Expatriate health management: the untapped value of virtual care

As shopping and services increasingly go online, shopping malls are emptying out, queues at banks are disappearing and people are having everything from fresh produce to new cars delivered to their doorsteps.

But there’s one place you can still be assured of a long wait in many countries: the doctor’s surgery (or office). A 2015 study in the U.S. found that the average doctor visit took 121 minutes, including 37 minutes of travel time, 64 minutes of waiting time and just 20 minutes of face time with the doctor.¹ And those wait times have an impact beyond the inconvenience they cause: a Harris Poll survey found that 36 percent of respondents had delayed seeing a doctor either because they were too busy or because doctor visits take too long.²

However, that situation is rapidly changing as virtual care goes mainstream. In fact, the global industry looks set to be worth $19.5B by 2025, up from $6B in 2016.³ In the U.S., some 96 percent of large employers now offer virtual care as a benefit. While employees’ utilisation of their virtual care benefit has been rising in recent years, it remains relatively low. So, what will it take to tip the balance in favour of virtual care services? And what difference can employers expect virtual care to make to their sustainability, the health of their workforce and their bottom line?^4,5

Download the thought leading article and employer’s guide to virtual care here.

The benefits of virtual care

Virtual care, also known as virtual health or telemedicine, encompasses a host of technology-powered tools that deliver health care services remotely. As Dr Sneh Khemka, Vice President, Population Health Solutions and vHealth, Aetna International, explains, ‘With virtual health, consumers in almost any global location have remote, real-time access to primary care — a valuable doctor-led service that can help to diagnose or treat an illness or manage an ongoing condition. And more than that, the service can help people proactively get well and stay well. With virtual care, the technology merely provides the point of access, whether it’s by video, phone call, mobile application, secure email or messaging. The real value lies in its convenience, quality of care and affordability’.

Virtual care offerings are particularly appealing to many expats. As Richard di Benedetto, President, Aetna International, says, “With virtual care, people save a lot of time, because they don’t need to travel or take time off work [to attend a doctor’s appointment]. In some geographies, people might need two hours to go and see a family doctor, while with virtual care, you need just an appointment via phone or video.”⁶ Moreover, with virtual care people may be less likely to skip general check-ups, delay making appointments and ignore symptoms, all of which could lead to more serious health consequences down the line.

As technology continues to evolve, interest in virtual health looks set to grow, especially among expats who live in countries or regions where easy access to quality health care is a challenge. (According to the World Health Organization, “Approximately one half of the global population lives in rural areas, but these areas are served by only 38 percent of the total nursing workforce and by less than a quarter of the total physician workforce”).⁷

Dr Khemka agrees that virtual care is especially important for expats: “The greatest benefits accrue to international organisations with members working in host countries without a primary care infrastructure. It’s widely accepted that if you want to lower overall spending on health care, you need to address the primary care infrastructure.”

In India, for example, vHealth by Aetna, which uses our own expert doctors who are trained in telemedicine, shows the potential for virtual health. In a January 2019 survey, 92 percent of vHealth patients said they had saved time by using the service and 90 percent said they had avoided the need for an in-person doctor visit or additional clinical or specialist care.

Virtual care has the potential to be at least as effective as traditional in-person care, according to a Cochrane Library review of 93 clinical trials⁸. The review found no difference in mortality in patients with heart failure; that virtual care could reduce glucose levels in patients with diabetes; and that blood pressure and bad cholesterol levels were lower in those who used virtual care. The piece also reported improved blood pressure control in those with hypertension accessing care virtually. In seven studies, there was no difference for patients receiving therapy for mental health and substance abuse issues.

Outcomes are obviously of primary importance, but convenience may be the key selling point for people who no longer have to trek to the doctor’s surgery during work hours or pay extra to visit an urgent care clinic or emergency room after hours. Not surprisingly, many people express huge interest in virtual care. One survey found that 74 percent of patients would use telemedicine services if they were on offer. Another found that just 16 percent would choose the emergency room over virtual care for a minor medical problem. Aetna’s own recent survey findings show that expat employees’ willingness to adopt virtual health care grew from 50 percent in 2016 to 78 percent in 2018.⁹

Tackling the take-up rate

Despite the rosy outlook, however, there is a disconnect when it comes to utilisation. Deloitte found that just 23 percent of U.S. consumers have actually had a virtual visit with a doctor or a nurse — and that number may be artificially high. According to one report, ‘the share of large employers offering health plans that cover telemedicine has increased significantly from 2015 – 2018’. The report finds that 74 percent of firms whose plan had the largest enrolment covered telemedicine in 2018. In the U.S., telemedicine visits are projected to go from 23 million in 2017 to 105 million in 2022, but even then they will only account for 1 in 10 doctor visits.^10,11,12

“We’ve seen an acceleration in adoption in the last few years, but the real tipping point in utilisation is probably still between 5 and 15 years away”, says Dr Sneh Khemka. “However, virtual health is still highly beneficial today, particularly for people with no reliable access to primary care, organisations with time-poor executives, globally mobile employees and workers assigned to remote locations. It is also highly beneficial for individuals managing one or more chronic condition or who have trouble adhering to their medication, regardless of whether they’re an expat or not.”

“The uptake by employees is in part a cultural challenge”, says Simon Miller, Senior Director, Customer Proposition, Aetna International. “In many societies, such as the UK, we’ve been trained to believe that a doctor is a scarce and precious resource, so we often don’t use it unless we’re incredibly unwell. We need to reposition access to the general practitioner (GP) to focus on well-being as well as ailments, supporting people when they might be worried rather than just unwell. Virtual care provides access to a broader holistic view of your health and well-being, as doctors are trained (and have the time) to take a whole-person view of an individual’s health, circumstances, needs and goals, which can be discussed as easily online as in person”.

Miller continues, “Virtual care has the potential to lower costs associated with health care but only if it’s implemented in the right way as part of an integrated ecosystem. It’s critical to manage the end-to-end pathways for consumers, funnelling people to the right support at the right time and in the most convenient and cost-effective locations — which sometimes might not even need to be outside of the home or workplace. Home testing, digital tracking and online therapies are great current examples, and we’ll see more of this innovation develop over time.”

Virtual care and corporate health and wellness

Employers have a vested interest in virtual care and employee health and productivity. Done well, virtual care can reduce the indirect costs associated with employees missing work for doctor visits, showing up at work sick or being off work with a chronic long-term illness. An article in HR Tech Outlook magazine called telemedicine the top employer benefit quoted Bethany Schenk, Founder and CEO of Web Benefits Design, who explained why she offers all her employees a virtual care benefit: “One — I care about them. Two — they have important jobs; I need them here at work. Three — it is more convenient for my employees and more cost-effective for both my employees and me as the employer.”¹⁴

Even once they’ve found a virtual care service provider that is focussed on value-based care (achieving the best health outcomes for their workforce), employers can’t just offer a virtual care benefit and walk away. They must also educate their workers about it. ‘Be absolutely clear on how you’re going to promote your virtual health offering to ensure that you’re getting the right engagement, from the right people, at the right time’, says Dr Sneh Khemka. ‘Recognise that there will be a learning curve for employees; make sure they are aware of and understand the platform as well as guidance around how and when to use it. And continue promoting it so it becomes habitual for employees to use it for everyday health and wellness needs, to keep themselves fighting fit, rather than only when they’re ill’.

Simon Miller acknowledges that virtual health’s convenience is something of a double-edged sword. “When you provide easier access to health care, people may use it more or use it inappropriately, driving up short-term costs”, he says. “Long-term costs over an individual’s lifetime will be brought down, but the employer may not benefit directly if the individual changes companies or is on a different health plan at that point”.

That said, Miller believes it’s important for organisations to offer their workers access to virtual health: “In some cases, it’s about the convenience. In others, it’s about supporting them and their families when they’re overseas — a duty of care. And in other cases again, it’s about completing the care ecosystem. On the other hand, it’s also about making health care costs more sustainable in the long-term and ensuring a sustainable future for the organisation. By providing everyday solutions that help people keep fit and well as part of their benefits package, chances are that virtual care adoption will rise as people come to view it as a useful wellness tool, rather than a tool for people once they’re unwell”.

In terms of a sustainable future for organisations, it’s worth noting that younger workers are far more likely than their older co-workers to expect access to virtual health.  As Steve Wojcik, Vice President for Public Policy, National Business Group on Health, notes, “Young employees are used to getting everything through their phones. They want to access their healthcare through the same device.”¹⁴ One survey by the Employee Benefit Research Institute found that 40 percent of millennials — those born between 1981 and 1997 — consider virtual health to be an ‘extremely or very important option’, compared with 27 percent of Gen Xers and 19 percent of baby boomers. In other words, even if most of today’s workers aren’t clamouring for virtual health, future cohorts of workers certainly will be.^15,16,17

What does the future hold for virtual care?

Many Chinese models of virtual care, such as PingAn, are moving towards the concept of merging the online and offline medical worlds. According to Dr Khemka, we can “expect to see a blended service of virtual physician consultation and occasional things that need to be handled physically being managed by a machine. For instance, we might see prescriptions arranged electronically and delivered by a drone. We will see continued disruptive innovation.”

Virtual care looks set to become an increasingly sought-after benefit as part of a well-rounded employee package, particularly for international assignees and those in remote locations. As to whether it will help to lower health care costs for employers, the jury is still out. As Peterson-Kaiser stated in 2018, “For telemedicine to be able to move the needle on access to care or overall spending, more enrolees will need to take up these services.” What is clear, though, is that virtual care is a vastly untapped resource that has the potential to lead individuals to increasingly engage in their health, driving up positive health outcomes and, with it, value.¹⁸

An employer’s guide to selecting a good virtual care provider

1. Goals and objectives. Be clear on what it is your organisation is trying to achieve. Do you need to meet statutory requirements? Are you trying to reduce costs? Do you want to increase engagement through easier access to health care? Are you trying to provide the most complete health care package to your employees? Do you deploy workers to areas with poor health provision? Do you need to address specific problems, such as increased absenteeism or particular health conditions? By enumerating and ranking your goals and objectives, you can better determine which virtual care provider will best meet your needs.
2. Health care ecosystem. How do you envision the virtual care offering fitting into your health care ecosystem, including elements like insurance, onsite benefits and employee assistance programs? It’s important to look for a well-rounded solution that offers comprehensive ongoing primary care support as opposed to just infrequent consultations. It’s also important to look for providers that carefully screen their medical practitioners and/or employ them directly. And you’ll get more value from providers that offer additional services, such as ordering tests locally or issuing prescriptions.
3. Regulatory landscape. Check the regulatory landscape of the company you choose. Some virtual care providers take governance and regulations more seriously than others. Ask questions around this; it is very important.
4. Shared values and incentives. Choose an organisation that is aligned with you on your drive for cost containment and other key performance indicators such as reducing absenteeism and presenteeism. If a service is offered by an insurer, there’s a vested interest in helping you control costs and maximise workplace productivity. Contract with an organisation that has a shared incentive to avoid unnecessary medical costs, hospital visits and sickness-related absences and can work with you on reporting to evidence this.
5. Due diligence. Ensure that the solution is practical to implement, that the provider you’re working with delivers a robust and sustainable implementation approach. Find out how data is handled and other aspects of IT security and privacy. Look at the reporting. Ask who audits their data. Doing due diligence across the financial, clinical, data and security realms is essential.
6. Promotion. If you have invested in this valuable benefit, make sure your provider can work with you to effectively promote to office-based and remote employees through an engaging on-going multi-channel communications plan. At its best this should not just be about increasing general awareness of the service, but also prompting use amidst seasonal health risks and aligning with proactive health and wellbeing campaigns across your organisation.

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