Editor’s Note: Nicole Serfontein is a senior consultant in Towers Watson’s International Practice in Washington, D.C. What follows is part two of a conversation between Serfontein and Laura Carabello, publisher of Medical Travel Today. Part One of the interview can be accessed here. MTT: Are you familiar with health savings accounts – and do you see medical travel as an option that would benefit both HSA account holders as well as employers? NS:  South Africa was the first country to come out with individual health savings accounts within the private sector, and the US followed. Singapore, South Africa and the US now offer this option, and while there are some advantages to HSAs, there are broader policy issues that have to be considered when implementing these accounts because of the funding and tax implications around them. One purpose of the HSA is that it’s a cost management tool and supports shared accountability of an employee’s health with the employer. It is not however, intended by employers to provide comprehensive health coverage to employees outside of the US. An employee cannot anticipate the extent and cost of health services they may require after relocating. In some cases the medical condition may be severe or catastrophic. A HSA is not a sufficient coverage for these types of treatments. Local providers or hospitals overseas want to be assured that an individual has sufficient coverage for reimbursement.   MTT:  Do you see that medical travel would be growing in popularity for US-based companies that have an international footprint? NS:  I’m not aware of statistics or publications that clearly point to the growth of employer interest in medical travel outside of the US.  For those employers that support medical tourism, it will be important to reassure employees that the provider in another country offers quality services. The question remains, “How do you determine quality?” Another consideration is how to compensate the individual if he or she needs to remain in the hospital for an extended stay. There are other complex issues that tap into this discussion, including travel expenses and any required follow-up visits which fall beyond the duration of the individual’s initial stay.   MTT:  If you were confronted with an end-of-life disease or condition and you could get treatment outside the country that wasn’t FDA-approved – such as certain stem cell treatments or new treatments for multiple sclerosis — would you take advantage of this personally?  Is that something you think employers should even be aware of?  NS:  Again, I think from an employer’s standpoint, they need to evaluate why a particular product or service cannot be accessed here in the US. Partly, that comes down to company policy decisions and, of course, what services providers are willing to provide and the associated costs. The US is progressive with developing new products and services and bringing them into the market, which is in part responsible for the high cost of healthcare in the country. We see early adoption of technologies and drugs by providers and patients within the US. In particular, we see patients coming to the US to receive specialized care and treatment because of the knowledge and expertise that has been developed, relatively quick access to the treatment, and leading edge technology. For those rare instances when a treatment is not available here in the US — from an employer’s standpoint — they need to evaluate why they’d want to make an exception for an employee to go to a country to receive treatment. Employers should evaluate the reasons to allow the access to treatment that is not yet FDA-approved and weigh that overall philosophy against their response to all employees to provide medical coverage in a consistent and uniform way.   MTT:  That’s an interesting point, and probably worthy of a whole other conversation at a future time. But for the purpose of this discussion, let’s consider the uninsured or underinsured – whether or not health reforms survive — what is your prediction on the role of medical travel? NS:  Employers will need to evaluate their options as provisions of the Health Care Reform Act are implemented, as well as the changing market dynamics, and base their decisions on the advantages of treating their employees within the US in comparison to the viability of sending certain employees, most likely in rare and limited circumstances, outside the US for treatment. That’s not necessarily a simple decision but, from the employer standpoint, when taking into account crucial components such as improved productivity, lower absenteeism, higher engagement and so on, providing access to some form of medical coverage within the US can provide advantages to their businesses and profitability. In terms of policy and evaluating options over the next several years, the general sentiment is that healthcare reform will survive in some form, requiring employers to re-evaluate current practices towards their underinsured or uninsured employees. Based on our client portfolio within the International Consulting Group, which is the multinational organization with large workforce populations, there is either insured or self-insured insurance coverage in place.   MTT: For employers sending an employee to Africa or Europe or anywhere, do they identify the providers for them, or do they just let them choose who they want? NS:  One way we assist employers is to identify credible insurance carriers and their capabilities and services.  We carry out an in-depth analysis and review a variety of aspects relating to the carrier’s general capabilities in a particular country or countries, and examine how they negotiate agreements with providers, the credentialing process, the range and quality of health services available, administrative services, and the cost implications. The selection of the providers or carrier also considers the unique requirements and needs of employers. One important goal for employers is to better equip employees with an understanding of the local health environment and assist them in navigating the system.   MTT: This is something that employers are continuing to evaluate? NS:  Yes. Some employers carry out a regular assessment of their carriers to ensure that their capabilities still match their business objectives and health requirements.   MTT:  How about the US hospitals that have connectivity and reputable programs outside the US—like Johns Hopkins or a few others that have built satellite hospitals all over the world.  Does that give you an increased sense of confidence? NS:  The presence of some US hospitals and clinics, like Johns Hopkins, in other countries supports clinical research and development, but employers will have to consider issues that impact their workforce when travelling outside the US and ensure there are no medical gaps in coverage in the host locations.  If employees travel to several countries, they will need to visit different providers in each location, and there may not be US facilities such as Johns Hopkins.   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 Practice in Washington, D.C. 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 (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]