Finding the right balance between quality of care and medical costs

The cost of medical care worldwide reached a historic high this year, surging from 7.4% in 2022 to a peak of 10.7% in 2023, according to the WTW 2023 Global Medical Trends Survey. Customers are expressing their discontent with exorbitant prices, but not in vain: the healthcare sector is listening. 

Helen Calderini, Head of Global Medical Network at APRIL International, articulated the urgency of this challenge at the ITIC Global 2023 conferences in Barcelona, during the session on Hospital Pricing and Cost Containment Solutions: "Medical inflation is not sustainable, and we cannot continue with these increasing prices. It's time for us to refocus on the situation and work together with a shared mission of providing healthcare for everyone. We're at a point where we need to rethink everything concerning healthcare policies.” 

Identifying the regions with the highest rates of global inflation in medical spending is just the beginning. According to APRIL International's data, the following cities have the highest rates: 

• Dubai 

• Geneva 

• Hong Kong 

• Mexico City 

• Montreal 

• New York City 

• Miami  

• Los Angeles 

• Singapore 
  

90% if the work is done before admission is needed 

In the face of these escalating costs, APRIL International prioritizes the management of its members' policies and their healthcare experience to curb expenses. This involves maintaining continuous communication with policyholders to ensure quality service, ranging from ensuring they are going to the most suitable healthcare facility for their medical treatment, to verifying that the diagnosis provided by healthcare professionals is correct, or even confirming that the country they are in is the most suitable for the recommended treatment. 

Behind this effort, there is a team of 26 in-house medical experts located all around the world, dedicated to analyzing different cases of policyholders. This is where APRIL International's digital solutions, such as the Easy Claim app, play a key role, allowing policyholders to request pre-authorizations online, check their policy, review their limitations, and access telehealth services with just a click; or the recently launched Easy Pay Card^[1], a digital payment card issued to insured members with expensive  outpatient treatments so they can directly pay healthcare providers for their medical treatment at the time of service.  

For instance, if the team of medical experts identifies that a patient underwent an MRI or a CT scan, they will engage with the insured individual to ascertain their well-being and advise them accordingly. This strategy hinges not only on persistent dialogue with policyholders but also on collaborations with healthcare providers and healthcare professionals. 

"We have 2 million healthcare providers that are part of APRIL International's medical network, where at any given time, we can rely on their expertise to help us with specific cases and cost containment. We can also leverage the expertise of our telemedicine partner, Teladoc Health, to provide second or even third medical opinions when needed," explains Helen. 

Additionally, APRIL International offers a solution for its healthcare providers: the provider portal, where healthcare providers can access APRIL databases to check if the member is covered, review their policy coverage, identify medical exclusions, and offer direct billing services. 

Negotiations with providers, a key action 

Part of the effort to offer fair healthcare costs also involves the ability to negotiate with both current and prospective healthcare providers. "If we have a high-cost case with a particular provider, we won't hesitate to go back to the provider and discuss the costs," explains Helen. 

However, there is more to the story; new network structures play a pivotal role. APRIL International is rolling out a tiered hospital system in select countries, a move intimately connected with product design. An example of this is in Dubai, where the MyHEALTH Dubai proposition is available for individuals and SMEs/large corporate in the IPMI space, where APRIL has established a three-tiered hospital network.  'Tier 1' denotes the most premium—and costly—hospitals, while 'Tier 2' offers hospitals of comparable quality to Tier 1 but at reduced prices. 'Tier 3' follows this pattern, providing even more cost-effective options. 

What does this mean? A member who wants to be insured in Dubai can choose a policy with either the Tier 1, Tier 2 or Tier 3 network, based on their preferences and budget. 

"Let's take, for example, a member who has opted for the Tier 2 network. Their premiums will be lower because they are with healthcare providers that offer services at a lower cost. However, if they wish to have access to Tier 1 healthcare providers, such as the American Hospital in Dubai, they will already know that on their plan, there is a 30% co-pay if they decide to visit hospitals in the Tier 1 medical network," details Helen. 

To better understand how this works in practice on a daily basis, let's examine three common cases: 

Patient #1 - Transferred from Singapore to Bangkok 

A knee replacement was necessary for this patient. Facing significant treatment costs in Singapore, APRIL International arranged for his transfer to Bangkok. This included covering his flights and hotel expenses, resulting in a saving of US $9,000. 

Patient #2 - Extremely high-cost estimate from a Swiss hospital 

An estimated cost—exceptionally high—for the hospitalization of a Swiss policyholder was received by the Hospital team. After reaching out to the Swiss hospital without a prompt response, APRIL International considered transferring the member from Dubai to France. Eventually, the Swiss hospital replied, acknowledging an error in their initial estimate, which allowed the Hospital team to save over US $22,000 just by questioning the cost estimate. 

Patient #3 - A gynecological case in Los Angeles 

For this member who required gynecological services, an estimate was received. The chosen facility was out of network, leading to higher costs. APRIL International entered discussions with the member and the Doctor, successfully bringing them into the medical network and saving over US $111,000. 

These examples represent just a fraction of the daily successes achieved by the Case Management team, underscoring APRIL International's commitment to ensuring mutually beneficial outcomes for all parties involved in the healthcare journey of its members. 

[1]  APRIL International is launching the new payment solution to policyholders from its French entity in Paris.