Interview: Eve Jokel of Luz Saúde on Patient expectations

What are the trends in Portugal regarding tourism and new expats in the country? How does this affect your objectives?
Over the last seven years, Portugal has doubled the number of international people who have become residents in the country. In 2022 we had the largest number ever in the country, 757 thousand people.

Furthermore, tourism in 2022 was just six per cent below 2019 levels.

We are keeping an eye on these changes in the expat community, and the international tourists who visit, so we can get a sense of the general activity level we might expect from this group in our health units, and so we can plan or adjust our services. Last year, Brazilians topped the list for new residents, while the UK decreased, France remained stable, and China dropped out of the top ten. Nepal, India, and Italy were among the countries who saw larger increases in their resident numbers. With regards to tourists the markets that grew the most were the US, Poland, Ireland, Germany, and Spain.

We experienced a few years where there was a strong influx of French and Chinese people moving to the country, many of whom were not very comfortable speaking English and had little or no Portuguese. We added client managers/interpreters for these groups so they could access our services more easily. More recently, more Americans are visiting, and some are moving to the country. Several companies have appeared to support their transition and we have partnered with them to do webinars, host visits to the hospitals, and provide information in other forms about healthcare in Portugal.

What does your role involve doing on a day-to-day basis, and which parts of it do you enjoy the most?
I work with other departments in the headquarters, as well as several of our hospitals, to strengthen and expand our international patient support in the group. I also respond to requests from our hospitals, work on agreements with insurers, and assist them in achieving special requests or changes in access for their clients or a client group. I work on engagement with the local expat and diplomatic community as well as companies supporting tourists in Portugal, and I have a daily review with the International Patient Services (IPS) team in our flagship hospital. This is an important part of the day because it keeps me involved and close to the operations and policies in play at the hospital.

Luz Saúde operates a number of clinics and hospitals in Portugal – what is the size of the group?
Currently, we have 27 hospitals and multispecialty clinics on mainland Portugal and Madeira, with two additional clinics opening this year. We are continuing to develop a hub and spoke network to meet the regular health service needs of underserved areas with multispecialty clinics with comprehensive diagnostic resources while providing advanced medical services in hospitals working closely with those clinics in the region.

In terms of ensuring your hospitals are offering the latest and best standards of care, what equipment and resources are you investing in to ensure that you are considered a centre of excellence for care in Portugal and Europe?
Our medical facilities work according to the highest standards of care, in terms of the internationally proven clinical protocols we adopt, the promotion of multidisciplinary teamwork, the pursuit of quality accreditations, the continual expansion of our participation in clinical research, as well as our clinical training opportunities within our group.

We maintain a strong investment in information technologies as well as diagnostic and treatment equipment. We have maintained long and productive partnerships with Siemens, General Electric (GE), Oracle, Dräger, and OutSystems, which allows our flagship hospital in Lisbon to sometimes be among the first in the world to receive the latest or beta editions of software and diagnostic equipment.

How did the pandemic change how Luz Saúde works? Do you rely more on telehealth solutions now, and are patients and doctors more accepting of tech solutions?
We were already well into the process of digital transformation when the pandemic hit. The pandemic required a rapid implementation of expanded access of the telehealth services we were offering, in particular for urgent and specialty care.

The number of physicians offering video consultations skyrocketed at the beginning of the pandemic. Our free 24-hour telephone nurse triage service had only been active for one month. It became an important point of access and support, as well as for covid screening and advice. Our app, My Luz, increased its functionality to include the ability to select the day and time of appointments. We also increased the number of health cards in the app to assist chronically ill patients to monitor their health at home.

Do you find there are significant differences in patient expectations when it comes to different nationalities? How do you manage these?
I think it’s fair to say that most people will have a higher level of stress than usual when first using a health system outside of their home country. Some pay attention to every detail – this is normal. Others treat non-urgent matters as urgent, and some make excessive demands to reassure themselves that the hospital is responding well. Some require longer appointments and more explanation than the Portuguese client might require. We understand all these reactions, and work to reassure, respond in good time, answer questions well, select and recommend physicians who work well with different cultures, and mainly let the client know they are heard and are in control.

Working closely with assistance companies from all over the world to manage the patient care journey is essential when dealing with international insured patients. What for you are the key pain points in the international medical assistance process?
I have a high regard for the difficulty of the work of assistance companies, and try to encourage our hospitals to quickly resolve their requests. Experienced companies understand hospitals well. They usually have realistic expectations, but often demanding timelines. These timelines can sometimes lead to repetitive and excessive emails that actually make it take longer to answer or force attention towards a less urgent situation than other cases that are being treated by the insurance departments.

I encourage our insurance departments to send acknowledgement emails at least to inform the companies that the information has been received – but this also takes time. Assistance companies may also ask too frequently for medical reports to update them on the client’s condition. Generally, we send additional medical reports when something has changed since the last report. Assistance companies might instead ask if the status is the same or if an update is available.

Finally, payments are either done as expected, in the correct amount, and on time, or certain companies will need to be chased, and then we run the risk of hearing that they can no longer submit those invoices to the insurer. Having sent our invoice at the right time, it is a pain point that risks the relationship and continued access to the hospitals. Some companies track whether they have received their invoices and ask about them if they cannot locate them in their system.

What are you most proud of in your current role?
I’m most proud of growing our service from zero and seeing it become a strong model of providing care and support to international clients in a company whose main client is and will always be the national client. And this is the case for 95 per cent of hospitals receiving international clients. Luckily, my team and myself are creative in our strategy to keep growing even with limited resources, by using our relationships and support, both internally and externally, and by aligning with the direction of the company.

Winning the ITIJ award for Medical Provider of the year in 2022 was a wonderful moment for us – an important recognition!

What are the major challenges right now for the international insurers and assistance companies working with hospitals?
We are struggling to fill positions and avoid rapid turnover. There are fewer candidates for front line jobs, while at the same time, those jobs are changing as more and more automation and self-service becomes incorporated. We are seeing the impact in what we can expect from front line staff with regards to managing international clients, especially in our flagship hospital. I think that international insurers and assistance companies are not yet recognising that this wide paradigm shift into a more digital world makes it harder for hospitals to sustain highly personalised services that have different processes from the national client. I would suggest that insurer and assistance companies provider portals are only useful for the billing and collections departments, and not for reception staff to check eligibility and benefits in a company they see very infrequently. Telehealth and video consultations, as well, by these companies, is also not the path forward, since these services may only resolve a handful of situations and are not incorporated into the continuum of the client’s care in any sense, that I know of, or from what we have tested.

What do you recommend in order to maintain good access to care for international clients?
International payers need to simplify their terms of access, simplify or deliver differently their guarantee of payments (GOPs) and put more power in the hands of their members to use their benefits. They need to consider that if the hospital does not have reception staff that understand their GOP, this is going to lead to more rejections or mistakes. With reduced staff levels and less experienced staff, the front line in the era of digital transformation is managing less variability, and is therefore going to be less and less equipped to manage an international client from a company they have never seen before.

My hope is that insurers and assistance companies manage to expand their apps to enable beneficiaries to consult a specific service and receive the benefits to which they are entitled instantly, with the possibilty to email a GOP document with that information to the provider – before or even at reception, and maybe even in the language of the country they are in! This can be managed if the document is written to enable a front-line staff member to accept it – meaning, they must limit the amount of disclaimers, and terms and conditions on the document and make the key information highly visible and clear. This is possible, but insurers need to weigh the risks versus the easier access. If processes for gaining access are not simplified and, I believe, put into the hands of the beneficiaries more, ambulatory care, in particular, is in danger of reverting back to reimbursement protocols simply because there is no time nor competence to decode complicated GOPs and/or portals.