Destination Spotlight: A review of Portugal and Madeira's healthcare system

The Iberian dream

Mandy Langfield asks what resources are available for international visitors seeking healthcare

The Iberian Peninsula, with miles of unspoiled coastline mixed with popular holiday destinations, is a fantastic option for European holidaymakers. The Atlantic coast of Portugal offers plenty of surfing opportunities, while the southern Algarve coastline is peppered with family-friendly resorts filled with international tourists throughout the year, thanks to its temperate climate. The Portuguese island of Madeira, which is actually closer to northwest Africa than it is to Europe, is also very popular with retirees and other tourists. Inevitably, some of these holidaymakers will find themselves in a hospital emergency room during their vacation, so how is the healthcare system prepared to cater to this significant population?

Tourists and travel assistance

Portugal’s National Statistics Institute reported in 2017 that the number of foreign tourists visiting the country rose to a record high of 12.7 million – an increase of nearly 12 per cent year-on-year. Data showed that hotel revenues increased by almost 17 per cent over the same period, reaching €3.4 billion. In 2018, tourism revenues increased by 9.6 per cent to €16.6 billion, with over 12.8 million visitors welcomed into the country.

Most tourists are British (1.8 million in 2018), followed by Spanish (1.7 million), French and German (1.3 million each), while the number of American, Polish and Brazilian visitors is increasing significantly, putting pressure on the healthcare system to step up to the challenge in terms of increased emergency patients, and working effectively with insurers from all over the world.

The southern coast, known as the Algarve, saw most of the visitors, followed by the capital city of Lisbon. Marilia Cabriata of Grupo HPA Saude spoke to ITIJ about the healthcare on offer in the Algarve for visitors. She said: “In 2018, the Algarve welcomed approximately three million foreign tourists, mostly from the European continent and, more recently, from North and South America and Asia. As far as medical care is concerned, to cater in particular for the Algarve’s foreign population, both resident and non-resident, the HPA Health Group has three hospital units in the region, open 24 hours a day, seven days a week.” Most tourists, she added, do carry travel insurance. Expats tend to be enrolled with an international health insurance plan, while others choose a local provider that offers insurance to expatriates.

travel suitcases

Healthcare system

The healthcare system in Portugal consists of three entities: a National Health Service (Serviço Nacional de Saúde or SNS), a social health insurance scheme for certain occupations, and voluntary private health insurance.

The state health system is universal, and eligibility is residence-based. Everyone, regardless of nationality, economic status or legal status, is entitled to free emergency healthcare in the SNS at a state health centre or hospital. Non-residents and temporary visitors to Portugal will need to purchase private health insurance to cover their stay in Portugal, which enables them to access doctors, emergency treatment and other Portuguese health services. Those on short visits from the European Union (EU), European Economic Area (EEA) and Switzerland can access public healthcare in Portugal through their European Health Insurance Card (EHIC). Nationals from non-EU countries that have reciprocal healthcare agreements with Portugal may also be able to access public healthcare in Portugal for free or at a reduced cost. The countries with agreements currently in place are Andorra, Brazil, Cape Verde and Morocco.

The Euro Health Consumer Index 2018 is based on, among other items, waiting times and results. It ranked Portugal 13 th out of 35, just behind France and Germany, and the country was particularly commended for its price/quality ranking. Portugal currently spends around 8.9 per cent of its GDP on healthcare, just slightly below OECD averages. Around 70 per cent is public expenditure and 30 per cent private expenditure, with the EU reporting less than five per cent coming from social security contributions.

Joint Commission International lists 15 hospitals that are accredited in Portugal, with a fairly even geographical spread from Faro in the south to Porto in the north, as well as in Lisbon and the popular area of Cascais.

Joint Commission International lists 15 hospitals that are accredited in Portugal, with a fairly even geographical spread from Faro in the south to Porto in the north, as well as in Lisbon and the popular area of Cascais.

In terms of private hospitals in Portugal, there are several groups that run multiple sites. These include Grupo HPA Saúde (14 hospitals/clinics on the mainland and one on Madeira), Grupo Luz Saúde (30 hospitals/clinics on the mainland and two on Madeira), Grupo SANFIL Medicina, Jose de Mello Saúde, Trofa Saúde and Lusiadas Saúde SGPS.

As with some other state healthcare systems, Portugal’s is under financial and logistical pressure to cater to a growing number of patients with complex needs who are living longer and requiring more care. This is inevitably having a knock-on effect on waiting times for some patients. Mónica Morais, Local Medical Provider Manager, Allianz Partners Portugal, confirmed to ITIJ that this is a concern for international insurance providers: “The main problem with public hospitals continues to be the long waiting lists for medical appointments and surgeries, the excessive waiting time to be assisted, and the lack of doctors.”

health insurance paperwork

Eve Jokel, International Patient Services Director for Luz Saúde, a private hospital group, echoed these sentiments, telling ITIJ that while access to emergency and primary care (depending on the location) for beneficiaries of the public health system is generally good, ‘the public system suffers delays for specialty care and surgeries that most people find difficult to accept’. Fast access to care is one of the primary reasons why a tourist will seek care from a private facility; the next is ease of communication. “International clients may have concerns the experience in the public system could become too stressful for them if they do not speak the language of the country,” explained Jokel. “The private options are much more focused on customer care and making an effort to address language/cultural differences for the impact on the quality of care provided, the adherence to treatment recommendations/instructions, as well as patient satisfaction factor.” Private hospitals add another level of security that the public system does not focus on: the client journey. 

While private hospitals may be ready and waiting to cater to international visitors with insurance, there are many tourists who don’t travel insured, and others who would rather rely on reciprocal health agreements such as the EHIC, which is available to all European travellers. To make use of this facility, visitors have to attend a public hospital. In some cases, tourists will attend a public hospital because it is the closest facility, or the most appropriate for their care. In these cases, there can be some challenges for assistance providers and their insurance partners, as Morais from Allianz explained: “In our activity, the main problems dealing with public hospitals are related to the fact that the majority of public hospitals don’t accept GOPs (Guarantee of Payment) for urgent appointments, so that means that the invoice must be submitted in the name of the client and not the insurance/assistance company. Other issues are related to the excessive time they take to send us medical reports and invoices.”

doctor patient explanation benefits

Hospitals and insurers

Staff working in hospitals in regions popular with tourists and expats often have specific international departments that are set up to cater to this group, with multi-lingual staff and a billing department that is experienced in working with insurers and assistance companies.

Cabriata of Grupo HPA Saúde confirmed this is the case: “We work with most national and international health companies and assistance companies on a direct billing basis. We have been dealing with this issue for more than two decades since we were the first private hospital in the region and the first in the country. This extensive experience has facilitated our relationship with the foreign community as a whole, resulting in the streamlining of all procedures. With these associates, we have maintained a relationship of mutual co-operation over the years, providing all the necessary information on the patient when necessary, in order to obtain a GOP.”

Allianz Partners works with most of the major hospital groups in Portugal

Allianz Partners works with most of the major hospital groups in Portugal, including José de Mello Saúde, Luz Saúde, Lusíadas Saúde and Trofa Saúde. Morais commented on the agreements that Allianz has in place with such groups: “Our relationship with private hospitals has improved over the years, as a result of local and global agreements that, in this last case, guarantees all Allianz Partners group companies direct access to these facilities and to agreed price lists.”

Luz Saúde has agreements in place with 30 international insurers and assistance companies, and says it works with a further 40 on a case-by-case basis. Reducing the administrative burden, said Jokel, is key to efficient collaboration: “We develop agreements that offer similar terms and service based on the standard GOP process for the international patient group in order to promote consistency across many payers, so it’s easier for the hospitals to manage. But we also consider and encourage processes that have potential to reduce the administrative burden and delays that are often part of the GOP process, such as the use of provider portals, blanket GOPs, and conditions listed on the beneficiaries’ membership card, once these methods have been reviewed and have been considered effective and reliable for the hospitals.”

Furthermore, International Patient Services in Luz Saúde has a presence in the corporate office as well as the hospitals, in order to support services across the group with regards to international payers, acceptance of GOPs when there are doubts, and management of operational guidelines for each agreement, while also serving the payers in case of a delay in the delivery of information they need, or in securing a special request from its hospitals, as well as reviewing any questions they have regarding the invoices they receive.

Inevitably, the process of co-ordinating international patient care doesn’t always run smoothly, and there are several reasons why delays or problems occur. Jokel told ITIJ: “Challenges arise when the payer is attempting to use a facility that does not see international clients on a regular basis, when the GOP does not arrive in good time, when the information contained in it is not clear or sufficient, or when they seek excessive amounts of medical information and/or require comprehensive forms to be completed by clinical staff.” Luz Saúde employs liaison officers to help support both the treating hospital and the international payer in such situations.

Lisbon aerial panorama over Praco do Comercio waterfront square Portugal

Working with new clients

Jokel spoke to ITIJ about situations where a hospital and assistance company encounter challenges when working together for the first time or on an infrequent basis, when misunderstandings or miscommunication are sometimes encountered. However, these situations can be managed effectively by both companies being open with each other from the start. Jokel explained: “Sometimes new assistance companies will contact us, introduce themselves and inquire about the possibility of our accepting their GOPs, whether as part of an agreement or on a case-by-case basis. We consider these requests and attempt to provide access whenever possible if the information we receive indicates that the risk of no or late payment is low, and the company has potential to use our facilities with some frequency. If this approach is complimented by a request for an in-person meeting and visit to one of the hospitals, this will greatly support our interest in working with the company while also securing that the necessary information and understanding about both companies has been communicated regarding how we operate and what to expect from each other.”

In some cases, assistance companies will send their GOP documents and simply expect them to be accepted

Not all assistance companies will take such an approach. Perhaps they are not used to working in the Portuguese health system, or cultural differences simply mean that a different approach is taken to working with hospitals.

In some cases, assistance companies will send their GOP documents and simply expect them to be accepted. Jokel explained Luz Saúde’s approach to this tricky situation: “I will try to confirm the acceptance of the GOP for inpatient or urgent cases where the client will be under pressure to pay significant costs they did not expect, but only if we secure enough information in time to validate the company and assure that they agree to the terms of the service of direct billing on a case-by-case basis. If we cannot accept the GOP we advise them to consult the list of assistance companies we work with and submit it through one of them. This is also the guidance given for those companies who rarely have a client in the country.” There’s always a way to co-ordinate the patient’s care, it just depends how easy or difficult a company – or healthcare provider – wants it to be!

Moving with the times

Portugal has almost 450,000 expatriates – many of which will be seniors needing healthcare – and over 12 million tourists are welcomed to the country annually. While, in the past, there may have been little support for these international visitors when they sought healthcare, it seems that the private medical providers have stepped in to fill a gap in the market. With well-developed international departments offering multi-lingual assistance services and an open-minded approach to GOPs, the international insurance and assistance community can rest easy knowing their clients will be well cared for and cases managed in an appropriate and efficient way.