ITIC Global 2024 | Provider Network Forum

The ITIJ team have been reporting live from ITIC Global in Vienna this week (November 2024) sharing the discussions that took place at the conference. Read all reports

Stephen Gitau, CEO and Accountable Manager, AMREF Flying Doctors

Stephen Gitau of AMREF Flying Doctors (AFD) began by explaining the environment that the Kenya-based air ambulance and medical assistance firm operates in.

He explained that Africa is a “vast” continent that encompasses 54 countries, many of which are low or medium-income, and with many different languages.

Across this multitude of nations, the level of healthcare, expertise, and specialisation can vary significantly, particularly between urban and rural areas – with some facilities being situated in very remote areas.

“We are not one economic bloc,” Gitau said. Rather, there are several – so there is a “difference in economic visions” across Africa.

Beyond this, there are considerable bureaucratic and geopolitical challenges in many countries, which can hinder cross-border operations – leading to a necessity for extensive on-the-ground assessment of risks beforehand.

Gitau explained that there are a number of ongoing trends currently affecting how providers in Africa operate.

In particular, there has been an increase in both foreign direct investment (FDI) and the number of tourists visiting the continent – leading to both greater demand for air ambulances and assistance providers, as well as more opportunities to expand in response.

Consequently, Gitau explained that there has been plenty of investment in healthcare across the continent, particularly in popular healthcare destinations, such as near beaches and mountains.

However, in line with this growth, the cost of business has also risen, both through high medical costs and increased pricing from providers. This has been exacerbated by more extreme economic volatility, which has led to fluctuations in exchange rates.

“We’ve seen very high prices for ordinary services,” he said, citing a potential cost of $2,000 for an X-ray in some parts of Africa, for example.

Additionally, there has been an increase in fraud and fraudulent claims – which has only increased the need for trustworthy “boots-on-the-ground” intelligence, service provision, and cost containment.

Dr Evelyn Leechawengwongs, Assistant Director, Bangkok Hospital, BDMS

Dr Leechawengwongs focused on trends within the Thai healthcare sector, and how her company has implemented an artificial intelligence (AI) driven tool to improve efficiency.

She began by summarising how the Southeast Asian country is experiencing a rise in cases of “simple diseases”, which is being met with an ongoing “digital transformation” across the insurance industry. Dr Leechawengwongs clarified that a range of diseases are defined by the Thailand Office of Insurance Commission (OIC) as “simple” if they are diagnosed without complications, including influenza, acute diarrhoea, fever, allergies, and dyspepsia, among others.

“Simple diseases are conditions that are usually treated as outpatient,” she said. “However, there must be supporting data to say that the disease can be treated as outpatient,” she explained, such as a sufficiently low pain score, low or mild dehydration, and other healthy metrics.

In response to a rising number of hospitalisations, Bangkok Dusit Medical Services (BDMS) has implemented an AI-driven tool called BURT (BDMS Utilization Review Technology) with the aim of reducing administrative burden, paperwork, and overall cost, while also supporting the decision-making and assessment process.

Dr Leechawengwongs was pleased to note that BURT had demonstrated a similar agreement rate to BDMS’s human physicians, at 86% for appropriate hospital admissions, and 96% when deciding the appropriateness of continuing hospital stay.

José L Castellanos, Head of Global Network, Falck Global Assistance

Castellanos focused on ways to drive innovation in the medical assistance sector.

He began by highlighting that innovation is not always obvious, and often relies heavily on communication between different parties to come about.

He gave two examples of such thinking – firstly, that it took over a hundred years after the invention of the suitcase for manufacturers to introduce standardised sizes and add wheels to their design.

Similarly, in the aftermath of the Cold War in the 1990s, some NATO militaries found that they could save costs by removing a requirement to provide buckets of water to support artillery. The rule had been introduced during the Napoleonic era with the expectation that the cannons would be pulled by horses, who would need to drink.

Castellanos recommended two tools to support the development of innovations.

The first, the Kraljic Matrix, is a strategic tool used in supply chain management for categorising based on risk and profitability.

The second, the Project Canvas, is a framework designed for visualising and managing projects, with the aim of breaking down the task into key components. It divides tasks into three main branches: Where; What, how and when; and Why.

Alberto Carson, General Manager, MKG Network

Carson’s presentation focused on the standardisation of rates – something that is at the heart of all negotiations surrounding healthcare pricing and reimbursement, but which he admitted was a “touchy subject”.

Understanding the usual and customary rates of a local area, he explained, is important when helping patients to manage the cost of expected medical services.

Carson said that there are four main factors that define what can be considered “usual and customary”, namely:

• Prevailing charges – those that are “common or typical” for medical services in a specific region
• Geography – the effects of the wider local market or community where the medical service is being provided
• Statistical data – rates are typically determined based on an analysis of claims data
• Negotiated rates – insurance firms and providers may negotiate rates that differ from the usual and customary rates.

Carson explained that, at present, healthcare costs are inconsistent and can vary dramatically between providers for the same level of care. As a result, there is often a lack of transparency surrounding pricing structures.

Carson suggested that a greater level of standardisation would help to align costs across providers, reduce unpredictability in billing, and ensure that both patients and insurers have a clearer view of the overall costs. Additionally, greater consistency allows better planning and easier evaluation of costs.

Beyond this, Carson said that working to standardise rates would ultimately create a more level playing field for all healthcare providers to be reimbursed equitably, and would make it easier to identify when fraudulent claims have been made.

He identified several approaches to achieve this: the implementation of industry-wide data-driven benchmarks; industry collaboration to develop common standards and guidelines; or, failing that, greater government regulation.

Beyond this, Carson recommended direct communication between insurers and healthcare providers, as well as the exploration of AI as a “fairness tool” to support discussions.

Joshua Snowden-Bahr, Head of Global Network Strategy, Cigna Healthcare

Snowden-Bahr focused on how providers can shift their focus towards “value-based healthcare”.

He began by saying that such a task requires insurers and assistance providers to start small, noting that “you can’t have global without local. We have to look at the local needs of our providers.”

However, beyond this, he recognised that the concept of “value” is a complex one that can be hard to define, but should ultimately be determined by the outcome for the patient.

“None of this matters if the patient cannot quickly access the pay they need,” he said.

Snowden-Bahr reflected that the current way of doing things for many healthcare providers and insurers was a “fee for service model”, where “I rendered this service to you, so I have to get paid for this service”.

While reasonable, he explained, the problem with such a system is that ultimately it incentivises healthcare spending to go up over time.

He argued that by placing the patient at the centre of the process – what he referred to as “people-centred care” – providers can “bend the curve” so that costs do not go up as fast as they might otherwise.

However, Snowden-Bahr acknowledged that while that is a good aspiration, “there are a lot of considerations … it’s difficult to say ‘On practicality, how can it apply to our industry?’”

He suggested that a good initial approach would be for insurers and healthcare providers to share and compare metrics more frequently, and for insurers to ask “How can I incentivise [providers] on these performance metrics?”

Additionally, he said that more work needed to be done to standardise what “good” looks like, noting that at present different countries have different standards and regulations – or none at all. He referred the audience to the International Consortium for Health Outcomes Measurement (ICHOM), an institution that is currently working to address this specific issue.