Medical Travel Today (MTT):  Tell us about yourself and your experience with medical travel. Nicole Serfontein (NS): I’m South African and after practicing law and consulting in the private health sector, I spent a few years in the U.K., where I reviewed health systems and the delivery of private healthcare services in Europe and Asia in relation to medical travel and expat business travelers. When we talk about medical travel, we are addressing a broad concept. An important point to consider is that various segments of an organization’s employee population are likely to be impacted by business travelers, the expat community, including third country nationals, and key local nationals. With businesses continuing to expand operations into different markets, more people are travelling or relocating to different countries. Chronic conditions are growing in prevalence, especially those related to lifestyle behaviors, and there is significant variation in the access and quality of services in healthcare systems across the world. Clearly, some countries do have good healthcare systems and others don’t — either because there’s a lack of financial or healthcare resources, or there’s insufficient qualified staff or facilities in a particular region. Whatever the cause may be, there’s a number of reasons for Corporate to make sure that their employees and dependents are covered adequately when accessing and receiving care in another country. As part of the assessment to determine the need for international medical coverage, the type of benefits and the term of the policy, employers need to consider both the duration and reasons for travel.  From a risk management perspective, I think it’s absolutely critical that employers identify their “mobile population,” the destination and the healthcare context of the destination. It’s important to assess the environments of the host country — especially in comparison to the home country. If employees or their family members access healthcare services or products outside the US, we know there is the potential for less than optimal outcomes, which could lead to intensive intervention or disability.  This could potentially have significant ramifications for an employer. MTT:  If you were talking to an employer, how would you recommend that they select either the country or the provider that they would be sending their employee to? NS:  It’s not necessarily a case of selecting the host country because primarily that is driven by business priorities.  The employer will have a strategic reason for employees to be travelling or relocating to a particular location. MTT:  Not necessarily.  If they are looking at saving money, particularly in the self-funded market, they are now looking at medical travel.  They may be investigating opportunities to save significant dollars on particular procedures.  Are you familiar with that? NS:  There are cases where US employers have sent an employee to receive medical treatment in a different country due to cost reasons. But this is less common and unrelated to business strategy or market growth. In terms of saving money, fewer US employers have embraced medical travel because of certain risks in terms of taxation, labor issues and employee liability concerns.  Sometimes, these considerations outweigh the actual cost savings, even though the treatment itself is less expensive. Complex operations carried out in another country without an immediate local support system carries unknown implications. Also, healthcare reform is sure to change the dynamics surrounding cost and delivery of quality of care in the US, which could affect medical travel. Another consideration is the fact that medical inflation is increasing rapidly in a number of countries. While prices aren’t at the level of those in the US, an employer shouldn’t consider less expensive access to care as the sole factor.  Instead, proactive, long-term thinking strategies are required to control costs. MTT:  What do you think the international healthcare community of hospitals/providers could do to raise the level of confidence that US employers have in their health systems?  Do we need international benchmarks for quality, outcomes or infection control?  Do we need to have an international medical travel association that would address these issues?  NS:   I think this is an important issue that is being recognized by many countries. International public health bodies, such as the World Health Organization, assess the quality of health systems and services to evaluate their overall performance, advantages and gaps. Within the private sector, there are private insurance carriers that credential health facilities or providers for their clients or members.  They often have an internal case or medical management team that will look at quality of services and the qualifications of providers. Their goal is to elevate the quality of care or, at the very least, review the level of services and products to measure and compare against care in the US. In addition, the JCI makes assessments at the global level. MTT:  There are 350 JCI-accredited hospitals internationally — so it’s a growing number.  NS:  Yes, which is good, and JCI appears to be playing a stronger role in the international arena.   About Nicole Serfontein Nicole Serfontein has worked in New York, London and South Africa, where she was a practicing attorney in the commercial and financial services industry. Currently, she is a senior consultant in Towers Watson’s International Practise in Washington, DC. Nicole is tasked with co-leading the global health initiative for North America and has consulted on health insurance and related matters for many multinational companies, government and plan trustees. In 2003, she was appointed by the Minister of Finance in South Africa to the South African Financial Services Board to draft and comment on regulations to the Financial Services Advisory Act. Nicole provides strategic consulting advice to multinational employers regarding global health programs, and consults to vendors to develop their global products. She has over 13 years of experience in the commercial financial services and healthcare sectors. The nature and scope of her assignments include:

• Market assessments and analysis of healthcare systems in key geographies for US vendors to develop global products and services relating to expatriate health plans and wellness programs for local workforces
• Designing global health and wellness strategies, governance frameworks and engagement/communication plans (including development of the Corporate business case to senior leaders, review of country data and cost and funding mechanisms, vendor procurement and negotiation and multi-country program implementation) for predominantly European and US Multinationals
• Regional assessment of HIV/AIDS provision and delivery in African continents, with deep expertise in South African legislation, delivery and financing
• Retiree Health Plan market assessment for the largest Indonesian private sector employer
• Design and implementation of expatriate health plans for European and US Headquarters

Nicole is an admitted attorney in South Africa and completed her Master in Laws in International Trade at Stellenbosch University (South Africa) and also her second Master in Laws in Global Health Law and Policy at Georgetown University Law Centre (USA). She taught the global health session on behalf of the Cached – Similar International Foundation of Employee Benefit Plans (You +1’d this publicly. Undo IFEBP; www.ifebp.org for its course in International Benefits.   Contact: Towers Watson 901 North Glebe Road, Arlington, VA, 22203 T +1 703 258 8286 M +1 703 975 6697 F +1 703 258 8093 [email protected]