While individual self-paid medical travel has taken off around the world, the more complex area of travel paid for by businesses or their insurers has not. Until recently, agencies and providers have not targeted the sector. Now in the US, several agencies are seeking corporate business. Some of these are established agencies with a track record, but others are new ones with no experience in offering medical travel to individuals, who think they see a golden opportunity.
This article is written by Ian Youngman, a specialist researcher and publisher of detailed research reports on insurance and medical tourism.
Some hospitals have been persuaded that as soon as businesses understand how cheap treatment is overseas, compared with at home, businesses and insurers will fall over each other to do deals. The “experts” who suggest this carefully say it will be “tomorrow“. Sceptics argue that it will never happen, and tomorrow will never come. The truth is in between.
Are businesses, insured or not, going to allow or encourage their employees to go overseas as medical tourists? Will insurers be prepared to pay the bills? Will employees go overseas? Will unions allow them to? Will employers have to offer incentives to encourage employees to go overseas? Our research suggests answers. Above all, it is clear that the position now and the future in the US and Europe are very different.
While US health insurers are starting to embrace medical travel, their counterparts elsewhere are mostly struggling to even understand the concept. The general view in the UK is on the lines of “we offer such great products and prices, why would any business want to send people overseas for treatment?”. Bupa even had the temerity to argue that the only way they would allow a UK company to send employees overseas for treatment was to charge them a much higher premium to buy an international policy (designed for companies with expatriate employees) than they charge them for the UK policy. Just think this through: to enable a company to take advantage of treatment in Asia at a fraction of the UK price, insurers will not only charge extra premium, but also pocket the savings on the treatment themselves. So there is no incentive for employees to go overseas, and a positive disincentive for employers to consider it. No major UK health insurer will currently allow any company to add medical travel cover to a policy covering treatment in the UK.
The response across Europe was not quite as antagonistic, but few insurers showed any interest in the concept or even bothered to defend their lack of interest. Most medical travel in Europe is dental or cosmetic, where there is a substantial price saving, motivating people in the more developed EU countries to go to less developed ones in Europe. The price differentials on conventional medical treatment are less clear-cut and a large number of people are covered by state health insurance. While the UK has a history of companies offering private medical insurance to provide private healthcare, in the rest of Europe almost all private health insurance is bought by individuals. Many of the companies offering insurance to their workforce are international ones, where a mixture of international health insurance and self-funding already allows for some element of treatment across national borders.
What hospitals and agencies, expecting a flow of corporate business from insurers based in the UK or other EU countries have failed to grasp is why insurers are not leaping to do deals. Insurers are seeing an increase in the number of businesses buying private medical insurance for treatment in their home country, the complete opposite of the US. And this despite a stream of above-inflation price rises over the past decade. So insurers have no interest in, and indeed a complete antipathy to, cannibalising their existing portfolio by offering businesses insurance which includes medical travel at a lower price than they charge now for domestic cover. The most they are likely to allow is for international businesses to have a wider choice of countries where their employees can get treated, but for a higher price than they pay now. Much of the inertia is due to the profitable nature of corporate health insurance, the cosy relationship with hospitals who charge them a lot less than they charge customers who go to them without insurance, and a general torpor that discourages any innovation. In the UK and on mainland Europe any corporate medical travel market will be driven by companies which want to offer something extra. The existing health insurers have many reasons not to seek that market, so innovation will depend, as is usual in health insurance, on new entrants.
European medical travel agencies show little interest in developing corporate business. There are three reasons. The first is a basic one that, while they can get affordable domestic health insurance, companies have no incentive to consider the option of medical travel. The second is that most think medical travel is only about individuals wanting dental or cosmetic surgery – neither of which is covered by most health insurances. The third is that most of the agencies are either linked to clinics or are so small that they are lifestyle family businesses run by people who would not know how to start negotiating with a medium or large business. We may have to wait until agencies with people who are used to selling health and other insurances to the corporate sector decide to enter the medical travel market. Whether the demand is there for any stand-alone business is debatable, and it would take a very brave man or woman to risk upsetting the health insurers they deal with daily, to run it as an extension of an existing insurance business. Perhaps the travel trade will get involved, but here again, several travel agencies have pulled back or out of the sector. Hospitals worldwide tell us, off the record, that motivating travel agencies to sell medical travel is much harder than they thought it would be.
What may be the only way forward in Europe is for agencies or hospitals to concentrate on areas not covered by health insurance, ie dental and cosmetic. They may need to set up their own medical/travel agencies in Europe to get this to work. Hospitals argue that surely companies must be interested in the huge potential savings. But they miss the point. Few European companies buy health insurance, but for those that do, it is the difference between what they are paying on insurance and what they would pay direct for overseas health treatment that matters, not the difference in prices between Europe and Asia. Come what may, the vast majority of employees will still prefer being treated in their home country. One model that may work could be voluntary employee schemes. So an agency or hospital would offer discounted prices to employees who wanted cosmetic, dental or other treatment not provided under their employee benefit package. This would be more likely to be on a self-pay rather than insured basis, unless a form of health plan for medical travel could be created.
Apart from in the US, outside Europe, there are even fewer employers offering health insurance and almost no interest from companies buying, or agencies selling, medical travel cover for employees.
Unlike Europe, the average employee in the US has no state-funded healthcare system. The US healthcare crisis shows no signs of ending, as none of the presidential candidates have a viable affordable solution. This means that people have to buy private health insurance and, as the figures show, less and less can afford to do this. Many companies do care about their workforce. Some have no problem in providing full health insurance for all employees and their families. Others would like to do so but cannot afford it. At one end of the spectrum are employers arguing that in a recession, employees should be lucky they have a job, so what has healthcare to do with anything? At the other end are those who have had to tailor their offering to their ability to pay, and have cut back on cover or gone for simpler health plans covering basic care. The result is that the potential market for company-paid medical travel is reduced to companies who cannot afford full conventional cover but want to offer something. You can rule out big national and international companies where either they can afford to buy insurance, or the decision is not a local one to make. Thus, the potential market is small- to medium-sized businesses, plus locally based public employers.
Those promoting corporate-paid medical travel argue that there is a huge differential between domestic US hospital prices and what companies/insurers would pay overseas. They suggest that the real reason US insurers are now involved is they see that healthcare and US health insurance are so expensive that unless they do something, an increasing number of businesses will either stop paying for any insurance for their employees, or reduce cover to stop the premiums being unbearable. The recession means that US businesses will look at how they can reduce expenses. Partly to stop a dramatic outflow of business, but mostly to put pressure on the US hospital system to find ways of cutting prices, insurers are publicly or privately testing the water on either developing medical travel-specific policies, or their preferred option, extending a policy to allow overseas treatment in one or two select locations.
According to Mark Slitt, spokesperson for leading US health insurer CIGNA: “we have had numerous inquiries from our employer customers regarding medical travel, but at this point we don’t have a customer that is ready to offer medical travel as part of their benefit plan. We believe that the push for medical travel will continue to come from the uninsured and the underinsured, but we don’t see the same motivation in the employer-based market. Factors that US employers are considering are clinical quality, safety, cost and liability.“
Because CIGNA has an international arm, it already has a huge hospital network worldwide, so quality of care is not an issue. The insurer tends to tread cautiously and, if it is running pilot programmes with customers, is unlikely to go public with that information.
Aetna has a pilot programme with supermarket chain Hannaford Bros Co of Maine. The supermarket group has been very public and upfront about the pilot, so even if the insurer had wanted it kept quiet, it could not (see box). Aetna is also currently considering the use of certain hospitals in Mexico.
UnitedHealth International, the international arm of the UnitedHealth insurance conglomerate, is working on plans listing overseas hospitals as an extension of the US hospital network. For the international businesses, it offers health insurance to for expatriates and local nationals, so it already has a large network of international hospitals. It is currently working on ways of offering non-US cover to US-only employers and employees.
Rudy Rupak, co-founder of PlanetHospital, is one who sees potential: “This trend is beginning to take hold because employers are under intense cost pressure from every aspect of their need to provide quality healthcare to their employees. With the emergence of medical travel, employers are seeing a unique capability to provide their employees with the quality healthcare they expect, yet with a significant cost savings that employers need to maintain their business viability. Employees and retirees are also being incentivised to do so. We have three employer clients. We have worked with several insurance companies on a one-off basis, and major employers are in talks with us. The only barrier to entry is a meaningful malpractice cover to protect the employer or provider – but we are working on that. We have businesses that have signed up to participate in SIMPOL (Self Insurance Medical Plan Overseas 4 Less), a plan designed for self-insured businesses. With the Simpol Plan, employers can provide employees with a choice of either a domestic plan, where they have a co-pay and deductible, or they can get care abroad with neither. We have helped 19 employees to get paid-for overseas treatment.”
EMPLOYEE AND UNION OPPOSITION
Not all employees have warmed to the idea of travelling overseas for surgery. Two years ago, Blue Ridge Paper Products Inc of Canton, North Carolina was set to send an employee to India for gallbladder and shoulder surgeries. But the trip was cancelled after the union that represented its employees objected. Suggestions that once they understood medical travel better, unions would embrace the concept, show little understanding of American unions, and how the principle of outsourcing overseas is hated. (For a full report, visit IMTJonline.com)
Jay Siva, author of The Complete Guide To Medical Travel argues: “Insurance companies are beginning to send their patients overseas for treatment. Medical travel facilities have also started heavy marketing campaigns to employers, particularly those with a blue-collar labour force as these companies have a higher rate of injury and worker’s compensation claims.“
That blue-collar workers are at a higher risk of accident worldwide was true decades ago. Liability insurers now see more claims coming from “white collar” workers – the biggest problems being stress, nervous problems and backache. So concentrating on “blue-collar” employees may not be a wise strategy. Another problem with this sector is the strong union resistance.
Stan Johnson, the United Steelworkers union Southeast director, has a clear antagonism to medical travel. “Is it voluntary now? Is it involuntary at some point? Do you end up sending your 80-year-old mother to India when she has never been sent outside of a 50-mile radius from home? You’re going to put her on a plane and ship her to a hospital where they don’t understand her language or her culture and where conditions may be suspect?”
In smaller local companies, many employees will be reluctant to travel far from home for anything, let alone overseas. It is difficult enough persuading employees to go to a hospital in another state, even if the procedure can be performed better there. Patients like being close to home, seeing familiar physicians and getting visitors in the hospital. One Pittsburg construction firm was recently quoted as saying: ”We haven’t overcome the how-do-we-get-them-to-Boston issue, let alone how would we get them to Asia.”
Quietly hidden is the tacit acceptance by some national and local state plans that treatment abroad can save everyone money. One large federal insurance programme, Federal Employees Health Benefits Program (FEHBP), for the million or so federal employees and their families, has some plans that include overseas medical treatment. One recently increased what it pays for non-emergency treatment in overseas hospitals from 70 to 90 percent. Some disabled veterans and retired military are also covered overseas. Apart from some overseas preferred providers with direct billing, most plans work on the basis that those covered to make their own arrangements and pay for treatment, then seek to recover it under the plan.
US employers play a significant role in the choices available to US consumers of healthcare. Employers have provided preferred provider networks for decades. Accordingly, employer participation in the medical travel industry would provide a boost to the medical travel industry. But the initial efforts of some employers have produced strong reactions from labour unions. Will employers eager to save money on health benefits push to make medical travel a part of the benefits they offer? It is happening – and sometimes because of interest expressed by employees. Will medical travel become a negotiating point under labour contracts? Not while jobs are at risk. Will employers incorporate medical travel into their self-insured health plans? This is happening. Payers are coming up with a variety of plan designs, and are assessing issues arising under state insurance regulations.
Despite the optimism from some agencies, networks and providers, employer-paid or sponsored medical travel is in the foreseeable future going to be very small compared to individual business. Worldwide, insurers, businesses and hospitals have a huge stake in not upsetting the status quo. There is little if any competitive advantage to offer medical travel, for anyone with any existing Involvement in the provision of health and health insurance to companies.
Europe is not going to offer a market, except perhaps for employee-paid dental and cosmetic treatment. In the US, the situation is more promising as more employers struggle with exiting health insurance costs. But even here, it is at best going to be only an option for the small percentage of the workplace that will consider overseas, while most get treated at home. The most fertile market is small- or medium-sized companies, not the big nationals or multinationals. This will often come in the form of self-pay or part self-pay schemes where the business bypasses the conventional insurance market.
Any hospital or agency expecting US businesses to even partly replace domestic treatment with overseas treatment, just by offering low prices, is going to be rapidly disillusioned. Another concern is that new agencies with no experience are targeting employers as a golden new market. The risk is that they, their investors, and employers will be disillusioned when the over-hyped claims and promises that we are already beginning to see, prove imaginary.
Employer-paid medical travel will grow, but will be a long slow hard sell needing patience, experience, initiative and imagination.
Read some case histories.