by Maria K Todd, MHA PhD
Center for Health Tourism Strategy
As an expert in the healthcare industry and the author of the best selling-books on provider contracting with insurance plans, it should be no surprise that I receive calls from all over the world asking how I can help a hospital or clinic "get contracts" with medical tourism insurance companies. I also get consumer calls asking where a person can buy a medical tourism insurance policy.
I am thrilled to be able to share what I believe is a workaround that might offer many the next best solution. Protection from high medical bills for medically necessary treatment, diagnostic testing and surgeries. The catch is this: You must buy your own airline ticket to a country in Central Europe to get you to where the care is available.
To the best of our knowledge, a "medical tourism insurance" policy specific to medical tourism coverage is rare, if one exists at all. Some attempted to enter the market and failed in short order.
The reason that it is rare is because of 3 reasons:
- The likelihood is high that the policy would only be purchased by people intending to use the policy - this is called "adverse selection" in the insurance industry - meaning, in short, "when people with known high cost risks choose your product". Adverse selection risk is typically mitigated by policy holders who never submit a claim. The ratio of medical tourism insurance policy buyers to users would likely be 1:1. That is a kiss of death for an insurer. They need to sell policies to people who are never going to submit a claim to offset the claims costs of users.
- The underwriters and actuaries would not know how to assess the financial risk of the utilization and covered services - which creates a problem for regulators who oversee "insurance" programs. Regulators must verify the actuarial projections and underwriting assumptions to determine if the premium is set at a level high enough to cover anticipated risk. Premium calculations are often vetted 2 years in advance of selling the first policy. This allows for the regulators to do their work, push back with questions for clarification to actuaries and underwriters, and to train insurance sales agents to sell the policy.
- The cost of network development for an empanelled network of providers to be contracted to accept the fee schedules as payment in full would cost the health plan roughly $15,000 per facility (at a minimum). And that's if credentialing and privileging of doctors and dentists is delegated to the participating facility. If not, network development costs and site visits would be cost prohibitive and take years to build an adequate network. Since network adequacy is determined by the number of policies sold and estimated utilization patterns, network adequacy would be difficult to establish.
The alternative is not to establish an insurance product solely for the purpose of medical tourism. Instead, one could add a benefit option to an existing plan sold to cover most traditionally covered health care claims for medically necessary services, and add the option to travel for care as a plan participant's choice.
This is what we help Plan Administrators at self-funded employers and multiemployer groups (unions, associations, etc.) to arrange through our Mercury Health Travel subsidiary. You can see how Mercury Healthcare International, our master brand, ties our work in health and wellness tourism together in the depiction below.
Mercury Health Travel's typical clients are employers and unions of self-funded health benefit plans with 50-1000 plan participants and dependents. In the USA, about 80,000 of these employers and unions exist. They no longer pay premiums to a health insurance company to cover employee and eligible dependent health claims costs.
Our self-funded employer and labor union clients set their own rules, design their own plan, and negotiate with providers directly. Alternatively, they access existing networks of providers through a PPO, TPA, or ASO. (An ASO is a group health self-insurance program for large employers wherein the employer or labor union assumes responsibility for all claims risk for covered services, purchasing only administrative services from the insurer.)
Our clients embed a customized medical travel program as a pilot program at first and then later expanded if the reception by employees and dependents is positive. The model and approach we recommend requires little, if any modification to a self-funded company's or union 's existing policy documents. With one call and a little bit of data, we can determine if a medical travel program might benefit them. To learn more about our health travel division, visit Mercury Health Travel's website.
I've been finishing up the manuscript for my soon to be released book, titled, The Employer's Guide to Medical Tourism Benefit Design, which will be published by CRC /Productivity Press. In 2007 Productivity Press became part of CRC Press and the Taylor & Francis Group, LLC. Taylor & Francis is a division of Informa plc, a United Kingdom-based publisher and conference company. They have published 10 of my books in recent years.
What you can buy if you cannot afford care in the USA
During one of my research trips to Central Europe, I identified a potential alternative if you don't have a catastrophic policy, are ineligible for a catastrophic policy, or otherwise uninsured. You must be open to traveling to an international destination in Central Europe for care. You should be eligible to enter the country as a regular traveler. If you have no medical insurance, can afford to write a check for between $2500-$4000 plus your travel expenses, this policy may really be your solution. This policy covers most medically necessary (not cosmetic) surgery, dental care, rehabilitation, dialysis travel coordination or high-cost diagnostic testing or cancer staging, required prescriptions, and more. I was amazed and the rich benefit design for such a low cost. How they do it? the policy is offered by a subsidiary of the hospital. You must use that hospital to get most of your care. Very similar to an HMO plan with a very narrow network. The benefit year runs Jan 1-Dec 31, and covers you for the entire year, not just the single episode of care. The hospital is JCI-accredited and I have inspected it, been a patient there for an orthopedic consultation, and some other services, and have observed their safety and quality practices directly. It has my full professional endorsement without reservation. By withholding their name, I maintain this as informational and not advertising for them.
Some waiting periods apply for specific services and conditions. Other conditions and services are covered right away. The program is not intended for regular use to cover claims incurred within the USA. It is intended and designed so that the majority of your care will be rendered at the affiliated partner hospital in Europe. It is not "travel insurance".
To the best of our knowledge, this program is intended as full coverage, private medical and hospital insurance for local residents of that country, but is available to anyone willing to pay the premium and follow the in-network rules to obtain services.
A sworn affidavit of certain representations about your health is required, probably having to do with full or partial exclusions related to pre-existing conditions. Follow the rules and travel to the treatment destination for elective care and you may save tens of thousands of dollars if you need costly healthcare that you cannot otherwise afford. To go beyond that level of detail is uncomfortable for me as it exceeds my competency with their product and insurance policy interpretation is a regulated profession for which I have basic knowledge but lack adequate credentials.
You will probably be asked to pay your premium annually, in advance. The premium amount is set actuarially by age and gender and ranges about $2500 to $4000 per year. We are unsure about pre-existing exclusions, copays and other matters. We'll direct you to someone qualified to answer your questions rather than venture a guess.
If you choose to purchase a policy through this program, Mercury Health Travel will help you coordinate your care and travel plans to the Approved Provider(s) in Europe.
To be referred to the program and a qualified sales agent, call us and mention"ACUNES-MHT" so that our switchboard receptionist knows where to direct your call. Since we don't sell any insurance, failure to mention "ACUNES-MHT" will cause the switchboard receptionists to respond as if you dialed a wrong number and they will not transfer your call. Again, we derive no compensation whatsoever for the referral. This is simply an internal code to get past the switchboard since it is an anomaly to what we do every day at the Mercury Healthcare International companies.
DISCLAIMER: We are not insurance agents for the program, and we are not paid any sales or referral commission, in cash or in kind, to connect you to the appropriate parties to help you further.
ABOUT THE AUTHOR
Maria Todd is a trusted adviser and expert specialist to hospitals, clinics, governments, healthcare business owners, investors, and independent professionals. Clients call on her to help them do a better job of marketing, branding, or contracting with insurers and employers, and to grow their business.
Maria is the CEO of Mercury Healthcare International, in Denver, Colorado and the founder of Mercury Health Travel, the leader of the Health Tourism Practice Group of Mercury Advisory Group, the Executive Director of the Center for Health Tourism Strategy, its research and education resource center, and a Board Member and Advisor at Higowell, the world's first health tourism operations platform. She has been recognized as an Academician with the Ukrainian Academy of Rehabilitation and Human Health and is a member of the Scientific Committee of Termatalia in Spain. She is also a Board Member at Global Health Connections, a nonprofit organization associated with the University of Colorado MBA-HA program. She is the author of 15 internationally-published business improvement books in healthcare administration and health tourism.
Invite Dr Todd to speak at your next event. She presents a compelling workshop of interest to tourism and economic development officials, foreign investors, healthcare strategists, healthcare providers, hotels, and consumers.