ITIJ - Santo Domingo Review 2019

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ITIJ 218 | March 2019

Held in the beautiful surroundings of the El Embajador Hotel, ITIC Santo Domingo brought together leading industry figures from across the travel and health insurance spectrum on 24-26 February. Expert speakers from North, Central and South America shared their insights and experience with the gathered audience, providing an excellent platform for the exchange of information and an opportunity to learn from one another

After a busy networking breakfast, ITIC Americas 2019 began with an address from Alejandro Cambiaso, President and Founder of the Dominican Republic Health Tourism Association, who shared with the audience his insights into the inner workings of the local healthcare system. 

He shared statistics and data showing the number of public and private facilities on the island, as well as the funding system that forms the backbone of healthcare provision. Medical tourism, said Alejandro, is becoming more important for private health service providers, most of whom are in the process of gaining international accreditation. An overview of some of the top hospitals on the island serving international patients highlighted the different specialities available, which include cardiovascular care and oncology; however, dental treatments, general and plastic surgery are currently the most popular treatments for medical tourists. During the discussion following Alejandro’s presentation, the fact that medical tourism has pushed forward the development of medical services in general on the island was emphasised – as the public healthcare system lacks the resources to cater to tourists, private providers catering to international patients are considered the best place for tourists to go. There is an upcoming move towards the development of urgent care centres on the island, which will help to treat tourists needing emergency care.
"Medical tourism is becoming more important for private health service providers"
Dale Buckner, President and CEO of Global Guardian, focused on the issue of data security in communications. Medical records have a financial value, said Dale, and for hackers, medical records are extremely valuable in significant numbers. The problem, he explained, is that ‘every single thing you do now is trackable – if you have a cellphone in your pocket, or a laptop, depending on how you connect to wi-fi, you are making your information and that of your company accessible to hackers’. With 90 per cent of companies’ cyber budgets being dedicated to defending systems, Dale said that this has to change, and more money needs to be invested in training the end user to navigate the internet more securely before systems will become more secure. During the discussion, an audience member asked about why medical records are worth so much, to which Dale explained that each record is worth around US$70 and, on the dark web, that information can be sold and then used for loans and credit cards multiple times – it’s not the medical information that’s valuable, it’s the administrative info.
Following Dale’s (slightly terrifying) presentation, we moved on to the more sedate topic of travel insurance regulation in the US. Greg Mitchell of Frost Todd Brown LLC gave attendees an overview of the different regulations affecting the sale of travel cover, including the Limited Lines Travel Insurance Model Act, which has been widely accepted. There are, he said, a number of ongoing regulatory challenges, including differing opinions as to how definitions and provisions of model acts and regulatory settlement agreements should be implemented; licensing; bundling of insurance products; mandatory coverage; and the definition of assistance services.
The positive and negative effects of advances in medical technology was the next topic under the ITIC microscope, with contributions from Eduardo Cruz of Humano SegurosArturo Aceves-Serrano of Philadelphia International Medicine, and Dr Cai Glushak from AXA Partners. Diagnosis and treatment have both been revolutionised by the application of telemedicine services, whether this is applied through online consultations or wearable technology, according to Arturo. However, there are challenges that need to be overcome in order to ensure telemedical service availability – these include legal, protection, privacy and access to internet connections. 
"Diagnosis and treatment have both been revolutionised by the application of telemedicine services"
Agreeing that telemedicine has the potential to improve care and access to medical services, Cai asked whether or not utilisation rates could increase as a result of telemedicine services, which would actually mean insurers would spend more as they have more members using their services, and while there are savings to be made, perhaps the cost difference isn’t as significant as it could be. Cai’s presentation focused on medical spending from AXA’s point of view, identifying where in the world is currently more expensive for a traveller to become sick. Examples of how technology advancements can affect costs in different ways, he pointed out that ECMO patients used to cost a huge amount of money as they spent a lot of time in the ICU in recovery, but now these patients can be flown on air ambulances, they can be repatriated, and costs contained. The same is not true, however, for all procedures, and sometimes technology moves so quickly that there isn’t time for enough research to show that clinical outcomes are being improved through the use of technology.
"ECMO patients used to cost a huge amount of money as they spent a lot of time in the ICU in recovery"
Eduardo said that technological progress has improved health outcomes, but has not lowered costs. The cost of healthcare will only ever increase, and Eduardo’s presentation considered what is driving these cost increases, one of which is the development of technology – and this applies to wearables, drug development and 3D printed devices. The advent of the Internet of Everything has taken over from the Internet of Things, and the application of this to healthcare information gathering and feedback to users and insurers could be very valuable. “Biology,” he concluded, “is going to be the new software.”
The next session focused on traveller security and other risks in South and Central America. Andres Zahnd, Special Projects Manager of Universal Assistance, pointed out that while perception of the risks to travellers in South and Central America focuses on security issues, actually around 90 per cent of assistance cases handled by the company are medical in nature. Andres followed up with a detailed examination of medical claims costs in Latin America, considering the causes of claims, and what insurers can subsequently do to educate their clients and minimise the risks to which they are exposed during their travels. Andres’ presentation also explained the detail of a case that started as a security issue and resulted in becoming a complex medical assistance case, which emphasised the importance of utilising knowledgable local providers to ensure the best use of resources available.
Developing the topic further was Augustin Freitas from Ed Broking Miami Inc., who said that there were over 111 million travellers inbound to Latin America in 2017, the vast majority of whom (40 million) went to Mexico. Natural disasters, he pointed out, are common in these areas, and in fact most countries to which travellers are heading are exposed to a heightened risk of hurricanes, earthquakes and volcanos. Andres’ data showed the typical medical expenses limits of policies the company sells, and also the policies that people are buying, which showed that most policies sold had a limit of around US$50,000. The problems facing the industry, then, are low sum insured plans, no (or limited) natural disaster coverage, and an inefficient reimbursement process. Solutions on the table include product development, telemedicine services and enhanced underwriting to cover natural disasters and pre-existing conditions.
Bruce McIndoe, President and Founder of WorldAware, then took to the stage to point out that risk maps are very general, and you have to dig deeper into a country’s dynamic to recognise what is driving the risks to travellers. Once more, it comes down to perception – while much is made of kidnap risks in South America, in actual fact, the reality remains that the biggest risk to travellers is road accidents. Threat assessments, said Bruce, need to be detail specific – it is only by making geographically specific information available to travellers that they can be informed and err on the side of caution, avoiding areas that may pose a heightened risk. Bruce concluded his presentation by giving attendees threat assessments of various Central and South American destinations such as Cuba, Puerto Rico and Colombia.
The second day of ITIC Americas began with a panel session on treatment and evacuation options in the Caribbean, with contributions from Gonzalo Castillo Lopez from HelidosaDr Ferial Ladak, Medical Director of Global Excel Management, and Dr Frank Gillingham, Chief Medical Officer of GeoBlue, who was first on stage. 
Dr Gillingham discussed the reasons behind a medical evacuation, detailed the tiers of assessment that GeoBlue uses to make a decision on whether or not an evacuation is necessary, and listed the typical conditions from which patients are suffering that result in a medical evacuation, as well as the conditions that wouldn’t necessitate a medevac. Moving on, he then explained how he chooses his partner medical providers and air ambulance partners, and shared information about how GeoBlue rates the care provided in different Caribbean nations, with details about the islands from which the company always evacuates members.
The value that local assistance companies can provide was a topic of discussion after Dr Gillingham’s presentation, with opinion divided as to whether or not a local company’s loyalty in a questionable medevac situation would be towards the local healthcare provider, which wants to keep treating the patient, or towards the insurer that is paying for care and is seeking an evacuation for their client.
"would a local company’s loyalty in a questionable medevac situation be towards the local healthcare provider or towards the insurer?"
Dr Ladak’s presentation detailed the challenges faced by international insurers with clients needing medical care in the Caribbean, which include a misrepresentation of abilities, a lack of quality medical information, a focus on insurance coverage (patients not being treated until coverage is confirmed) and a refusal to allow patients to go to a higher level of care. By sharing details of case studies involving medical evacuations, Dr Ladak highlighted these issues, and how they can adversely affect patient outcomes and thus underline the need for prompt medical evacuation from certain places, especially when patients are suffering from certain conditions that depend upon immediate high quality treatment.
Gonzalo’s presentation focused on the importance of communication between payers and providers of air ambulance services, with prompt notification from the insurer that an evacuation is necessary, keeping in mind limitations such as local regulations and typical airport operating hours. Transparency in communication is key, he said, and this is not always the case for insurers – an inability to share information with an air ambulance operator can result in delays in service. Gonazalo also detailed the key attributes that air ambulance providers should offer to clients, with safety being the primary consideration.
"Transparency in communication is key … and this is not always the case for insurers"
The mid-morning session focused on the challenges insurers and assistance companies face during the Atlantic hurricane season. These include staffing issues in local hospitals just before a storm hits (staff will leave the island), and then afterwards the possible damage to infrastructure that makes communication with treating facilities difficult, said Eugene Delaune from Europ Assistance. Sourcing an air ambulance company just before a hurricane can also become extremely troublesome, as hospitals will pre-emptively evacuate their patients, and this is when having established agreements with local providers means an insurer can be less affected by the drop in provision.
"Sourcing an air ambulance company just before a hurricane can become extremely troublesome"
Abbe Bendell, Vice-President of International Services at Broward Health International, focused on the issue of hospital preparedness during the hurricane season, which is a constant process of ensuring adequate provisions are in place should the facility take a direct hit from a storm. As a hurricane approaches, a hospital will consider whether or not patients should be moved to a place of safety. Abbe highlighted certain other issues that insurers should be aware of, which include determining when a hospital will stop accepting patients and which international patients (and their families) can be moved to a hotel or flown home.
During a storm, hospitals that are in the path of the hurricane can typically expect power outages that could last for several days, the biggest implication of which is an inability to communicate with international insurers. Following a hurricane, a hospital must make an assessment of readiness to fully open or partially open should the building have sustained damage. International insurers and assistance companies may not be aware, but in a federally declared emergency, FEMA takes control of the airspace, making flights in or out extremely difficult, if not impossible. What hospitals need is understanding from their insurance partners that communication might not always be possible during an emergency, and flexibility is key in such a situation.
"Following a hurricane, a hospital must make an assessment of readiness to fully open or partially open should the building have sustained damage"
The final session of ITIC Americas featured presentations from independent consultant Julie RemmingtonRaija Itzchaki of GMMI and Eric Shatanof from Baptist Health South Florida, who all spoke on the topic of regional cost variations in the US, where the disparities in cost between east, west and central states is very relevant to the international insurance audience. Eric’s presentation focused on the cost of providing cutting-edge care; Baptist seeks to ‘employ the optimal modality of care for every cancer patient’, and this care, such as proton beam therapy, does come at a significant cost. The fact that certain hospitals can provide such treatment, while others can’t, inevitably results in variations in costs and charges to patients and their insurers.
Raija focused on the reasons behind the differences in the cost of care in different regions of the US and assessed the ways in which payers and providers are attempting to ensure fair prices for all, regardless of location. “The continuously rising cost of healthcare provides a key challenge for those settling and negotiating hospital charges,” said Raija, “but there are key tools that enable reasonable prices to be set.” She then shared some real-life cases with the audience, demonstrating how charges can be limited and costs controlled. Julie explained how the huge differences that exist for the same treatments by hospitals across the US present challenges for European insurance providers. In the first place, the risk is difficult to rate, and the lack of direct agreements with hospitals, combined with little or no chance to direct patients to a pre-selected facility, means that the chance of containing costs for international patients is slim. There are key differences, said Julie, in what hospitals want versus what travel insurers want, and these conflicts and a lack of transparency don’t always make for easy relationships. Julie concluded by offering some solutions to these issues that international payers are facing with high medical costs in the US for insured patients 

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