is very, very important. You are bringing someone to Singapore from Bangladesh who might not have a visa or a passport, or their family members might not have those papers, so you need somebody to go to the airport to talk to immigration officers so that a conditional visa can be granted. You need people who can do that. Certain airports in Indonesia aren’t open when you think they should be, so knowing someone good on the ground is key, because in a country such as Indonesia, you can get somebody, when asked, to open the airport for you. That’s how it works there.”
Some of our most valued relationships with insurers have developed through a common desire to ensure the best clinical outcomes for patients
At Matilda hospital in Hong Kong, Fung says that good communication between healthcare providers and insurers helps to ensure the best outcomes for patients. “Some of our most valued relationships with insurers have developed through a common desire to ensure the best clinical outcomes for patients. This has enabled us to shift conversations from the purely transactional to the transformational, allowing us to understand the insurers’ direction and to work together. Exciting initiatives such as the services offered by our Patient Service Centre and Referral Teams have been the result. Driven by a need to better serve the patient and improve communication, we can now effectively guide patients through their healthcare journey and ensure they have swift access to the insurers’ preferred medical providers.”
Responsiveness is essential for the best outcomes, highlights Fung. When a patient presents at a medical facility in pain or needs urgent care, speed is of the essence. “Treatment plans and estimated prices need to be communicated quickly to get letters of guarantee; fast and effective joint communication with the patient provides solid assistance and removes uncertainty,” she said. “Preferred rates need to be pre-agreed.”
It’s also important to measure outcomes, says Fung. “Extensive external clinical audits, management reviews, insurer audits and a robust clinical risk management system form part of our DNA. The results speak volumes about a healthcare facility and we share key clinical indicators such as average length of stay, incident reporting, patient satisfaction, hospital-acquired infection rates, and so forth, with our business partners as well as publishing benchmarked maternity statistics on our website.”
The hospital has clear positions on price transparency and requests for discounts: the former is essential; the latter are unhelpful – a sentiment shared by many medical providers. “The same professional level of personalised care and attention is given to all our patients,” says Fung. “Patient anxiety stems from uncertainty of coverage, which is why insurers and medical providers work in tandem when people are in need of assistance, never more so than when travelling. Experience shows us that there is a poor understanding of insurance plans by patients … something we hope to see improve. Discussion on discounts is held offline from patients. It does not impact them negatively unless the insurer withholds guarantee of payment for the treatment during this time. This is why we put so much effort into ensuring price transparency, and that prices are pre-negotiated. We will terminate relationships with partners who put the outcomes of patients at risk.”
Cost containment, she says, is not all about discounts. “Value revolves around providing best practices in care that optimise patient outcomes with effective spend that minimises wastage. There is more to take into consideration than purely price and discounts. Focusing on core centres of excellence and examining efficiency and effectiveness creates value.”
She recounts for ITIJ the story of a case made more complicated and stressful than it might otherwise have been due to discount requests: “Following an accident, a European living in mainland China requested transfer to our hospital after having received treatment in East Asia and Southern China. Orthopaedics is one of our centres of excellence, so we accepted the case. The fracture fixation point had become heavily infected and required isolation, strong antibiotic treatment and six surgeries, including a skin graft. The main insurer was in the US, and as we had no previous connection, an assistance company was appointed to act for them. Hospital estimates were provided at each step of the treatment, but slow communication and invalid letters of guarantee created immense stress for the patient as he was understandably worried about his condition, and if treatment would be covered.
“A week-long delay in approval for the final stages of treatment created great tension for the patient, specialists and operating teams, with only a small window of opportunity to perform the skin graft under optimum conditions. It took a lot of communication with the insurers, as well as the assistance company, over several time zones to clarify fees and resolve payment problems, including one payment to the wrong account. There was a definite lack of understanding of Hong Kong practice and an expectation that it was acceptable and reasonable to ask for a 35-per-cent discount at the end of care, despite repeated explanations that there would be no reduction in fees.
“Focused on providing the highest level of professional care, we worked closely with a team of eight specialists throughout the 57-day stay. It is a testament to the expertise of our clinical teams that the outcomes were successful, though the enormous amount of work across multiple support teams placed a heavy burden on resources.”
The ageing population
While Asian economies – despite ups and downs in China – are seen as engines of global economic growth, the populations in the APAC are ageing more rapidly than ever before. A Grant Thornton International Business survey published earlier this year reported that business leaders in the region saw ageing as the most significant threat to their companies over the next five years. It will, they fear, reduce the supply of labour, increase wages and reduce competitiveness. Health and medical technology businesses, however, were identifying opportunities in this disruption, which is most marked in Japan and China.
So, how will this changing age balance affect travel and health insurers? “While it has improved markedly in the past 15 years, China is certainly one of the more challenging countries on this front, because it is more environmentally and culturally diverse from Western cultures,” says James Page, Chief Administration Officer and Head of Assistance and Claims at AIG Travel in the US. “What’s more, pollution levels in China’s larger cities – which are the more likely destination for business travel – present a remarkable challenge to the health of travelling employees. So we would look at these elements as presenting a higher risk factor for ageing, travelling workforces than might be experienced in other APAC countries.”
An ageing traveller, he says, presents factors that do not come with younger populations. “Our main challenge today is that we deal with a lot of business travel programmes that are sending people from an ageing workforce on trips, and because the employers want to avoid any appearance of age discrimination, they are not able to have frank conversations with employees about their actual ability to travel and what limitations they might have. The idea of an employer asking their travelling employees, ‘We noted you’re getting a little older; do you have high blood pressure? Do you have any form of diabetes or any other chronic issues?’ is, of course, unthinkable.
“However, there are ways to convey these concerns. Many companies frequently conduct duty-of-care training sessions for travelling employees, where they can say: ‘Hey, if you have medical/chronic issues, you need to think about how your travel might impact those.’ You have to find a way to present, to your ageing employee base, ways in which they can educate themselves and make good decisions about when and if they should travel … without asking them to disclose any medical or private information.”
Jet lag, eating food that’s new to you in foreign countries, not getting adequate sleep because you don’t sleep well when you travel, are issues that might pose problems for any business traveller, but particularly those who are ageing, says Page. “The biggest challenge for employers is determining how to help an employee make the right decisions when they might be fearful for their job; if there might be a perception that their inability to travel makes them a less valuable member of the team.”
These increased risks, he says, drive premiums and exposure for insurers, and premium increases will ultimately be passed on to customers. “If an insurer sees a company that tends to send people with serious medical issues to remote locations, that company is likely to see rate increases. To evaluate the risk, insurers have to factor in the demographic of a given company’s travelling group: are you sending 20-something-year-old consultants, straight out of college? Or is your business a highly specialised one that requires a great deal of knowledge, which would indicate that you are sending an older, more experienced age group.” If an insurer sees a loss exposure that’s greater than expected, says Page, then those costs have to be passed on, particularly if it is emerging as a general trend.
“We do see a higher incidence of these issues in the APAC region,” he explained, “because the ageing population that travels to it has greater challenges with culinary changes and mental health issues than those who travel to Europe. And for travellers coming from the US and Europe, the flight times to Asia are much longer. Because the flight times and time-zone differences are greater, we do tend to see a higher prevalence of impacted travelling employees in Asia than, perhaps, in Europe or South America.”
The doctor will talk to you now
Ulink Assist’s Tan Chien-Wei says managing client expectations is important. “They sometimes don’t understand why a hospital in Laos or Myanmar hasn’t provided a detailed medical report. That’s not how it works! Sometimes I have to send my doctor to a government hospital, where she will wait for hours outside the treating doctor’s room until he gives her the time for her to write down what he tells her. He dictates it; he’s never going to write it down.”
At EMA Global, Group CEO and Medical Director Dr Winston Jong notes that the APAC region, which saw 700 million international arrivals in 2018, has also seen a ‘noticeable’ improvement in standards of care for travellers in top tourist destinations, especially in South-East Asia, thanks to significant investment in the healthcare sector. “Activation of medical assistance has become more and more common in the region, thanks to a rapid increase in the take-up rate of travel insurance.”
But – there is a ‘but’ and it’s an important one. “Communication with treating doctors is more often than not challenging,” stated Dr Jong. “There is the patient confidentiality issue, which treating doctors have to fulfill before they will talk to anyone. Some institutions require paperwork before they will reveal medical information. It could be a form of family or insurer authorisation. Getting that paper across can be time consuming. It would a four-way communication: the patient or next-of-kin, the insurer, the assistance company and, finally, the treating doctor."
Other doctors are happy to discuss medical conditions when they know they are talking to the paymaster, but they are often too busy or impatient when talking to assistance providers, explains Dr Jong: “It is always difficult to catch them at a good time. Very often, the request to speak to him is denied as they seldom see the need to communicate with the assistance company, especially when the patient is lucid or there is a next-of-kin around. When we can get him on the phone, there could be interruptions as he might be multi-tasking with another patient. Thus, our precious two minutes on the phone with him becomes fragmented. In that two minutes, we have to control the conversation so that we can get the most out of it.”
Dr Jong’s advice is to write down all the questions you want answered before you make the call. “Avoid letting the conversation drift off to matters of no significant medical value in treatment or repatriation plans,” he advised. “Other than the presenting symptoms and diagnosis, one would want to know the treatment plan, the imaging and biochemistry results, and the anticipated length of stay. With this information, we can take the next step in planning discharge and/or repatriation.”
It is also crucial, when speaking to the treating doctor, to have sufficient medical knowledge about the patient’s illness. “This is important so that we can ask relevant questions about the treatment plan, enabling us to anticipate the length of the hospitalisation,” said Dr Jong. Such a conversation carries more value. “When we ask relevant questions, the treating doctor is more tolerant and getting information from him is a little easier,” he said. “With enough medical knowledge, the discussion on invasive procedures such as plasmaparesis and ventilatory support becomes more relevant. This gives us leverage in planning a discharge. Doctors looking after an insured or foreign patient tend to keep them longer than necessary, something we can help to minimise.”
Despite the apparent global ubiquity of the English language, language can be an obstacle in communication. “Staff in many Chinese hospitals, for example, speak in their own dialects or in regional accents, making comprehension difficult,” explained Dr Jong. “Medical terms might be different, too. Google translate might be useful.”
AIG’s Page shares some of Dr Jong’s frustrations with treating doctors averse to communication. “The only challenge we encounter, on occasion, is actually getting a doctor on the phone. If you’ve got a patient with broken leg or some other minor medical problem, and the treating doctor is going to release that person to get in a car and travel a few miles to get home, that’s a scenario with one treatment and one outcome. It’s a different situation when we have that same type of minor medical issue, but we’re then putting that individual on a 12-hour flight. Sometimes it’s hard to communicate with treating physicians in APAC markets because their mindset is: ‘This person is fine to go home, and I’ve released them – what is there to talk about?’
“Our challenge is to get the treating doctor to understand that we are now going to put this patient on an airplane, pressurised at 8,000 feet, and they’re going to be on that plane in a seated position for 12 hours, and then perhaps an onward flight on a smaller plane. We want to have conversations about factors that might be exacerbated by getting on an airplane. But these doctors often don’t want to bother getting on the phone to discuss this, because they don’t understand why we want to talk about something they would consider a routine medical matter.
“If you have a cast on someone’s leg and you put them on a plane, that patient’s leg is going to swell at elevation, and they have an increased likelihood of getting deep vein thrombosis, with the possibility of blood clots. So we have to explain to the doctor that they have to cut the cast all the way open, allowing the patient to loosen the cast while on the plane and then, when they arrive at their destination, we can arrange for them to get a new cast. Aeromedical considerations are very important, but are not often appreciated by treating doctors. It can sometimes be challenging to get the level of engagement we need.”
AIG Travel has centres in different cultural areas, such as Okinawa, Guangzhou and Kuala Lumpur, staffed by medical professionals and assistance co-ordinators in those markets who understand the languages and cultures.
“These professionals,” Page says, “are able to open doors in hospitals to get us in contact with the treating doctors, and we can also put physicians who understand the language and culture on the phone with those doctors so that the typical cultural and language barriers are lifted. Many doctors that we deal with – around the world – are Western-trained, so many of them speak some level of English. But when dealing with unique medical issues, you cannot overvalue the ability to communicate in your native language with another medical professional who lives in your time-zone and culture and understands what’s going on. So our key to maintaining those contacts is making clear the level of respect we have for professionals in those markets through the investments we’ve made in our own professionals who have the same language and the right skill sets and capabilities in order to communicate with treating doctors on their terms,” said Page.
What was that about hidden costs?
“When a patient has been admitted into a hospital, one would expect to pay the room charges, laboratory tests, imaging costs and the professional cost of the treating doctors,” says EMA Global’s Dr Jong. “Simple mathematical computations of these published charges are often far less than what the paymaster needs to fork out. Scrutiny of the detailed bill often gives surprises, such as double-billing or billing of a procedure or an imaging that was not done.
“In the simplest case of day surgery admission, when a patient was admitted for upper and lower endoscopy, the following – with the figures taken from those published by a private hospital in Singapore – illustrates the hidden cost. The endoscopy would typically take 30-45 minutes to perform and the patient would be admitted for four to six hours. The typical endoscopy room charge for six hours is $100. The procedural room where the endoscopy is carried costs $130 for 30 minutes. Other costs include those for IV sedatives – IV cannula is estimated to be $100 – amounting to approximately $330, not inclusive of endoscopist and anaesthetist professional fees.
“There are hidden costs in the use of the endoscopy room: oxygen – $10; one photo of the gut – $20; PVC tubing for suction – $15; re-usable pulse oximeter probe – $10; suction container – $8.00; nasal O2 catheter – $5; endoscopy room set-up fee – $16.00; daily treatment charge – $68, although it’s difficult to understand why there is a daily treatment charge when the patient was admitted as day surgery for an endoscopy; nozzle for oral LA spray, which is obviously a re-usuable item – $8; latex surgical gloves – $26; and a hygiene sheet – $30. The unexpected charges amount to $201, 66 per cent more than what one would expect given a hospital’s published rates.”
Hidden costs are greater when a patient is on a general ward or in an ICU, says Dr Jong. “A typical ICU bed costs $580. One would expect this to include basic nursing care and at least oxygen. However, other than the bed, everything is extra: oxygen, nursing care, monitoring charges, ventilator use, syringe driver/infusion pump, and isolation precaution. Laboratory tests are easily 40 per cent more for inpatients compared to that for outpatients. The same applies to imaging; costs after office hours can come with a 100-per-cent surcharge. If a CT scan or an MRI is needed after office hours, the call back fee is easily double a hospital’s published rates. If you are unlucky enough to stay in an ICU for ten days, the total bill including that of the doctors would easily be $90,000, and that’s based on the assumption that you do not have surgery during that period. Many insurers are taken aback by such astronomical bills.”
Treating and repatriating international patients in the APAC region certainly presents its own unique challenges, but the ability to call on local experts can assist insurers in overcoming these obstacles. ■