Building the right provider network in the right place

Healthcare and international medical assistance Japan

The travel and tourism sector in Japan will provide a significant boost to the nation’s economic recovery next year, with its gross domestic product (GDP) contribution set to reach near pre-pandemic levels. The forecast from WTTC’s Economic Impact Report shows the sector’s contribution to Japan’s GDP could reach nearly ¥40 trillion by the end of 2023, just 2.2 per cent below 2019 levels.

The data also reveals employment will surpass pre-pandemic levels, recovering more than 23,000 jobs, to reach more than 5.8 million by the end of the year. Over the next decade, travel and tourism’s GDP is expected to grow at an average of 2.6 per cent annually, more than three times the 0.7 per cent growth rate for the country’s overall economy, to reach more than ¥46.7 trillion (7.8 per cent of the total economy).

But as economies recover and borders reopen, are assistance providers prepared to cope with a sudden influx of international tourists? Have medical systems evolved since they were last working with international clients, and how has Covid affected healthcare provision? Assistance providers building medical networks and evaluating potential medical partners need to think of these questions, and more, when considering their next steps.

The travel and tourism sector in Japan will provide a significant boost to the nation’s economic recovery next year

Aetna International states on its website that expats in Japan will usually be able to locate clean, effective medical facilities, efficiently managed by the government. Japan spends around 8.2 per cent of its GDP on healthcare (roughly the same as Canada and the Netherlands) and has a good ratio of doctors to population (nearly three per 1,000 people – similar to the UK). Healthcare is funded via insurance payments – either through an employer or by the individual.

Legally, resident expats are required to enrol on either one of these schemes, whether they choose to top this up with private medical insurance or not. Aetna explains on its website: “The employer-based scheme only covers some of the cost of treatment (in the region of 70 per cent to 80 per cent, depending on what the treatment is for and who is being treated), and covers the worker and their dependent family. Until this cover is arranged, private health insurance can be reassuring. In large cities with established expat communities it is possible, with a little effort, to find English-speaking doctors, dentists and pharmacists: in other areas, it may be necessary to take someone with you to act as a translator if you aren’t fluent in Japanese.”

Takatsugu Iwai from Emergency Assistance Japan spoke to ITIJ about the unique challenges that expats, tourists and international insurance companies may encounter when seeking healthcare in Japan. Firstly, he noted the issue of guaranteeing payment to medical institutions: “There is no culture of cashless medical service in Japan, and patients have to pay the cost of treatment. Therefore, the introduction of cashless medical services in Japan is a difficult sell compared to other countries. We are working hard to cultivate a deeper understanding of cashless medical services by partnering with medical institutions that deal with a large number of foreign nationals and then provide guidance and education.” The fact that Japan has a universal health insurance system makes the introduction of cashless medical services even more difficult.

Touching on Aetna’s point of the challenge when trying to find an English-speaking doctor, Iwai agreed: “Many medical institutions have difficulty in providing foreign language services.” However, this is being mitigated through the introduction of translation machines, and consultation services for foreign patients, which include the dispatch and introduction of interpreters. EAJ also offers a call centre that insurers and hospitals can use, to assist in providing consultation services to international patients.

Finally, he explained that the payment of medical expenses by foreigners is a concern for the government, hence the lack of interest in a cashless service.

Paul Hogan, International SOS General Manager, Assistance EMEA and Group General Manager, Air Rescue, noted: “In Japan, the field of medical assistance is not a familiar concept to many medical institutions and they therefore tend to have limited understanding of it. Large public hospitals in the major cities offer a wide scope of services and specialties. However, high bed occupancy rates, long waiting times, complex administration, lack of privacy, and low levels of English being spoken across Japan can cause issues for foreigners, as well as the corresponding challenges brought about by cultural differences.”

China travel and tourism jobs boost over the next decade

The WTTC has revealed the travel and tourism sector in China is expected to create more than 30 million jobs over the next decade, representing a quarter of all new jobs globally. The forecast from WTTC’s latest Economic Impact Report shows the sector will reach more than 107 million employed by 2032. According to the global tourism body’s latest data, travel and tourism’s GDP is expected to grow at an average of 9.7 per cent over the next 10 years, more than twice the 4.4 per cent growth rate of the national overall economy, making it one of the fastest-growing countries. This growth will boost the sector to reach more than ¥25.2 trillion (13.7 per cent of the total economy) by 2032. The report shows the travel and tourism sector’s contribution to China’s economy could also surpass pre-pandemic levels next year, when it is projected to rise almost 10 per cent above 2019 levels.

With the largest economy on the planet, China attracts workers from all over the world: many of these find the right standard of care in the major hospitals of Beijing and Shanghai, but according to Aetna International, ‘it’s useful to take a companion who can translate for you if you don’t speak a local language such as Cantonese, Hanyu or Putonghua’.

In major population centres, the availability of hospitals with international patient units is fairly good – in Beijing, for instance, many will have a specialist foreign clinic that accept patients with foreign passports or ID certificates from Hong Kong and Macau. Given current political tensions, visitors from Taiwan are unlikely. Some of the more well-known institutions include Peking Union Medical College Hospital, Beijing Friendship Hospital, International SOS Clinic, and Beijing United Family Hospital and Clinics.

The US Embassy in China also states that Western-style medical facilities are readily available in Shanghai, Guangzhou, and ‘a few other large cities’. Tourists and expats have been warned though, that emergency services may not meet Western expectations: “Ambulances do not carry sophisticated medical equipment, and personnel generally have little or no medical training. Therefore, injured or seriously ill Americans may be required to take taxis or other immediately available vehicles to the nearest major hospital, rather than waiting for ambulances to arrive. In rural areas, only rudimentary medical facilities are generally available. Medical personnel in rural areas are often poorly trained, have little medical equipment or availability to medications. Rural clinics are often reluctant to accept responsibility for treating foreigners, even in emergency situations.”

Paul Hogan of International SOS commented: “In China, the main challenge is the wide variation in the standard of medical care across the country, especially when considered against international standards. Quality medical care, emergency services, prescription medicines, and dental care are widely available in major cities such as Beijing, Shanghai, Guangzhou, and other first-tier cities. However, elsewhere, the availability of international standards of care may be limited, especially in remote and under-developing regions. Seeing the patient as a client is still not very widespread in China. Therefore there can be a reluctance for medical providers to join a network, mainly in second and third tier cities where the understanding of the provider of what we intend to achieve when building a network may be an issue.”

Accepting flexible payment terms and cooperation with international insurers can also be a challenge outside larger first tier cities. By 2025, there will be further improvements to China’s public health system according to the country’s 14th Five-Year Plan period (2021-2025). “Therefore, medical network capability is growing rapidly in some areas and for a country as vast as China, it is challenging to keep the information up to date,” said Hogan. “Some public hospitals find it hard to get the information they need, that can include epidemiological data, quality management and governance information to inform their understanding of the standard of care.”

The availability of international standards of care may be limited especially in remote and under-developing regions

In China, doctor-patient communication can sometimes be a challenge. As a highly digitalised region, online tools are widely used in a variety of scenarios, which has become a new challenge for foreigners to register applications, book appointments and complete the payment all online.

There may also be challenges for international visitors who need medication, said Hogan: “Foreign manufactured medications and vaccinations are not widely available. High-quality ‘joint venture products’ – medications produced in developed countries and packaged in China – may be available and there can be a blend of cosmopolitan medicine with traditional Chinese medicine.”

“Overall,” concluded Hogan, “the care is very hospital based and there can be variations in healthcare even within the same facility. Multi-disciplinary approaches are not as developed outside the larger tertiary care facilities and payment is expected at the time of service. Patients may be expected to pay a deposit at the time of admission and international credit card is not accepted at all places.  Currently, there is a severe shortage of mental health specialists in China.”

In a further indication of an increasing focus on healthcare quality in China, accreditation organisation Joint Commission International (JCI) has a dedicated subsidiary – JCI Accreditation (Beijing) provides certification of healthcare and social welfare services on the Chinese mainland.

Meanwhile, earlier this year, German healthcare accreditation organisation Temos International expanded access to its International Society for Quality in Health Care External Evaluation Association (ISQuaEEA) accredited standards to the Asian markets. In a collaboration with healthcare executive Henning Kalwa, it plans to grow its services in Southeast Asia and China, out of a new regional office in Bangkok, Thailand. Temos CEO Dr Claudia Mika pointed out that ‘treatment providers in Asia are seeking unique selling points to stand out in a competitive market’, and international accreditation is one way of doing so.

David Broderick, Head of Global Medical Provider Management, Allianz Partners, told ITIJ that like anywhere in the world, the local market norms very often differ, and this can be more evident in certain markets such as China. Particular challenges, he noted, relate to geographical reach: “Beyond the Tier 1 cities, the challenge of frequency of utilisation of providers versus the staff turnover at local medical facilities can lead to some servicing issues," he explained. Other issues that cause difficulties for international assistance providers are, as Iwai noted above, language barriers.

Understanding the culture of difference nationalities

While most assistance providers, especially those with local offices, will have staff that speak many languages, the issue of understanding the nuances of a culture is of particular importance for our industry. You may be dealing with a customer of one nationality who is being treated in a country where they can’t relate to the culture of the people, nor their healthcare system under which they are being treated.

“Understanding the local practices and operating procedures – including medical treatment norms – is a significant challenge,” said Broderick. Some of the elements that make the Japanese and Chinese markets different to others include the method by which you access care, the ability to access public hospitals, medical treatments and the associated cost models. Familiarity with these is essential in order to render assistance effectively.

When it comes to considerations for data privacy, data localisation and regulations always play a part – and this can add challenges for international/global players.

In China and Japan, said Hogan, some national/public hospitals and university hospitals are still hesitant towards change and are conservative to the approaches made from medical assistance company. “A big challenge is managing patient expectations in locations where the local facilities do not meet the required standard in medical care. However, with no other facilities in the location you have to make the best of what is available. This is why an upgrade in care is often required with an associated need for transportation (ground or air) to a new location,” Hogan said.

“In both China and Japan, building relationships with network providers and leveraging our own standards to provide quantifiable and measurable supplier selection criteria locally is critical,” he said. “Maintaining regular interaction with key providers is fundamental to ensure a strong relationship remains when there are difficult discussions to make. In China particularly, face-to-face communication is essential. It also helps to maintain a flexible system to adapt quickly to particular situations and find the right solution.”

When it comes to considerations for data privacy, data localisation and regulations always play a part

In Japan, he added, investing time in face to face meetings with full and detailed explanations of the scope of service in the context of the Japanese healthcare system is essential to establishing and most importantly maintaining a strong network.

Assistance companies learning about the insurance market

“Each market brings its own unique set of challenges,” Broderick said. “All of which can be overcome, but they can add complexity to day-to-day operations in support of our members.”

Overcoming the challenges noted by the experts who contributed to this article takes many skills, but some core pieces of advice could help an assistance company struggling to find their feet in a new market:

• Have a strong understanding of local conditions and operating practices. “This significantly helps in overcoming challenges as they arise,” Broderick said
• Know when and why certain procedures are ordered, and how to navigate the public/private healthcare system
• Be transparent with providers in terms of what is/is not covered
• Have a local legal and operational presence that has a local payment capability and language support.

“These are critical to (a) that understanding and (b) the ability to swiftly find a resolution to any challenges that may arise. The sense of proximity to the provider helps build a joint understanding and collaborative partnership,” concluded Broderick.