Victor E. Navarro, President, LATAM, Global Excel
Navarro started the session by saying the US healthcare market is unique and expensive. It is also primarily a private system, with the same bill produced regardless of payer. Prices are unregulated, there is no universal coverage, and it’s a very heavy system administratively, with the US spending more on healthcare per capita than any other country. Almost every bill is discounted, while the size of the US healthcare industry was approximately USD$4 trillion in 2022.
He said the rest of the world is different for the following reasons:
- Primarily public healthcare systems
- We often see different billing for international patients
- Generally cheaper than the US, but some individual hospitals can be as expensive
- Often strongly regulated
- Discounts possible but not common
- The size of the global healthcare industry (including the US) in 2018: USD$8.5 trillion.
Navarro then went on to compare bills for various procedures in different locations – from Australia to Chile, Germany to the US. For example, the average price for a coronary bypass surgery was $23,497, with the US coming in at $76,384.
Navarro said best billing practice includes: accurate and transparent pricing, pre-authorisation, communication, and timely billing. It’s important to establish clear policies and procedures for pre-authorising medical procedures, then communicate them effectively to assistance companies. He said worst billing practice includesfraud, overuse and abuse.
Healthcare prices are unregulated, Navarro said. Billing in the US is based on the quantity of work done – the more a provider does, the more they earn. The bottom line is that the quality of care is generally good, and often excellent, but it’s a for-profit ‘industry’ that works differently to any other healthcare system.
Risk management can help assistance companies prevent costs by 'starting at the start’, mitigating costsby managing treatment, while containing costs via an assortment of tools.
A member of the audience talked about the Global Transparency Act and how it will help with billing. Navarro said he hopes more hospitals take up the Act, and Lynn wants more hospitals to join in, but there has been a delay because of Covid.
Diane Lynn, Assistant Vice President, Global Health Care, Atrium Health
Lynn started her session by stating that global healthcare insurance is in a fast-changing landscape. She spoke about the Emergency Medical Treatment and Labor Act (EMTALA) and said that US federal law requires emergency departments to treat and stabilise patients, regardless of their ability to pay.
Lynn said that hospitals must comply with EMTALA, or it can result in hospital fines and termination of provider agreements with the Centers for Medicaid & Medicare Services (CMS), or civil suits.
The global demand for high-quality healthcare will increase payer system complexity, and key drivers will include: changes in global economies driving governments to adapt public health systems; ministries of health increasingly moving to value-based care and insurance models in their country’s long-term strategies, to offset increasing healthcare expenses; a rise in the global medical tourism market; development of global insurance products, enabling a new market of clients to travel globally for care; billing to become more complex globally, as more insurance offerings become available; and a global quest for value from patients, payers and providers.
Lynn concluded by saying that everyday payers, medical transport and assistance companies – plus healthcare providers across the globe – are working to deliver the best care and outcomes for customers. At times, misalignment of priorities for each of these related groups can result in process delays and unintentional frustrations for patients and families. However, with improved communication, education, and engagement with each other as stakeholders with aligned goals, ‘we can work together to improve the lives of those who’ve given us their trust and are counting on us’.
Serge Avice du Buisson, Head of Network and Analysis, Falck Global Assistance
Avice du Buisson began by outlining international healthcare spend as part of the total spend in the US. He said the total US spend in 2021 was estimated at $4.3 trillion, and that the total international spend 2021 is estimated at $8–12 billion.
He said there are red flags to be aware of with US healthcare:
- Bill submissions
- Not bundling services
He said carriers (local medical insurance companies in the US) manage usual, customary and reasonable (UCR) with company programmes and state and federal programmes. Between three and 10 per cent of cases are fraudulent, Avice du Buisson said.
UCR is the amount paid for a medical service in a geographic area based on what providers in the region usually charge for the same or similar medical service.
South Dakota has the most expensive healthcare costs: $10,000 per person in 2020. Michigan was the cheapest. Five of the ten most expensive states are in the east. The western states, including Washington, are the cheapest.
Value Based Care is a US approach to paying for healthcare. It aims to provide better care for individuals and a reduction in healthcare costs. The use of VBC models is developing, Avice du Buisson said. Private healthcare insurers also aim to provide better care for individuals, improve population health management strategies and cut costs.
“Value-based care models centre on patient outcomes and how well healthcare providers can improve quality of care based on specific measures, such as reducing hospital readmissions using certified health IT and improving preventative care.”