As Greece’s 2022 summer holiday season draws to a close, the country’s international tourism figures appear to have rebounded to near pre-pandemic levels – not least due to the government’s bold decision to ease lockdown and travel restrictions much earlier than many other destinations.
After six years of solid growth, visitor arrivals reached a record 34 million in 2019, before plummeting to 7.4 million in 2020, then rebounding to 15 million in 2021. Tourism Minister Vassilis Kikilias has said he expects a full recovery in arrivals and spending by the end of 2022, after tourism receipts doubled year-on-year in 2021.
“This is based not on wishful thinking, but on the hard data we are getting on the number of new flights, new routes, and interest expressed in Greece from the tourism industry,” Kikilias said.
“Because Greece announced early how it would open up to international tourism [after Covid], clients and airlines were given confidence to plan,” he added.
Greece is also keen to extend its holiday season into the winter months by incentivising retirees from colder European countries to visit relatively clement Greek holiday destinations like Rhodes, which boasts 300 days of sunshine annually, with winter daytime temperatures rarely dropping below 15°C. Older travellers are more likely to seek medical assistance as a result of illness or accidents, so that could have implications for medical providers and assistance companies.
For medical assistance companies working with healthcare providers in island and mainland resort areas, the recovery means a return to business as usual. That implies coping with demand for medical assistance that soars during the summer holiday season, when popular holiday isles are swamped by a tidal wave of vacationers, leading to a massive increase in treatment callouts – for everything from minor injuries and ailments to life-threatening injuries.
Public and private hospital options in Greece
Public versus private sector healthcare provision is a long-standing political hot potato in Greece. National health service reforms put forward by the centre-right [Kyriakos] Mitsotakis administration earlier this year have been decried by opponents as a drive to expand the private for-profit sector, by shifting the cost of healthcare to patients by channelling them to private providers. How this affects international medical assistance operators and their clients in practice remains to be seen.
Greece’s public health infrastructure – a mix of larger urban hospitals and small village health centres providing basic treatment for minor injuries and ailments – is barely capable of meeting the needs of local residents, let alone the more than 30 million visitors expected this year.
Greece’s public health infrastructure ... is barely capable of meeting the needs of local residents, let alone the more than 30 million visitors expected this year
That could seem like an opportunity for entrepreneurial private health practitioners, and indeed many long-established tourist hotspots like Corfu or Rhodes are quite well provided with multilingual GP and dental practices. While there is plenty of demand for ‘splint and pill’ treatment in high season, there’s not enough for private medicine on islands without a big local population all year round.
“There are many islands with only an outpatient clinic, and public health provision is very bad,” says Dr Dimitrios Papapavlou, CEO of Healthwatch SA – a medical assistance and cost containment specialist. Even very popular islands such as Mykonos and Kos have no private clinics, so air ambulance evacuation to an Athens facility is mandatory for surgery or complicated cases.
Year-round clinics not financially viable
According to a report earlier this summer in the online English-language edition of Greece’s main newspaper Kathimerini, air ambulance missions collecting patients from popular island destinations hit a 10-year high in August (2022), with 571 flights carrying 721 patients from the Cyclades islands alone – compared to 640 patients evacuated in the whole of 2021.
There is no interest from investors, as they can’t make their expenses
Mykonos can expect more than 450,000 visitors by the end of the summer 2022 season, Kos one million-plus. But Kos has only 25,000 permanent residents and Mykonos 10,000, so between November and April, demand for emergency and even routine medical treatment is insufficient to make running a year-round private clinic a viable financial proposition.
“There is no interest from investors, as they can’t make their expenses,” notes Dr Papapavlou. “Even in big islands like Rhodes, the limits are at the edge of survival.”
Rhodes, largest of the popular Dodecanese islands, presents a slightly different picture from its smaller cousins. With a permanent resident population of around 50,000, it supports the private Euromedica Rhodes hospital, which offers intensive care, emergency and surgical services. It also benefits from a patient catchment area that includes Kos and other nearby isles.
Pre-agreed healthcare prices a priority for insurers
Greece is struggling to cope with soaring energy costs, and inflation that has hovered around 12 per cent in 2022 (compared with 8.9 per cent in the Euro area as a whole), so cost containment becomes an ever more pressing issue.
Energy is a major challenge for Greece, with consistently high non-household electricity prices in comparison to the rest of Europe. Hospitals and clinics are heavy electricity users, with little leeway to cut costs by turning off round-the-clock lighting, heating and air conditioning, still less vital life support and diagnostic equipment.
Developing networks of providers with pre-agreed prices and charges is of paramount importance to containing costs, says Dr Papapavlou.
“We have a vast network in Greece with 5,500 doctors, of all specialities for domestic insurance and travel programmes, with medical visits from €20 to €30; diagnostic centres which charge us set governmental prices; and physiotherapists with a fee of €20 to €25 per session, all included.
Developing networks of providers with pre-agreed prices and charges is of paramount importance to containing costs
“In tourist regions, we have agreements with all medical providers and clinics around Greece, on a pre-agreed charge. This can be a flat fee, regardless of disease, number of visits or category charges.
“For example, in a category charge, the doctor knows that our payment may be €165 excess minus a 15-per-cent discount. So, from one side, everything is clear to all parties involved and our reserves to the insurer have an accuracy above 99 per cent.
“The same is valid for all clinics on an island and the mainland. Apart from agreed prices and discounts, we also have package prices for heart surgery, orthopaedic surgery and robotics, so overcharging and overtreating is practically out of the question.
“The second issue is for every single guarantee of payment. Even for €5, we do two signoffs and the last one is from a medical doctor – our auditors are specialised. For example, a cardiologist will check a cardiology case, and dispute with the treating cardiologist for treatment offered. We are the only company using this process with 11 different specialities,” Dr Papapavlou claims.
Convenience of e-consultation for patients and payers
Online applications are becoming a useful cost containment tool in Greece, potentially eliminating the need for expensive and time-consuming visits to a doctor or clinic.
“Another way we contain costs is through our app. Clients can press a button and have an emergency e-consultation, meaning no need to visit a doctor in 82 per cent of cases. The patient is given directives, and even an e-prescription. An e-consultation costs from €60 to €90. A visit to a tourist doctor or clinic would see this charge multiplied.
“Finally, it is very important to show professionalism to all providers. This means experienced staff (our company average is eight years of employment) and sufficient numbers to deal with high volume. What needs to be shown to providers is immediate response within 24 hours; new case notification and guarantee of payment (GOP) sent within 48 to 72 hours; and prompt payment with 15 days,” Dr Papapavlou concludes.
Air ambulance capacity doubles
Geography and demographics make air ambulance provision for short-haul medical transfers even more important in Greece than most European holiday destinations. With almost four million people (out of a total national population of around 11 million) living in and around Athens, private hospitals are overwhelmingly clustered in the capital. But most visitors spend time on the islands, where the absence of private clinics and hospitals means that policyholders suffering even relatively minor injuries or illnesses may need a short medevac flight to an Athens facility.
“Cost containment companies must have an air ambulance provider on an agreed price list, with the mechanism to get a package price for referrals, discounts and agreed prices,” advises Dr Papapavlou.
He cautions that a few medical providers pre-emptively arrange medical transfers and admission to their own clinics, informing assistance companies only after treatment is completed.
“In these cases, we heavily credit-control and always deduct the air ambulance costs as not authorised,” he emphasises.
Greece’s private air ambulance fleet complements medevac services provided by the Hellenic Air Force for the National Centre for Emergency Care. It’s also more than doubled in capacity, with the arrival of two Beechcraft Super King Air fixed wing air ambulances and two Leonardo AW9S Trekker helicopters, donated by the Stavros Niarchos Foundation. For insureds needing transport to a mainland hospital, but not requiring critical care en route, transfer by scheduled domestic flight is a widely available option – carriers include Aegean Airlines and its subsidiary Olympic Air, serving every island airport at least daily in summer.
As a result of ambitious expansion by private sector players, Athens was arguably over-supplied with private hospital facilities. That was brutally corrected by the financial crisis, which began in Greece in 2008. According to a 2017 Deloitte report, healthcare spending in Greece fell by 40 per cent between 2009 and 2015, and rising costs and increased competition led to a 21 per cent fall in the number of private hospitals.
The Stavros Niarchos Foundation (funded by the legacy of the billionaire shipping magnate) is a significant player in the Greek healthcare sector. It’s behind a US$750 million project to design and build three new hospitals: one in Greece’s second city, Thessaloniki; one in the northern city of Komotini; and one in the south, in Sparta.
The cost of healthcare is still rising
As one of the world’s leading tourism destinations, Athens is very well supplied with hotels of all price levels, so sourcing short-stay accommodation for accompanying family members is not a problem for insurers.
Greek tourism is in strong recovery, presenting new opportunities and challenges for the country’s health infrastructure and assistance providers. Especially in its small but popular island destinations, a lack of private medical infrastructure is likely to remain an issue, necessitating significant demand for patients to be transferred to mainland hospitals for treatment. That means cost containment will continue to be a factor for medical assistance companies and their insurance partners.