Ian Cameron, ITIC Chairman, introduced the speakers before Federico Tarling, Chief Servicer Officer, Assist Card, opened the session.
Tarling started by speaking about medical assistance onboard cruise ships. He talked about four different case studies where there were similar outcomes: one was a 20-year-old patient given intravenous medication, admitted for 24 hours, where costs came to USD$4,950. He said the treatment provided was beyond necessary. Another was of a 59-year-old patient with abdominal pain whose unnecessary costs came to USD$4,511. A third example Tarling covered was a 71-year-old who had a cough for three days. His treatment came to USD$3,450. And a final case was a 46-year-old with a skin rash. She was provided with corticosteroids via IV and orally, and kept in ER for three hours – costs came to USD$2,800.
Public networks at ports of call
Tarling went on to say that while health professionals in many South American countries are generally well qualified with high expertise, the medical equipment and quality of facilities are not always the most consistent, particularly in the public sector, where standards of comfort and equipment are uneven. The best-equipped facilities are concentrated in the major cities and often belong to the private sector.
The public sector, he said – whose care is fully covered by a mandatory health insurance system – is usually very popular with local populations, and as such, wait times can be very long.
Many hospitals remain underfunded, understaffed and under-supplied. The public hospitals and clinics provide very low-cost and almost free healthcare services to anyone who approaches them, which results in long waiting queues.
Tarling said that expats tend to go private, as funds are insufficient in public hospitals. Patients sometimes need to buy their own sheets, food, and even toilet paper.
He added that many small hospitals tend to hand over billing services to a third party – again causing higher costs. A delegate posed the question – are pre-existing conditions covered in policies? Tarling said it used to be that these were too broad, but that now they offer upgrades to policies. Cameron asked who should be taking responsibility – how do buyers know that $20,000 is an insufficient coverage amount? Tarling said that insurers should take some responsibility, but that buyers also need to know their limits – to not be stupid in the activities and places they go, especially if they have pre-existing conditions. Abril agreed, and said some responsibility needs to lie with the travellers.
Case study – nightmare on a cruise ship
Tarling went on to speak about an Argentine woman who got sick on holiday and was misdiagnosed onboard. She was operated on in an unreliable hospital in Jamaica, when she already had a generalised infection. The hospital removed an ovary and tubes and liquid reached her lungs, but in the private clinic there was no artificial respirator so she was transferred to a public hospital. She spent several weeks in a coma, but survived. She was then charged $500 for the transfer. Her family tried to look for a way to transfer her to Buenos Aires, but then the story hit the media, and her colleagues started a campaign to raise money because the hospital in Jamaica was charging $4,000 a day. She had a travel assistance plan from Assist Card for £20,000, which covered part of the costs for the hospital in Jamaica. Once the cap was exhausted, her family began to take steps at the foreign ministry to obtain a medical plane and, in the end, the travel assistance company ended up paying for the medical plane. She arrived at the Finochietto Sanatorium in an induced coma.
There are good private medical facilities in all tourist areas in South America, Tarling said. “But the bad news is patients might be overcharged for treatment, some of which may not be needed.”
Many times, unnecessary third parties get involved in a case prior to the initial notification of the emergency by the patient (or their family), he said. “When this happens, regular and irregular costs start to accumulate and can easily turn into an overbilled admission.
“In general, small facilities don’t have billing departments – and do not have experience with international insurance/assistance companies. Therefore, they use collection agencies, which act as factoring companies, purchasing bills which are inflated in order to yield high profit.
“Getting paid from international insurers is difficult, the revenue cycle is unpredictable, and there is a higher default rate,” he said. “This all contributes to a higher cost of care.”
Tarling suggested that if you are a traveller involved in cruise travel throughout the Caribbean you should:
- Purchase travel insurance from a company with sufficient credentials
- Make sure they have agreements in place to provide cashless assistance
- Buy coverage with at least a USD$100,000 cap to ensure an air evacuation can be easily covered, even after a hospitalisation.
He added that cruise liners should be open to discuss agreements with insurance and assistance companies (some are); and that for as long as it is possible, try to coordinate with the insurance or assistance company before disembarking a sick patient at a port.
To assistance/insurance companies, he advised the following:
- That they have agreements in place as long as it is possible to be able to steer patients to contracted suppliers
- People on the ground where volumes justify it, to be able to monitor cases from a close distance
- Agreements with air ambulance companies with experience in the region
- Reach out to cruise companies to be known to them and facilitate coordination whenever possible.
Thomas Lescot, Group Chief Medical Officer, Europ Assistance
Lescot began by saying that cruise passenger numbers had seen substantial and sustained growth globally over the past decade, from 17.8 million in 2009 to 29.7 million in 2019, and that the most popular destinations in 2019 were the Caribbean, Bahamas and Bermuda, where they saw 11 million passengers.
The most common issue associated with medical assistance for cruise passengers was that they, and crew members, are very far away from medical facilities. Lescot also said that ships are closed or semi-closed settings, in which infection may be easily spread and difficult to control. He pointed out that poolside activities, dancing, slippery decks, stairs, rough seas, and ship maintenance hazards pose trauma risks to both passengers and staff. Issues related to elderly passengers include important past medical history or comorbidities (high risk of decompensation) and that some clients might have mobility limitations.
Onboard doctor: minor medical cases can be managed
Lescot pointed out that according to the Maritime Labour Convention 2006, ‘ships carrying 100 or more persons and ordinarily engaged on international voyages of more than three days’ duration shall carry a qualified medical doctor who is responsible for providing medical care’. All other ships are required to have at least one onboard seafarer, competent to provide medical first aid.
Patterns of illness and injury amongst passengers
Data on illnesses extracted from the passenger and crew arrival registers, and passenger and crew illness logs for all ships and maritime vessels, arriving at Barbados ports and passing through its territorial waters between January 2009 and December 2013 show that:
- Over 50 per cent of sick passengers were aged over 60, with a median age of 64 years
- The overall event rate for communicable illnesses was 15.7 cases per 100,000 passengers
- The overall event rate for non-communicable illnesses was 3.4 per 100,000 passengers
- Gastroenteritis was the predominant illness, followed by influenza
- Myocardial infection being the main non-communicable illness experienced by passengers.
Hip fractures among elderly females constituted the lion’s share of all injuries sustained aboard passenger cruise ships, requiring transportation to an offshore facility. Just over 70 per cent of patients were 65 or older, and a majority were female (59.9 per cent). The most common mechanism of injury was a ground level fall (79.1 per cent), while the most common injury encountered was a femur fracture (52.2 per cent). Traumatic brain injuries were uncommon, occurring in 7.5 per cent of cases.
The average length of stay in the hospital was 6.6 days, he said, with average total hospital charges of $50,178 per patient hospitalisation.
How to be prepared to assist cruise passengers: build a strong medical network
Lescot’s advice was clear – ask for cruise itinerary, stops with excursions and number of passengers; know the ground services capabilities around the seaport; know about the ER facilities and OPD facilities in the area of the seaport; define a hospital of reference; prepare a medical evacuation plan; check the availability of hotels that can be easily paid by the local agent/entity.
He said to also think about additional specific issues that may have to be taken into account such as: no English being spoken; that there may be elderly clients with important past medical history; they may have lots of luggage; that there may be family members disembarking with patients who will need help and accommodation and that they might not have visas or passports (if the cruise is not expected to have stops in a country with those needs).
How to be prepared to assist cruise passengers: share info and protocols in advance with business partners
Lescot advised sharing capabilities and activation SLAs with the business partner in advance and define a list of specific info/documents that need to be given to the Medical Platform in the activation phase (i.e. cruise doctor first evaluation). He also said to define the governance of specific actions (i.e. the first transportation service to the nearest facility to be done by EA if there are at least 24 hours of time to arrange the assistance vs the BP port agent if there are less than 24 hours of time to arrange the assistance) and to create mini protocols with the BP for specific difficult locations, services and emergencies.
In managing the assistance, it is very important to be informed about the situation promptly by the ship, with all medical and logistic information
He said they share, with the cruise companies, the port destination in advance in order to check the hospital network and be prepared. “In managing the assistance, it is very important to be informed about the situation promptly by the ship, with all medical and logistic information. We also receive a lot of help from local port agents on the spot.”
To conclude, Lescot said that specific challenges for assistance companies need to be addressed and that preparation and communication are key.
Cameron asked if insurers should be encouraging islands to improve their facilities? Tarling pointed out that because there are not enough patients coming from cruises, that they won’t.
Sergio Abril, Chief Commercial Officer, Helidosa Aviation Group
Abril spoke of mission preparedness and said there are three main things that should be considered:
- Patient clinical profile/medical report
- Logistical requirements
- Timing and communication.
He added that timing is mission critical and that costs may be able to be contained.
He said that partnerships are vital for:
- Proactive collaboration.
Abril said partnerships may be able to help with critical decisions. Operators will have local insight about ports and airports – open communication is key from the insurer. He added that ships won’t want to delay or divert for one passenger, so proactive collaboration is vitally important. Everyone must learn from each mission, so that things can improve over time.
Ships won’t want to delay or divert for one passenger, so proactive collaboration is vitally important
Abril went on to say that civil unrest, airport operations and political complications can cause large challenges. He used Haiti as an example of where there is civil unrest, and there can be no night flights. In Cuba, there are many political implications which can cause delays.
Cameron posed the question that surely it is incumbent on insurers to make partnerships with cruises. Abril and Tarling concurred, and said they do – with some, but that many cruise ships just see them as providers.
Tarling added that people will still go on cruises and still pay the money. Abril agreed and said that every case will be dealt with in some way or other. Cameron then asked if there’s any point in trying to communicate with cruise liners. Lescot said yes, of course, and that escalation processes should be clearly defined, with responsibilities also defined.
Finally, Cameron asked each speaker that if there was one thing they could change, what would it be? Tarling would like to strike more deals where there are cashless payments – that this would make things much easier. Lescot wanted an improvement in communication and preparation, while Abril said that proactive collaboration would help everyone.