Eric Barthélémy, Head of Operations and International Networks at Europ Assistance, noted that with such a well-established tourism industry, Spain is a destination that has attracted international patients for more than 50 years. He said that, today, there is a high demand from international visitors for eye surgery, organ transplants, fertility procedures, and plastic and cosmetic surgery. 

Elsewhere, Spaincares – a network of organisations promoting health tourism, including the Spanish Private Healthcare Alliance (ASPE) and Barcelona Medical Agency (BMA) – asserts that there are 21 Joint Commission International (JCI) accreditations (and 25 Da Vinci robots) in the country; while others in the industry suggest that good regulations of popular medical services, such as IVF, help with the country’s medical reputation.
But Spain’s healthcare system sits at a ranking of eighth in the world by volume of patients – a number that is growing at a rate of 20 per cent per year, as noted by Barthélémy: “Spain is considered to have one of the best healthcare systems in the world, with both public and private facilities equally suitable in terms of medical care quality,” he said. 

The Spanish healthcare system has enabled the country’s citizens to live the longest in the EU – life expectancy was 83 years in 2015, according to the Organisation for Economic Co-operation and Development (OECD). It’s also one of the best countries in Europe to be in should someone have a life-threatening condition; mortality rates for cancer and heart conditions are lower compared with much of the rest of the world. 

The Spanish healthcare system has enabled the country’s citizens to live the longest in the EU

In 2017, Spain managed double the average amount of organ transplantation procedures in 2017 compared with the entire EU. And the country manages this while spending less on healthcare than the EU average (healthcare expenditure per capita in Spain in 2015 was €2,374, below the EU average of €2,797). 

A typical international patient

Interestingly, Quirónsalud, a sizeable Spanish hospital group, says that just 15 per cent of its international patients have travelled for elective complex surgeries and specific high-level treatments (of which around 45 per cent are from the Commonwealth of Independent States and one-quarter are from the Middle East). The vast majority (85 per cent) of its international patients are tourists and expats. They require entirely different services from those travelling specifically for medical treatment. “A tourist or business traveller in Spain has a good network of walk-in clinics, with individual GPs speaking a foreign language for easy access to minor outpatient care,” said Barthélémy. For acute emergency situations, a network of hospitals with emergency departments open 24/7 is available. 

Expats tend to require a more varied selection of medical specialists within both the public and private sector, demanding emergency procedures as well as planned treatments. And this is because they are usually older Europeans who live in Spain for six months of the year or more. “These expatriates look for the good and warm climate of our country to make winter more bearable,” said Joaquim San Nicolás, Head of the International Medical Network for AXA Partners Iberia. “Normally these people already have medical pathology because of their advanced age, which means they require medical assistance.” 

AXA Partners runs a medical network in tourist areas that is tailored to the medical needs of older expats, including blood pressure control and rheumatology services. There are other expatriate groups too, of course – such as the directors of large multinationals, who tend to receive medical assistance in larger cities such as Madrid and Barcelona, San Nicolás added. He recommended Hospital Clinic, Barraquer Ophthalmology Clinic and Puigvert Clinic in Urology, all in Barcelona; MD Anderson Hospital in Madrid; or Clínica Universidad de Navarra – a European Society for Medical Oncology (ESMO) designated centre – as suitable facilities for international patients. 

Healthcare system

For many international patients, there is a great deal of choice in both the private and public health system. The Spanish National Health System, or Sistema Nacional de Salud as it is known locally, is funded by taxes and operates primarily through a public network of providers. It ensures medical coverage in all regions, from outpatient assistance to top-level inpatient assistance, and is used by more than 90 per cent of Spanish citizens. 
Unlike medical travellers, expats are entitled to free public healthcare if they are a legal resident in Spain and meet several requirements; such as being employed, being an EU pensioner entitled to pension benefits, or temporarily staying in Spain with a European Health Insurance Card. 

However, despite the reputable quality of public healthcare services, 18 per cent of the population has a private healthcare plan either as a supplement or alternative to the public option according to Sebastian Kaisin, Head of Providers at MAPFRE. “As in any other developed country, the main advantage of the private healthcare scheme is greatly reduced waiting times and immediate access to specialists,” he said. The OECD said that average waiting times for elective surgery in the public sector – such as cataract surgery or hip replacement in Spain – are well above that of other EU countries, including Italy and Portugal. And the number of private healthcare plans tends to spike after public cuts or economic crises.

Despite the reputable quality of public healthcare services, 18 per cent of the population has a private healthcare plan

Another drawback of the public health system, Kaisin said, is that while private health insurers generally cover the full amount of treatments in private facilities, they only cover 75 per cent of treatments within the public 
healthcare system, where some services – including dental treatment – are not covered. And although medical professionals generally have a reasonable command of English, patients require a good level of Spanish to navigate the public healthcare system. “Private facilities have multilingual staff available, making things easier for overseas residents,” Kaisin said. 

International insurers and assistance companies say they find it easier to deal with the private providers of facilities, often within tourist centres, with dedicated international patient desks and multilingual staff. “For an international medical insurance or medical assistance company such as AXA Partners, which needs the help of medical providers to monitor the patient or to be able to set up the repatriation protocol to the patient’s home country, private hospitals already help us,” said Nicolás of AXA Partners Iberia. 
“Their administrative management is more agile than that of the public hospitals, although in my region of Iberia we work with all the facilities.” 

Hospitals

The Spanish private hospital sector has plenty of big players, from Quirónsalud Group and HM Hospitales to Vithas, Hospiten and Sanitas. This is the result of a much-needed shakeup after the country’s economic crisis. Many hospitals consolidated, in what was a very fragmented market according to Jesús Bonilla, Managing Director of Sanitas Hospitales – a hospital group owned by healthcare services giant Bupa. “The healthcare market is a very complex one, for sure,” he said. “The previous fragmentation gave room to not-so-qualified providers, but right now, private healthcare provision is running on an excellence basis.” Today, with fewer players in the market, there is a better overall quality to private healthcare. “All private healthcare providers present an outstanding track record of excellence,” Bonilla said.

Indeed, each player is refining its portfolio of hospitals and services. Take Quirónsalud Group, a network of 48 hospitals spread across 13 regions in Spain. It is buying new hospitals all the time, according to Mónica Figuerola Martín, Head of International Business Development at Quirónsalud. The hospital group sees more than 30,000 international patients per year and has agreements with more than 570 international insurers. 
For international patients, Quirónsalud provides what it calls a ‘G24 service’, which simplifies administrative procedures. “Starting with the first phone call, our team provides customised support for these patients and guarantees them healthcare that fits them,” said Martín. “Our single point of contact enables us to meet the needs of our patients in a co-ordinated fashion, guaranteeing a swift response.”

Martín points out that private hospitals like Quirónsalud must provide exemplary healthcare services like G24 because there is so much competition from the public sector. “Doctors who have expertise also work in the public system, and because our public system is really good, we have to be excellent to get the Spanish patients,” she said. 

That’s why hospitals have evolved in recent years from being merely alternative providers of surgery to the public sector or hoteliers, to carrying out broader activities such as research and becoming centres specialising in particular medical disciplines. Last year, Sanitas acquired Ginemed – an IVF clinical group – in order to expand its portfolio of services; it’s just about to open the Advanced Oncology Institute at Hospital Sanitas CIMA; and is expanding its current facilities at Hospital Universitario Sanitas La Moraleja. Quirónsalud is now linked with seven university hospitals and says it is involved in more than 1,000 clinical trials.

Although medical professionals generally have a reasonable command of English, patients require a good level of Spanish to navigate the public healthcare system

Regional variations

Healthcare varies with region. Although private providers say their services stretch throughout Spain, the highest concentration of private healthcare can be found in the capital, Madrid, and in Barcelona. Quirónsalud’s new proton therapy department, the first in Spain, is located in Madrid for example. And Barcelona attracts 20,000 foreign citizens from the UK, Italy, US, Middle East and Russia alone, according to BMA. 
Within the public sector, health services, budgets and spending priorities have been devolved to each of Spain’s 17 autonomous regions. Those living in and around Malaga and along the Costa del Sol will be covered by the healthcare services of Andalusia, SAS (Servicio Andaluz de Salud), for example. 
As a result, there are substantial variations across the autonomous regions. Basque Country, the Principality of Asturias and Navarre spends over 30-per-cent more on healthcare per capita than Andalusia, for example. There are 2.7 doctors per 1,000 people in Andalucía and 5.3 physicians per 1,000 people in Navarre. Patients in the Canary Islands, Catalonia and Castilla-La Mancha wait on average more than 160 days for surgery, compared to less than 50 days in other regions, according to the OECD. The Atlas of Variations in Medical Practice in the Spanish National Health System has found massive regional variations in a range of procedures from carotid endarterectomy to knee replacements, for example. 

That said, it’s unusual for assistance companies to move patients beyond their region. “With the current level of medical care in Spain, it is rare for us to refer a patient from one hospital to another outside of their current region due lack of healthcare facilities,” said Europ Assistance’s Barthélémy-Maviel. “Every single autonomous community in Spain has a hospital that’s able to cope with complex conditions. The combined public and private structure ensures that every single speciality is covered in each one of the Spanish provinces.”

Insurers and assistance companies

The highest concentration of private healthcare can be found in the capital, Madrid, and in Barcelona

To iron out these discrepancies, AXA Partners directs clients to preferred suppliers within its network. Only audited suppliers with a signed contract are offered a quality seal by AXA Partners to identify their facilities. 
Meanwhile, Europ Assistance uses a pool of doctors to audit the hospitals it deals with. Auditing doctors provides a detailed list of medical specialties offered, equipment available and an internal rating, which is used when directing clients to appropriate facilities. 

Nonetheless, there are still many other challenges facing insurers; from the underinsured traveller to overtreatment and the unnecessary use of expensive scans and tests. For the latter, Europ Assistance prefers its members to call in first – that way they can be referred to an audited hospital and avoid ending up somewhere that is insufficiently equipped to treat their medical condition or liable to exploit the patient’s insurance. “Very frequently, for simple outpatient cases – say ER visits lasting less than 24 hours – members don’t call us. Instead, they send us the invoices for reimbursement when they are back home,” Barthélémy-Maviel said. “In situations like this, it’s harder to avoid abuse.” With the patient’s written consent, it’s possible to closely monitor their medical condition, as well as review all items to be billed, he added.

Perhaps the greatest challenge is communication at hospitals. Nursing and administrative management teams almost always speak English, but not necessarily other languages such as French, German, Polish or Russian. Sanitas’ Bonilla said: “During the last few years, we have noticed an incremental number of Arabic and Slavic patients willing to access excellent healthcare,” he said. “The organisation has the resources to guarantee that language is not going to be an obstacle for the communication between patient and specialist.”
Ultimately, patients and hospitals look for recognised international labels such as that of JCI or the European Foundation for Quality Management, said Bonilla. Many of the hospitals in Spain, including the Sanitas network, have that. “Patients from all over the world seek information on the centres that offer the most guarantees and have the best care results,” he said. “In this sense, we are perfectly positioned to meet the needs of the international patient.”   ■