Telehealth in the Portuguese private healthcare sector
by Micaela Seemann Monteiro
International Society for telemedicine an ehelath The Portuguese Private Healthcare Sector
The Portuguese private healthcare sector has been continuously growing throughout the last decades. Citizens who have access to private healthcare are usually also users of the public system. Waiting lists, not having a free choice of the treating physician in the public system, as well as convenience are the main reasons pointed out for choosing a private provider. About 31% of the Portuguese population held a private health insurance in 2019 . In the same year, 35.9% of the country’s health expenditure was private. From the 36,100 existing hospital beds 11,600 belonged to private hospitals, 33.8% of surgeries, 40.2% of outpatients ́ consultations and 26.6% of urgent care episodes were performed outside the NHS . There has generally been a constructive relationship between the NHS and private healthcare providers: The private sector has been collaborating with the public sector to combat NHS waiting lists. Thus, in 2019, the Portuguese SNS contracted 1.4 billion euros to the private sector for surgeries, consultations or complementary diagnostic tests . There also exist a few public-private partnerships in the management of NHS hospitals . On the other hand, there is also a controversial and potentially conflicting practice: a large proportion of health professionals are shared, i.e., they work in NHS institutions as well as in private hospitals.
Adoption of Telehealth among Traditional Private Healthcare Providers
The adoption and success of telehealth among private healthcare providers depends highly on the market’s reimbursement models. Whereasteleconsultations are fully covered by the main health insurances, other modalities, like telemonitoring are still not. Nonetheless, almost all major private healthcare providers – some forced by the COVID-pandemic – now offer telehealth services. Cuf is the largest Portuguese private healthcare provider and, since its foundation in 1945, the one with the longest experience in the market. It runs a large network of hospitals and ambulatory clinics. Teleradiology was the first telehealth service established in the early 2000s. This made it possible to provide all its hospitals with 24/7 radiologist coverage. In 2018, Cuf launched its first telemonitoring pilot for diabetes patients. In January 2020, Cuf created a new position in the organisation: the position of Clinical Director for Digital Transformation. It is the first of
its kind in the Portuguese healthcare sector and a strong indicator of the importance given to new models of care leveraged by new technologies. Since then, Cuf has been committed to actively redesigning care pathways based on a clear vision that the patient's clinical journey will be hybrid: remote touchpoints (e.g., teleconsultation) and digital touchpoints (e.g., app), will synergistically integrate with classical contact points, with professionals in physical health units. In March 2020, Cuf launched its teleconsultations as a new channel for follow-up consultations in more than 30 specialities, but also for first appointments in selected ones. In the first 12 months more than 75,000 video consultations were performed. During the COVID-19 pandemic it created a remote monitoring service with biometrics for patients assisted in Cuf’s urgent care services, that not having an indication for hospitalisation, benefited from clinical surveillance. In June 2020, it launched its first service following a remote first concept: a video-consultation designed for assistance to acute, non-urgent illnesses. It has a dedicated medical team, geographically decentralised, but with its own clinical governance and specific clinical and non-clinical procedures. It serves adult and paediatric clients from all over the country and even beyond its borders and is integrated with the physical offer, whenever necessary. One of its main features is its high-resolution rate. Less than 10% of cases need referral to onsite care - only 3% to an emergency or urgent care service . Luz Saúde, the second largest private healthcare provider in Portugal, was the first healthcare provider in the country to launch direct physician- to-patient video consultations in 2016. For this purpose, it created Hospital da Luz Digital Clinical Center, with a dedicated physical infrastructure, clinical leadership, as well as specific rules, procedures and training to ensure quality and safety of its services, as well as providers’ capacitation. In 2020, Luz Saúde created its own, free-of-charge, 24/7 nurse phone triage, Luz24, based on algorithms for paediatric and adult patients with the aim to support clients and to streamline urgent care flow in their physical units. During its first year, it performed more than 25,000 triage episodes. When eligible, patients can be directed to an urgent video consultation with a doctor for further evaluation and guidance. Other telehealth services so far provided by Luz Saúde are teletherapy in the areas of speech therapy and physiotherapy . Lusíadas, the third largest private healthcare provider, also launched teleconsultations and a nurse phone triage during COVID-19 pandemic .
Private Health Insurers - From Financier to Provider Leveraged By Telehealth
In Portugal, private health insurers have traditionally limited their role to financing and have not directly provided healthcare. This has changed in recent years - much leveraged by telehealth. The three largest companies, Multicare (Fidelidade) Médis (Ageas), and AdvanceCare (Tranquilidade) today offer nurse phone triage, symptom checkers, as well as general medicine and paediatrics video consultations – some free of charge for their policy holders . However, the insurer Medis has the longest history of using telehealth and has been especially innovative in this field. In 1996, it created the first nurse phone triage service in the country. This inspired the Portuguese NHS to set up its own service for the paediatric population. Médis supported the creation of the phone line "dói, dói, trim, trim" in 1998, which later widened its scope and evolved into the current NHS Contact Centre, SNS24. In 2015, Médis was the first to launch telemedicine booths for corporate partners, equipped with medical devices that enabled more sophisticatedvideo consultations. Recently Médis partnered with SWORD Health, a Portuguese tele-physiotherapy start-up .
Tech Innovators as New Healthcare Providers
Technological companies have been vigorously entering the healthcare space around the world over the past years. In Portugal, several health tech start-ups have emerged on the market – some with remarkable international success. When it comes to healthcare provision, the 2014 founded SWORD Health stands out. SWORD Health offers a virtual solution for musculoskeletal conditions that traditionally would be treated by physical therapy. The company offers remote physiotherapy through its licensed physical therapist and the SWORD Health Digital Therapist, an FDA and CE listed device with a tablet and motion sensors. The company already operates as care provider in three continents and has gathered 135$ million in funding. By the end of 2021, it is expected to have reached unicorn status. . Knok is a start-up founded in 2015. It developed a digital platform to connect patients with physicians. Initially it adopted a marketplace model for home visits or video consultations. Today it has its own medical team and performs about 130,000 video consultations per year. Meanwhile it extended its business providing its video consultation platform and advisory to third parties in Portugal, Spain and Latin America .
Telehealth Leveraging Private Philanthropy
The Instituto Marquês de Valle Flôr is a private Portuguese institution of public utility for development and cooperation with Portuguese-speaking countries. It was founded in 1951, first with a special focus on São Tomé e Príncipe. Health is one of its priorities. "Saúde para Todos" (Health for All)is a main project: Portuguese clinical teams from around 17 specialties are regularly brought in to help local teams in care and education. Since 2012, it has also extensively integrated telemedicine to support local doctors remotely from Portugal. To do this, it worked together with Portugal Telecom's (now Altice) innovation team and co-created a new telemedicine platform, which could overcome bandwidth constraints, often a problem in destination countries, thus enabling teleradiology, teleophthalmology and other image-intensive teleconsultations .
 https://observador.pt/2019/11/27/um-terco-dos-portugueses-tem-seguro-de-saude- privado-classe-media-e-baixa-sao-as-principais-clientes/
 Instituto Nacional de Estatística - Estatísticas da Saúde: 2019. Lisboa: INE, 2021
 https://www.sns.gov.pt/noticias/2020/09/30/mais-de-1400-milhoes-de-euros-com-o- setor-social-e-privado/
 www.cuf.pt self-reported data
 https://www.hospitaldaluz.pt/lisboa/pt; self-reported data
 https://www.medis.pt; self-reported data
 https://knok.pt; self-reported data
 https://www.imvf.org; self-reported data