International employee health care trends: 2019

Four doctors discuss health, health care, international assignments and health insurance trends for the year ahead.

What will the 2019 health care trends be, particularly in relation to expats living abroad and the globally mobile? What new technology, markets, methods and mindsets might emerge or change? What will be less important and what will continue to be a focus of the health care and health insurance industry?

To help build a picture of the year to come, we joined four Aetna International clinical experts in conversation — Dr Lori Stetz, Dr Stella George, Dr Mitesh Patel and Dr Charushila Thadani. You can read short biographies of our experts at the bottom of this page.

The conversation highlighted that there will be four key areas of focus next year, as far as international employees are concerned:

1. The influence of social determinants of health on health care
2. The rise in mental health conditions
3. The importance of managing non-communicable diseases while abroad
4. The move towards a predictive, preventative, personalised and participative health care model  

You can also listen to Dr Anushka Patchava discussing health care trends for 2020 in our Fit For Duty podcast episode below.

1.    Social determinants: a focus in 2019

The health care industry is increasingly switching on to the need to build a rich picture of a person’s life — meeting them where they are — to really help them achieve the best possible health. It’s recognising that good health is about more than just the absence of sickness. This is because the health care a person receives influences their health and life expectancy by just 10 percent. So, for health care and benefits providers to be able to help people get on the path to better health, it’s crucial that they look beyond the person’s medical history and view them more holistically. This means taking the factors that have a 90 percent influence on health into consideration — the conditions in which people are born, live and work, including their behaviours and socio-economic circumstances. Otherwise known as the social determinants of health, these factors include economic status and stability, education, upbringing, neighbourhood, community and family.

Holistic well-being

“As medical professionals, we can’t look at a person’s health in a silo,” explains Dr Stella George. “We must look at the person as a whole, what socio-economic factors impact their life, what attitude they have towards their health and life, and the stressors on their overall well-being.”

Taking these stressors into account is as important as giving someone medication to treat an illness. Health care companies need to consider these factors to help ensure health strategies succeed.

Only 10 percent of the impact on health and life expectancy is determined by the care individuals receive by health care providers. The rest is influenced social determinants, genetics, lifestyle, preventative medicine, education and so on.

At a high level, 40 percent of health is driven by individual behaviour, 30 percent is determined by genetics, and 20 percent by social and environmental factors.

“For example,” says Dr Mitesh Patel. “Your economic class influences your alcohol intake, attitude to exercise, and whether you smoke. So, the social determinants are inexorably linked to your health and life expectancy. The key is that these things can be modified or influenced to an extent to impact a person’s health.”

Social determinants in an expat context

As Dr Lori Stetz explains, Aetna International’s population of expats “may not be living in a ‘food desert’ or struggling to simply make ends meet most of the time.”

This population’s social determinants are: moving somewhere new and different, dealing with integration and/or being separated from family. Expat social determinants are there, they’re just defined differently to other populations.

Economic stability

Those on international assignments or living abroad often face the unknown in terms of economic stability, and this is a key social determinant of health. Not knowing what to expect in terms of expenses in your host country is one of a multitude of economic events or conditions that may trigger stress (also known as stressors) that expats face. Life can be unscripted with an international move and employers have a duty to provide education and support to employees facing these stressors. Setting people off on the right foot will pay dividends for the employee and the organisation.

Neighbourhood and physical environment

Neighbourhood and physical environment can have a significant impact on a person’s behaviours and health. “For example, you might be moving to live in an expat compound in Saudi Arabia where you’re restricted in your movements and by the climate,” says Dr Patel.

Education, culture and health care

The relationship between a person’s national culture and education can also make people vulnerable and this can negatively impact an international employee’s health. Dr George explains one example where highly educated professionals who, in their first trimester of pregnancy, are socially isolated in their host country. These individuals prefer to consult with a doctor back home, because they don’t know how to access the care they need in their new environment, and only engage a local hospital in their third trimester. “The result,” she explains, “is high levels of preterm labour, high demand for neonatal intensive care and very high claims costs.”

Dr Stetz concludes, “So, as you can see, there’s so much more that international employers and communities can do to understand the influence of social determinants on health and life expectancy. The importance of ongoing support before, during and after a move — once an individual has repatriated home again — are going to be a key focus for medical insurers, employers and health care providers.”

2.    Tackling the rise in mental health conditions

At Aetna International, we’re starting to see employers and governments becoming increasingly aware of the implications of anxiety and depression on the well-being of individuals. Dr Stetz explains that as a result of this, many corporations, government bodies and policy makers are now taking meaningful steps to help people achieve better mental health as part of a drive towards helping people achieve greater overall well-being.

Expat and globally mobile stressors

“When it comes to expats and mental health, whatever job the individual has will impact their overall health and well-being,” says Dr George. “Quite often, employees on assignment face intense pressures of a work promotion at the same time as managing their family life and health in an overseas context. Unfortunately, health and family come second.”

Other factors also have an impact:

• frequent travel;
• always being available and ‘switched-on’ via technology;
• the stressors of living abroad; and
• removal of social support structures.

Changing attitudes to mental health

There was a time in mental health where clinicians and providers would talk about psychiatry and psychiatric medicine but now there’s a focus on meditation, mindfulness and yoga. People want to learn to manage their levels of stress and anxiety, and most employers want to offer information and support mindfulness.

“But,” as Dr George adds, “there are also places &mash; such as the Middle East — where these things are not gaining popularity.”

“In the UAE, changes are happening, but it is the expat community and their attitudes to mental health that are driving change,” explains Dr Charushila Thadani. “What you will see is a Western patient talking to physicians about stress or mental health issues, rather than the Asian or local population.”

“As much as we want to say mental health is recognised and an important aspect of any chronic disease management, it’s still taboo. We don’t see many physicians even acknowledging mental health issues before addressing them accordingly. In the UAE, there are many things available that don’t get used because of the stigma attached to mental health issues.”

Dr Stetz cites how Aetna International are helping to facilitate this change in Hong Kong — supporting the Mind Hong Kong charity which raises awareness and helps people to access mental health care. “Hong Kong is unique,” she says. “It’s an Asian culture but it’s also very multicultural. This has been driven, in part, by the expat community (Mind Hong Kong is similar to Mind UK) and it’s an example of where the winds of change have arrived.”

Gaming will help some mental health sufferers

There are specifically designed gaming apps now that can help people with mental health issues. These games can also be used to gauge what individuals need from care. “This is something novel where health providers and promoters can achieve a really different outcome than just sending an email saying: ‘look at the bright side’,” says Dr Stetz. 

3.    Taking steps to manage conditions on the move

There’s a back-to-basics trend, focusing on body, mind and spirit, and a renewed emphasis on ‘total wellness’. We know about the physical wellness aspects of eating right and taking exercise, but there is an increasing emphasis on the emotional and spiritual aspects of wellness which can help manage non-communicable diseases.

We know non-communicable diseases (NCDs, such as heart disease, cancer, diabetes and chronic respiratory diseases) are continuing to rise on a macro level. At an individual level, increasing emphasis is being placed on the preparation that can be done prior to an assignment or a business trip to ensure a person stays well on the move. International travel can exacerbate pre-existing conditions.

“The focus is on managing your health and wellness rather than only worrying about the the outbreaks of diseases such as Dengue, Zika and Ebola that receive a lot of media attention,” says Dr George. “There’s also a rise in incidents arising from individuals travelling without their medication, without means to refill medications and being caught out by buying medicines that turn out to be fake.”

Dr Stetz explains that while Aetna International routinely facilitate transport for individuals suffering from illnesses such as Malaria and Dengue fever, medical evacuations are often for routine things such as kidney stones and heart attacks. “It’s not always unusual or exotic.”

“Relatively few of the emergency evacuations we have received this year have been due solely to location risks. Sometimes it’s a bit of bad luck or actually people not taking necessary precautions,” says Dr Patel. “Even highly educated people, some of whom work in health care can get caught, so it can happen to anybody.”

Aetna International’s main concern is not only on communicable diseases. We’re also focused on non-communicable diseases — those that relate to our lifestyle, socio-economic circumstances or the behavioural decisions we make. We’re focused on the preventative side of health care and, as such, pre-trip planning remains important. People should speak to a health care nurse before relocating overseas or travelling. Prevention is better than cure — that’s an important premise to remember.

“Getting a good understanding of the country an individual is moving to or living in as an expat is going to remain a challenge for employers,” adds Dr Thadani.

More long-term international assignments will become short-term

Expat assignments are getting shorter to cut employer costs — and we expect that to continue. If the job can be done in less time, it will save money and lower risk. When businesses send whole families to the other side of the pplanet, it’s a large undertaking and companies may find that they’re able to send employees on short-term assignments on a regular basis, saving time and money.

However, as Dr Stetz acknowledges, there are risks to both approaches. She explains how, when you send a family abroad, there are the challenges of assimilation and getting used to school and health care for the employee and family. When the family stays at home, there are other risks.

“For example, solo international expats can sometimes fall into bad habits and increase their health risks. There will likely be a continued move to more short-term assignments and we’ll need to help our members confront and prepare for those specific associated risks.”

Being prepared for travel and relocation

As non-communicable diseases rise, Aetna International is able to see the difference between our expat members who are going through a pre-trip planning process compared with those who don’t.

Dr Patel offers a hypothetical, “Those who aren’t as well prepared for travel get caught without their medication, which they need to manage their condition. That means an emergency refill and if they aren’t using the proper channels, individuals can get caught out with ‘fake’ medicines. International travel can exacerbate pre-existing conditions.”

Pre-trip planning and pre-assignment health and fitness screenings are becoming more widely adopted and this trend will continue next year and beyond. Screening people and ensuring they’re set up to continue their treatment and medication journey abroad can potentially be the difference between assignment success and failure, and the costs associated with those scenarios.

Increased importance of single source of health, safety and security information

“Travellers can get ‘information whiplash’,” says Dr Stetz. “One minute we’re focused on Zika and everyone’s talking about that, then, three months later you don’t hear the word. But it’s still there, not much has changed. It’s the same with Ebola, it’s still smouldering.”

As such, it’s important for travellers and expats to keep up with emerging threats — including non-infectious diseases and security risks — in a world that switches its focus so quickly.

Increased travel system integration

Related to the above point is the increased integration of health and security information into travel logistics.

More travel systems will become integrated in 2019. For example, Aetna International’s employee travel system feeds into a tracker and delivers notifications of travel security risks. Many individuals currently don’t have access to a single source of safety, security and health guidance.

There’s a danger of data overload for consumers

The means of acquiring information has changed over the last 15 years. We have access to vast amounts of a range of data, but the issue now is how to sort through it: what’s real and what’s critical. This is because, as Dr Stetz explains, there’s a danger of overload.

“There are a finite number of actions that need to be taken on the part of the individual (though there can be more around chronic disease), but there’s so much information around wellness and well-being. It all comes down to eating well, exercising, getting enough good-quality sleep and not smoking! It’s almost that basic.”

4.    The P4 health care model: personalisation, prevention, prediction and participation

The expanding role of predictive, precision medicine

“The role of precision medicine (the tailoring of medical treatment to the individual characteristics of each patient) is increasing. For example, the use of genetic testing for different types of cancer — especially in the U.S.”

Governments, including the UAE, are working on creating a database of genome sequencing of local populations to provide information for precision medicine.

Dr Charushila Thadani describes how the UAE Government has realised that they need better control over the health care system. As such, initiatives such as diagnosis related groups (DRG — a fee categorisation schedule of hospital costs) will be introduced for 2019 and this is expected to bring down costs — especially with operations from provider to provider in terms of particular services and tariffs.

The expansion of genetic testing to include more diseases than just cancers

“The genetic testing I have seen so far tends to be related to cancer, but the ‘detection’ of more diseases is coming,” says Dr George. “I recently attended a conference in the U.S. where three big private companies projected that, as these methods develop, based on the scale, the cost will eventually come down.”

Dr Stetz concurs, adding that many genetic testing costs are coming down rapidly.

Genetic testing helps to provide targeted therapies that improve the safety and effectiveness of treatment. For example, genomic profiling in certain tumours can identify individuals likely to benefit from chemotherapy and those who may not.

Dr Charu Thadani describes how the UAE Government has realised that they need better control over the health care system. As such, initiatives such as DRG (diagnosis related groups) will be introduced for 2019 and this is expected to bring down costs — especially with operations from provider to provider in terms of particular services and tariffs.

“In the UK,” says Dr Patel, “all the high-risk groups (over-65s, certain patients with chronic diseases, young children and pregnant women) have been given flu vaccines for this year, to prevent another crisis and unnecessary admissions to hospital. When there’s one payer and one service provider, health care is definitely becoming more proactive because you can see an immediate return on your investment.”

Aetna International are witnessing another example of this in Thailand, as Dr Stetz explains, “We recently undertook a pilot programme to deliver a number of flu shots free of charge, in the hope that it would reduce more serious illness and hospitalizations in a population cohort that was under five and over 55.”

“Now we’re following those members to see how effective the vaccine is in this prevention effort compared to those who didn’t receive it. We believe in prevention and hope to demonstrate that commitment here. Obviously, it costs money to give a flu shot, but it might become an example of a win/win.”

Dr Stetz says in the international private medical insurance (iPMI) space there’s generally a specific benefit for what is called ‘preventative care’ or ‘wellness’ but it’s provided separately to other benefits.  She adds that there’s a need for the industry to put a holistic approach to wellness at the heart of every plan, but that insurance providers are slowly becoming more proactive. “There’s a lot more talk than action, but there’s still some action.”

Health care will become more personalised

Whether it’s an IT company or health care company, everyone is building their own ways of gathering and processing data. How that impacts health care is something to watch in 2019.

This also impacts how members talk to their providers. Services have to be customised to entice members.

Dr Patel has a vision of the future: “Eventually we will see an Amazon of health care, where different technological pieces, variables and personalised medicine all come under one platform that makes sense to the individual.”

Currently, there are lots of different platforms, lots of different ways in which data is being collected, but it’s not being used to its full potential because no one holds the whole picture.

While we may not see this happen in 2019, by 2020 or 2025 we can expect a platform like Amazon where individuals log in and their entire health care journey is seamlessly connected.

Are you a health care broker looking to partner with an innovative and forward-thinking international health insurer? Find out more about working with Aetna International here.

About our experts

Dr Lori Stetz

As Senior Medical Director for Aetna International, Dr Lori Stetz, MHP, provides guidance, support, and medical leadership for all care management activities around the globe. Lori drives medical policy, and actively participates in strategic planning and program and product development in concurrence with changing markets and technologies. Lori also manages Aetna International’s emergency evacuation program, helping to ensure appropriate health care delivery for our members around the globe.

Dr Stella George

Dr George, MBBS, DPH, MBA, is the Head of Care Management (Americas) and is responsible for the delivery of all of our care management programs through her team’s global clinical operations. She is responsible for driving the care management strategy. She has oversight on the clinical program design which is focussed on developing member-centric innovative programs focused on increasing member engagement and improving health outcomes.

Dr Mitesh Patel

As Medical Director for Aetna International, Dr Patel provides guidance, support, and medical leadership for care management activities in Europe. Dr Patel also manages Aetna International’s emergency evacuation program, helping to ensure appropriate health care delivery for our members around the globe. Dr Patel graduated from King’s College University, London and also has a Healthcare Management degree from Imperial College, London. He is also a practicing physician in Emergency Medicine.

Dr Charushila Thadani

Dr Thadani, MBBS, MPH, is the Director of Health Services at Aetna International and oversees management of clinical operations in Middle East Africa and Europe region. She is responsible for executing the care management strategy and ensuring that our members have access to quality health care. She also provides clinical guidance on various health and wellness initiatives. Dr Thadani received her medical degree in India and has a Masters Degree in Public Health from London School of Hygiene and Tropical Medicine.

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