When firms send employees to unfamiliar, sometimes hostile environments, the quality of healthcare can make or break an assignment. Mark Coleman investigates
Business may have become global, but healthcare certainly hasn't. The sheer diversity of systems around the world is only matched by the disparity in the treatment and facilities on offer. Which means ensuring consistent, quality healthcare on a global basis can be fraught with risks. When companies invest as much as $1.3 million on the average three-year expatriate assignment, the financial implications of having an assignment fail are significant. The implications for a firm's business and reputation can be even greater.
Safeguarding the health of expatriates and their families is a key factor in the success of international assignments for any multi-national organisation. Research from CIGNA International shows a firm's investment in international assignments is most likely to be safeguarded when expatriates and their families are culturally prepared. Yet more than half of expatriates feel lack of company communications about health and security issues is detrimental to their peace of mind and prospects for success.
In general the incidence of infectious diseases is greatest in tropical countries – between the Tropic of Cancer and the Tropic of Capricorn. One explanation of this phenomenon is climate, but another probably more important factor is the level of development and standards of hygiene in the region. This means expatriates are more likely to experience illnesses that reflect poor levels of hygiene and public health, such as diarrheal diseases, including cholera and parasites, typhoid, hepatitis and tuberculosis.
Violence outside of war situations may be politically or criminally motivated. In some countries, such as Pakistan, New Guinea and Colombia, the level of violent crime including kidnapping, is so high that middle class citizens and foreigners need constant personal security. Expatriates assigned to these areas would be well advised to look for business, rather than tourist information and use sources known for being frank.
Global variations
The Foreign & Commonwealth Office's (FCO) website at www.fco. gov.uk and US Department of State website at www.state.gov both offer excellent information, ranging from the latest details on volatile areas, to visa requirements and the locations of American schools. The FCO website also has links to other useful sites, such as www.doh.gov.uk/traveladvice and will tell you if clients should definitely not be sending people to a region, while international health insurers often provide access to country guides and member websites as part of the healthcare package.
When it comes to access to medical facilities, there is no consistent approach, and as Table 2 shows, standards can even vary within a country. In many developing countries, the best healthcare is usually concentrated in the capital or major city, with significantly lower quality elsewhere. These same countries can also have problems with medical training, or ingrained cultural practices, while countries such as Vietnam, Myanmar, India, Philippines and Kenya are challenged by inadequate buildings and issues with staffing and equipment.
So how can advisers help their clients overcome these global variations in healthcare cover, to provide an employee benefit as mobile as the workforce it serves? The answer is to quiz healthcare providers on the nature of their service. It's easy to arrange healthcare cover for a single country of destination, but most expatriates will be mobile within a region, which means localised healthcare can be at best expensive for their employer (picking up the bill for additional cover for business travel on a piecemeal basis), or at worst leaves the expatriate exposed to the risk of finding they are without healthcare cover when they need it most.
For employers, the pitfalls of mis-handling expatriate healthcare include falling foul of the law, reduced profitability, and loss of repute. For the individual and their family on assignment, the risks are more personal – with issues of personal safety and wellbeing, career progression and financial inconvenience all coming into play. A truly global healthcare management service should provide employees with seamless access to a package of information, such as a secure website, and an online database of international doctors and healthcare facilities. It should also enable members to speak to a doctor and ask advice, before seeking medical treatment, and obtain telephone referrals to qualified local doctors, safe in the knowledge that they meet recognised quality standards.
It's also worth noting that many clients – even large employers – have small expatriate populations relative to their total global workforce. As a result, they have little experience on which to base their questions to a potential international healthcare provider. Here are 10 key questions advisers should be asking insurers:
1. Can members speak to a physician, in any language, at any time?
Immediate access to a knowledgeable medical professional is key to assessing a condition quickly.
2. Which assistance company do you use and how experienced are they? Probe the vendor's capability and experience and establish whether expatriate medical assistance is their long-term core business or a recent diversification. It takes significant medical case activity to build a worldwide resource and knowledge base.
3. How is your assistance company integrated into your service, provider network and healthcare processes? The more integrated the better. This avoids cases being handled in isolation, being misrouted, requests for help being overlooked and eliminates opportunities for error.
4. What medical assistance services are included in your basic service?
Some carriers bundle certain medical assistance services into their core offering, while others make this a fee-for-service option. Indemnified evacuation and repatriation services are often an option.
5. Do your staff deliver international medical monitoring and care management and what is their clinical experience?
Beware of a US-centric, nurse-led set-up. The most effective care managers don't simply receive information. Ask if staff have practiced medicine abroad and understand all of the locations where you have staff.
6. Do you employ a full-time international medical director?
Few health insurers have a full-time international medical director with international clinical experience. Their presence indicates a commitment to quality medical care.
7. What sort of providers are in your international provider network?
A member is best served by a real-time medical assessment of their current symptoms, to determine the most appropriate provider or specialist. If the health insurer provides a directory of network providers, do they provide guidelines on how members can use the network appropriately?
8. What is the selection criteria for inclusion on your international provider directory? There is no international qualification, accreditation standard or process applied by health insurers. The gold standard is on-site evaluations by medical professionals, or a quality assurance process.
9. Do members have access to a prescription pharmacy network?
Being able to collect prescription drugs from a network of approved pharmacies – and only have to pay the excess or co-insurance, as opposed to the full price of the drugs – reduces claims administration, the need for expatriates to use their own money, and adds to their peace of mind.
10. What is your underwriting experience?
International plans are very different to UK domestic policies, where primary care, dentistry, maternity, chronic conditions and alternative therapy wouldn't usually be covered. A large portfolio of business gives underwriters an understanding of expatriate healthcare issues, and the experience to assess and price your client's potential utilisation effectively.
These questions are all worth asking. After all, the premise of most insurance is that a customer might claim. With international healthcare, the premise is not if, but when and how often will they claim?
Mark Coleman is international sales director for CIGNA International Expatriate Benefits
