Medical Trend Report

BENEFITS
TM
2019 Medical Trends

Around the World
2 2019 Medical Trends Around the World
2019 Medical Trends Around the World 3
Contents
1 Message From Mercer Marsh Benefits........................................................................................... 4
2 Key Trends Shaping Employer-Sponsored Medical Plans................................................................ 6
3 Medical Trend Rate Exceeds Economic Inflation ............................................................................ 8
4 Causes of Claims — Risks and Conditions ...................................................................................... 12
5 Supplier-Driven Pressure on Cost of Care.................................................................................... 16
6 Levers Being Employed for Cost Containment .............................................................................. 18
7 Strategic Investments Into the Future ......................................................................................... 24
8 In Closing........................................................................................................................................ 30
9 About This Survey......................................................................................................................... 34

1
Message From
Mercer Marsh
Benefits
On behalf of Mercer Marsh Benefits, for 2018 was 9.7%, and a similar increase is
I am delighted to release our fifth annual expected for 2019. In the absence of using active
Medical Trends Around the World survey, plan management strategies, employers will need
which provides forward-looking insights to allocate more and more of their remuneration
into the rising cost of health insurance budget toward benefits. This is at a time when the
for our clients around the world. It is workforce is demanding a broader set of rewards
encouraging that insurance and adjacent and more engaging program delivery.
industries are moving forward with
I’d like to thank the 204 insurers across 59
advancements to help organizations
countries* who participated in this year’s “short
optimize their employee benefit plan
form” survey (each year we alternate between a
costs so that programs are financially
summary and detailed research), which ran from
sustainable into the future.
January to March 2019. Our clients tell us that data
from the survey are a key input into plan design
As the new leader of Mercer Marsh Benefits, I
decisions, so we are grateful to insurers for sharing
am keen to ensure that we maintain our industry
their perspective on interventions that are most
leadership position by working with clients,
likely to be feasible and effective into the future.
insurers and other partners to drive innovative
data-driven approaches that improve health
We hope that you find the data and insights helpful.
and well-being and ensure that the right care
We look forward to working with you to design,
is delivered at the right time in the right place.
deliver and finance programs that can help you
We are encouraged to see that insurers are
optimize cost, manage risk, simplify program
responding to the challenges of the rising
delivery and digitally engage your workforce.
medical costs by continuing to make strategic
investments in digitization and data analytics.
However, we all need to do more to ensure health Hervé Balzano

coverage and care are affordable for employers
and employees: medical trends continue to Mercer Marsh Benefits
outpace general inflation by close to three times. International Leader
The average global medical trend rate observed
*Excludes the United States

2
Key Trends Shaping
Employer-Sponsored
Medical Plans
This year’s survey continues to explore Key findings Considerations for employers
how health conditions, supplier factors
and consumer habits are driving cost. No reprieve in medical inflation Plan ahead for design, delivery and financing cost-
Medical costs continue to outpace general inflation by containment measures, prioritizing solutions that enhance
close to three times. The average global medical trend access to quality healthcare. In the absence of aggressive
It also provides insights to how insurers are
rate observed for 2018 was 9.7%, with a similar increase short- and long-term interventions, employers will need
responding to these. We found no surprises in to consider budgeting for higher costs.
expected for 2019 and even higher rates for 2020.
many respects:
Shifting focus toward making members Engage with your benefit advisor, other employers,
• C
ancer and diseases of the circulatory system
smarter healthcare consumers insurers and internal resources to seize opportunities
remain the top two highest causes of claims, The number of insurers investing in initiatives to enable to give plan members the knowledge, tools and
based on cost. quality-focused care (right care at the right time in incentive to change buying habits, promoting provider
the right setting) has more than doubled — 29% have and consumer accountability.
• T
he top three health risk factors remain
indicated it as a top strategic investment area. We view
metabolic and cardiovascular risk, dietary risk this as a natural evolution of recent investments in data
and emotional/mental risk. analytics, which continue to be the top strategic focus
for insurers (for example, to identify abnormalities
We would like to highlight four key findings from in costs and medical practices; in Europe, 15% more
this year’s survey. insurers are delisting health providers due to clinical or
business practices).
Exploration is increasingly shifting Embrace digital disruption to make healthcare

to execution accessible and affordable across a spectrum of service
Exploration of virtual care both to contain medical providers, including physicians, mental health providers
costs and to encourage consumer-based behavior is and physical therapists. Supplement this with engaging
increasingly turning to execution — 78% of insurers and personalized communication to improve adoption
around the world are now considering or already of the services.
supporting virtual health consultations (highest in the
Middle East and Africa at 88%).
Lifestyle factors continuing to drive Make health a business imperative. Develop a holistic
increases in medical costs health and well-being strategy that supports
Circulatory, gastrointestinal and respiratory conditions, employees across their physical, emotional, financial
largely related to lifestyle choices, continue to drive and social well-being.
the top claims by cost and frequency.
3
Medical Trend Rate
Exceeds Economic
Inflation
The data from this year’s survey reflect a Based on your block of group or overall medical insurance business, what actual
slight increase in the actual medical trend medical trend rate did you experience in 2018 and are you projecting for 2019?
rate experienced by insurers in 2018, just
0.2 percentage points above the average All aspects of healthcare — including hospitalization, outpatient, medications,
reported in our report last year. However, maternity and vision — can be included in your assessment, but where
the average global medical trend rate possible, please exclude dental. The trend rate should account for per-
of 9.7% continues to outpace economic person increases in cost due to medical inflation, changes in utilization
inflation by about three times. patterns and other factors, like changes in government regulation.
Projections by survey respondents for 2019 reflect 2018 medical 2019 projected
the potential for a 9.6% global average, with most 2018 estimated 2019 forecast
Country/Region trend rate medical trend
inflation rate2 inflation rate2
countries reporting they expect the trend to experienced1 rate1
remain similar to last year. Global3 9.7% 3.2% 9.6% 3.3%
North America
Please note that the US is excluded from this Canada 8.5% 2.6% 8.5% 2.2%
report because it is a unique healthcare market. Asia 10.4% 2.5% 10.3% 2.6%
For information on US trends, see our separate China 9.7% 2.2% 10.2% 2.4%
Mercer National Survey of Employer-Sponsored
Hong Kong 9.3% 2.3% 9.1% 2.1%
Health Plans 2018 report.
India 8.5% 4.7% 9.3% 4.9%
Indonesia 11.0% 3.4% 10.5% 3.8%
Malaysia 13.4% 1.0% 13.6% 2.3%
Philippines 13.0% 4.9% 13.7% 4.0%
Singapore 10.0% 1.0% 10.1% 1.4%
South Korea 6.0% 1.5% 5.0% 1.8%
Taiwan 11.5% 1.5% 9.1% 1.3%
Thailand 7.9% 0.9% 8.5% 0.9%
Vietnam 14.5% 3.8% 14.2% 4.0%
Pacific 6.0% 1.8% 5.1% 2.0%
Australia 4.0% 2.2% 3.3% 2.3%
New Zealand 8.0% 1.4% 7.0% 1.7%
2018 medical 2019 projected 2018 medical 2019 projected

2018 estimated 2019 forecast 2018 estimated 2019 forecast
Country/Region trend rate medical trend Country/Region trend rate medical trend
inflation rate2 inflation rate2 inflation rate2 inflation rate2
experienced1 rate1 experienced1 rate1
Europe 8.1% 3.1% 8.3% 3.0% Middle East and Africa
14.0% 5.6% 13.6% 5.0%
Belgium 4.3% 2.2% 4.1% 1.8% (MEA)
Bahrain 8.8% 3.0% 7.6% 4.8%
Bulgaria 14.7% 2.6% 15.5% 2.3%
Egypt 25.0% 20.9% 22.0% 14.0%
Denmark 2.2% 1.4% 3.6% 1.7%
Kenya 13.8% 5.0% 12.2% 5.6%
France 3.3% 1.9% 1.3% 1.8%
Oman 22.6% 1.5% 24.3% 3.2%
Greece 3.7% 0.7% 3.7% 1.2%
Qatar 11.0% 3.7% 11.0% 3.5%
Hungary 19.2% 2.8% 17.3% 3.3%
Saudi Arabia 8.7% 2.6% 8.2% 2.0%
Ireland 4.2% 0.7% 4.5% 1.2% South Africa 11.1% 4.8% 11.3% 5.3%
Italy 3.7% 1.3% 3.2% 1.4% United Arab Emirates 11.2% 3.5% 12.2% 1.9%
Latvia 8.6% 2.7% 7.8% 2.4% Latin America
9.6% 2.7% 9.2% 3.3%
Lithuania 8.3% 2.5% 11.1% 2.2% (LATAM)4
Norway 5.1% 1.9% 6.3% 2.0% Argentina 41.1% 47.6% 39.6% 29.0%
Poland 7.1% 2.0% 7.7% 2.8% Brazil 16.9% 3.9% 15.5% 4.0%
Portugal 1.6% 1.7% 2.1% 1.6% Chile 6.1% 2.5% 6.2% 2.7%
Romania 15.0% 4.7% 10.0% 2.7% Colombia 7.0% 3.2% 5.3% 3.7%
Russia 8.4% 2.8% 8.7% 5.1% Dominican Republic 7.7% 1.2% 5.5% 4.2%
Serbia 10.5% 2.1% 7.1% 2.3% Mexico 12.9% 4.8% 14.2% 3.9%
Spain 5.1% 1.8% 5.1% 1.8% Panama 10.5% 1.0% 11.0% 2.4%
Sweden 6.0% 1.9% 5.6% 1.7% Peru 6.5% 2.2% 7.0% 2.5%
Switzerland 4.0% 1.1% 4.0% 1.4%
Turkey 15.5% 15.0% 27.0% 16.7%
Ukraine 23.5% 10.9% 20.0% 7.3%
United Kingdom 5.2% 2.5% 6.0% 2.2%
Impact of Brexit5,6
Multiple stakeholders are expecting Brexit to adversely impact medical
1. The medical trend rates reflect insurer survey results and may not be MMB’s view.
2. Sources for inflation rates include: costs. The British Medical Association expects that the UK’s withdrawal
• For all countries unless noted: International Monetary Fund, World Economic Outlook Database, January 2019 from the European Union will significantly affect the quality of care received
• For Latin America: Mercer's Latin America Economic Trends, January 2019 by patients due to notable threats, such as workforce shortages of EU
• Note for China and Mexico cities, the data refer to China and Mexico overall country data, respectively.
• Inflation rate information is strictly for general reference purpose; Mercer gives no guarantees as to its nationals, the end of reciprocal health agreements and reduced funding
accuracy and will not accept liability for decisions based on it. for healthcare research. The cost of medical supplies is also expected to
3. Average of 51 participating countries with an acceptable number of responses. increase. Given this trend, coupled with the increasing pressures on the
4. Venezuela is not included in the table due to the current socioeconomic conditions. Also Argentina has been
excluded from regional and global averages. National Health Service system, we expect to see increasing utilization of
5. Nuffield Trust Research. private treatment — in turn contributing to the plan costs.
6. B
ritish Medical Association. Brexit Briefing — The Impact of Leaving the EU on Patients, 2018.
Looking to the future
Do you expect the 2020 medical trend rate figure will be higher, lower or the same?
Global* Asia Europe LATAM MEA

Higher than the prior year projection 52% 58% 53% 39% 61%
Lower than the prior year projection 7% 4% 3% 18% 11%
Same as the prior year projection 41% 38% 45% 42% 28%
Insurers are generally predicting further increases on the horizon in 2020.

*"Global" includes all responses to the survey, including Canada, Australia and New Zealand.
US health update
While midsize and large employers (those with 500 or more employees) were able to hold
cost growth to 3.2%, smaller employers (10–499 employees) were hit with a substantially
Medical plan cost trends for the US are drawn from the Mercer National Survey of higher increase. Smaller employers tend to be fully insured and have fewer resources to
Employer-Sponsored Health Plans, which uses a national probability sample. The most devote to cost management.
recent survey, conducted in mid-2018, received responses from 2,409 employers.
But cost experience varies considerably from one employer to the next across all size
For more information on US health trends, interventions and strategies to control groups. Among all midsize and large employers, 27% had no increase at all, while 18%
cost, click here to purchase Mercer’s National Survey of Employer-Sponsored experienced increases of more than 10%. The smallest employers were the most likely to
Health Plans report for 2018. have had these very high increases. Very large employers — those with 20,000 or more
employees — were better able to keep their cost increases moderate, but even in this
group nearly 1 in 10 had increases of more than 10%.
While employers are under pressure to achieve sustainable cost growth, they are also
focused on providing a benefit package — and working experience — that will support an
Health benefit cost growth remained moderate in 2018, at 3.6%. But with an
engaged and thriving workforce.
increase of 4.4% projected for 2019, the trend is slowly moving upward —
and it’s once again above Consumer Price Index and workers’ earnings growth.
For the past several years, the survey has asked employers about their most important
strategies for managing their health plans in the near term. Monitoring and managing
Drugs remain a key cost driver in health plans — in particular, specialty drugs.
high-cost claims was in the top spot in 2017 and 2018. Interestingly, “a focused strategy
Even though the specialty drug trend has cooled slightly since last year, it’s still
for creating a culture of health” has moved up from third to a strong second.
in the double digits.
4
Causes of Claims —
Risks and Conditions
Non-communicable diseases continue to be the Based on (dollar) amount claimed, what were the top three causes of claims cost in 2018 based on your
leading cause of claims across all regions. Globally, book of group or overall business?
cancer and diseases of the circulatory system 0% 10% 20% 30% 40% 50% 60% 70% 80% 0% 10% 20% 30% 40% 50% 60% 70% 80%
remain the top two highest claims reported
(respectively) by most insurers, with gastrointestinal 59% 13%
57% 7%
diseases and respiratory conditions tied to round Cancer 61%
Obstetrics
and pregnancy
16%
73% 12%
out the top four claim categories in terms of cost. 33% 28%
49% 11%
It should be noted that, consistent with prior Diseases of the 54% Accidents, conditions 15%
45% 13%
years, fewer insurers in the Middle East and Africa circulatory system 52% derived from violence 3%
44% 6%
reported cancer in their top three causes of claim
cost; their most claimed category was respiratory 34% 8%
Gastrointestinal 39% Genitourinary 7%
diseases. Respiratory diseases also continue to top diseases
29%
conditions
11%
33% 6%
the most frequent claims in the region. 33% 6%
While overall less than 10% of insurers globally 33% 7%

44% 10%
reported mental conditions as one of the top three Respiratory
21%
Disease of
7%
conditions 30% the sense organs 3%
causes of claims costs, we see an increase in insurers 50% 6%
in Asia and Latin America reporting this compared

25% 7%
to last year. Although our opinion is speculative and Osteomuscular 14% Other (not classified 1%
37% 13%
access issues continue to be pervasive, this could be diseases 21% in another group) 3%
6% 6%
as a result of a number of factors:
17% 6%
• E
mployers putting pressure on insurers to Endocrine and 14% Mental 4%
11% 8%
remove mental health exclusions as part of their metabolic diseases 21% conditions 6%
44% 0%
design philosophy, increasingly being driven by
diversity and inclusion as well as comprehensive 14%
18%
care considerations Infectious
diseases
9%
9%
28%
• Increased recognition of the importance of
treating such conditions, ideally with a lowering
of stigma and cultural barriers in accessing
mental health treatment
Key Global Asia Europe LATAM MEA
• Better data capture and reporting
Respiratory conditions and gastrointestinal Based on (frequency) incidence of claims, what were the top three causes of claims in 2018 based on
diseases, respectively, still have the highest your book of group or overall business?
frequency of claims globally. Cancer and diseases of
0% 10% 20% 30% 40% 50% 60% 70% 0% 10% 20% 30% 40% 50% 60% 70%
the circulatory system round out the top four claim
categories in terms of frequency, with the latter 48% 12%
67% 3%
showing a marked increase in frequency in Europe. Respiratory
33%
Obstetrics
16%
conditions 48% and pregnancy 15%
56% 17%
The next highest categories vary by region.

43% 11%
For example, there is a high frequency of Gastrointestinal 47% Accidents, conditions 17%
37% 13%
osteomuscular diseases in Europe and endocrine diseases 61% derived from violence 3%
22% 0%
and metabolic diseases in Latin America, whereas
infectious diseases have a higher frequency of 42% 9%
42% 8%
claims in Asia and the Middle East and Africa. Diseases of the
37%
Other (not classified
12%
circulatory system 52% in another group) 3%
39% 0%
30% 8%
Cancer 30% Genitourinary 5%
36% 11%
24% conditions 9%
17% 6%
26% 6%
Osteomuscular 17% Blood diseases 3%
41% 7%
diseases 15% (hematological) 0%
11% 28%
23% 6%
Infectious 29% Mental 2%
15% 9%
diseases 18% conditions 6%
44% 0%
20%
Endocrine and 15%
11%
metabolic diseases 36%
50%
Key Global Asia Europe LATAM MEA

Lifestyle-related risks continue to contribute to declining health
What three risk factors do you think influence employer-sponsored group medical costs the most?
The hidden costs of
poor mental health1
Global Asia Europe LATAM MEA
Metabolic and Metabolic and Metabolic and Metabolic and Metabolic and Research by Oliver Wyman and the City Mental
1 cardiovascular risk cardiovascular risk cardiovascular risk cardiovascular risk cardiovascular risk
Health Alliance Hong Kong has shown that 37% of
employees in the professional services industry in
Hong Kong have experienced poor mental health
Emotional/Mental while in employment and 25% while working for
2 Dietary risk Occupational risk Dietary risk Dietary risk
risks their current employer. This is in line with findings
in the UK, where the Mental Health at Work survey
Emotional/Mental Emotional/Mental by Mercer Marsh Benefits and Business in the
3 Environmental risk Dietary risk Occupational risk Community indicated 1 in 3 people in the workforce
risks risks
has been formally diagnosed with a mental health
condition at some point in life and nearly two-
Occupational risk Dietary risk Occupational risk Tobacco smoke Environmental risk
thirds of people have experienced a mental health
4 issue due to work.
Emotional/Mental Stigma remains a major hindrance to accessing

5 Environmental risk Tobacco smoke Occupational risk Tobacco smoke support. Among Hong Kong respondents, 55%
risks
indicated that they experienced stigma themselves
Childhood and and/or know someone who has.
Environmental risk maternal under
nutrition Oliver Wyman estimates that the tangible costs to
professional services employers in Hong Kong could
be between US$0.7 billion and US$1.6 billion per year,
which is 40 to 90 times the current expenditure on
Globally, the top three risk factors remain metabolic and cardiovascular risk, dietary risk and emotional/
employee assistance programs (EAPs).
mental risk. This poses a challenge, as these risks continue to persistently contribute to the incidence of
chronic conditions. We have been observing that employers view
mental health as a key business imperative. EAPs
alone will not be enough; better prevention,
intervention mechanisms and engagement are
strongly needed among all levels of leadership.
1
ity Mental Health Alliance and Oliver Wyman. The Cost of Mental Ill Health
C
for Employers in Hong Kong, January 2019.
5
Supplier-Driven
Pressure on Cost
of Care
High-cost pharmaceuticals and biologics were the top supplier-driven reason for
cost increases globally, most notably in Latin America and Asia. This was followed by
new and expensive technology, most notably in Europe. Controlling pharmacy spend —
Canadian example
Wastage has been observed in the healthcare system due to the overprescribing of low-value health
tests and procedures — particularly in the Middle East and Africa region, where this is one of the top
reasons for cost increases. This points to the strong need for making employees smarter healthcare Controlling pharmacy spend demands constant
attention to healthcare reform legislation,
consumers and leveraging interventions that steer patients to high-quality care based on adherence prescribing trends, new drugs, innovative
to protocols and outcomes. technologies and evolving benefit program
pricing methods. Furthermore, the arrival on the
market of biologic and biosimilar drugs, ultra-
What are your top three supplier-driven reasons for cost increases? high-cost specialty drugs for rare diseases,
curative medications and the recent availability of
targeted gene therapies for cancer, which could
2% 2% represent costs upward of US$1,000,000 per
4%
Key year, is threatening the viability of private drug
4% insurance plans.
High-cost pharmaceuticals and
29%
biologics We are increasingly working with employers on
drug plan management strategies that use:
New diagnostics and procedures 9%
Overprescribing of low-value • A
dvanced analytical skills for identifying
health tests and procedures issues and trend factors
Extensive hospital inpatient • P
lan design that meets several objectives —
lengths of stay cost control, employee satisfaction, optimal
9% drug use, increase in return on investment,
Other provincial legislation compliance and, most
important, an improvement in employee health
Limited access to high-quality
care resulting in limited payment • U
p-to-the minute knowledge of
competition in the market Canadian legislation and underwriting
capabilities of insurers for the design
Poor quality of care
and implementation of modernized and
innovative drug management plans
Regulatory environments that 18%
limit hospital payment competition • P
artnerships with providers who offer
23%
Regulatory environments that superior services and a “lowest price in
limit preauthorization or physician Canada” guarantee; these portable
management solutions allow our clients to freely choose
their insurer while offering stability and
continuity of service for members
6
Levers Being
Employed for Cost
Containment
To what extent does your organization perform 0% 20% 40% 60% 80% 100%
the following to help manage plan member health 54% 6% 13% 27% Global
62% 6% 14% 18% Asia
and/or contain medical costs for employer- Coinsurance 38% 8% 15% 39% Europe
sponsored medical plans? 64% 3% 9% 24% LATAM

71% 12% 18% MEA
67% 9% 12% 12% Global

65% 9% 14% 12% Asia
In addition to efforts to improve the health and Deductibles/excesses 61% 12% 14% 14% Europe
76% 3% 12% 9%
well-being of plan members, we are seeing more 76% 6% 6% 12%
LATAM
MEA
use of design and management of health providers

72% 7% 10% 11% Global
to contain costs. 66% 6% 14% 14% Asia
Preauthorization, including assessment of
65% 9% 12% 14% Europe
reasonableness of procedure/supply cost
85% 6% 3% 6% LATAM
Globally, 54% and 67% of the insurers indicated 100% MEA
that coinsurance and deductibles, respectively, 62% 9% 12% 17% Global

are an active part of their plan management medical appropriateness of treatment
58% 9% 17% 6% 15% Asia
53% 9% 15% 23% Europe
undertaken and active involvement in
approach to mitigate medical costs and introduce determination of treatment 76% 6% 3% 15% LATAM
88% 6% 6%
consumerism among plan members. This is a large MEA
increase from last year, where 42% and 52% 80% 6% 5% 9% Global
65% 12% 9% 14% Asia
insurers globally were using coinsurance and Negotiated rates with health providers 84% 3%3% 11% Europe
deductibles, respectively. 91% 3%3%3% LATAM

94% 6% MEA
47% 11% 17% 25% Global
40% 15% 20% 25% Asia

Coverage or incentive to seek treatment on
47% 8% 19% 26% Europe
outpatient basis
61% 12% 12% 15% LATAM
65% 6% 6% 24% MEA
60% 12% 19% 9% Global
49% 17% 25% 9% Asia

Negotiated packaged/bundled pricing for
58% 11% 19% 12% Europe
Key specific procedures

85% 3%3% 9% LATAM
71% 12% 18% MEA
This is an active part of our current plan 68% 11% 8% 12% Global
management approach 45% 12% 22% 22% Asia

Preferred/narrow provider networks 78% 11% 11% Europe
We are experimenting and/or have developed plans 91% 9% LATAM
to initiate this within the next 24 months 71% 18% 6% 6% MEA
We are currently considering this 54% 15% 15% 16% Global
40% 15% 23% 22% Asia

We have no plans to invest in this area
Second opinion services 47% 19% 15% 19% Europe
79% 9% 6% 6% LATAM
82% 12% 6% MEA
Note: Due to rounding, percentages may not total 100.

To what extent does your organization perform 0% 20% 40% 60% 80% 100%
the following to help manage plan member health 35% 14% 22% 29% Global
29% 11% 28% 32% Asia
and/or contain medical costs for employer- Centers of excellence 32% 11% 27% 30% Europe
sponsored medical plans? (continued) 48% 15% 9% 27% LATAM

41% 35% 6% 18% MEA
13% 9% 15% 63% Global
15% 8% 23% 54% Asia
Support for medical tourism 7% 8% 9% 76% Europe

18% 9% 15% 58% LATAM
24% 18% 18% 41% MEA
48% 17% 19% 16% Global

51% 20% 17% 12% Asia
Education to make plan members smarter
41% 15% 24% 20% Europe
healthcare consumers
55% 9% 15% 21% LATAM
59% 29% 6% 6% MEA
36% 14% 16% 34% Global

38% 15% 18% 28% Asia
Provision of medical clinics near or onsite to
28% 18% 14% 41% Europe
sponsoring employer sites
45% 9% 9% 36% LATAM
53% 12% 24% 12% MEA
27% 14% 20% 39% Global

23% 15% 22% 40% Asia
Influencing government around legislative
24% 12% 19% 45% Europe
changes/health reform
33% 9% 15% 42% LATAM
29% 35% 18% 18% MEA
38% 21% 19% 22% Global

32% 17% 26% 25% Asia
Virtual health consultations/telemedicine 35% 26% 20% 19% Europe
Key 48% 12% 6% 33% LATAM

47% 35% 6% 12% MEA
This is an active part of our current plan 60% 8% 15% 16% Global
management approach 38% 11% 23% 28% Asia

Delisting providers due to clinical or
business practices 66% 5% 15% 14% Europe
We are experimenting and/or have developed plans 82% 3% 6% 9% LATAM
to initiate this within the next 24 months 65% 24% 6% 6% MEA
We are currently considering this 63% 9% 13% 15% Global

55% 11% 15% 18% Asia
We have no plans to invest in this area Defining reasonable and customary
charging limits 58% 9% 15% 18% Europe
76% 6% 9% 9% LATAM
82% 6% 6% 6% MEA

Levers being employed for cost containment
Designing plans that incentivize behavior Managing provider delivery Creating new front doors to
accessing health
We have seen a significant increase globally and Insurers are increasingly employing
across all regions, especially in the Middle East preauthorization strategies and working to In a bid to make healthcare more affordable and
and Africa, of plans utilizing coinsurance and negotiate the rate with providers, including easily accessible, a larger number of insurers
deductibles to encourage consumerism and embed preferred networks and negotiated packaged/ globally are adopting virtual health consultations/
accountability by the plan members. bundled pricing for specific procedures, in an telemedicine. An increase in onsite/near-site
effort to contain costs. clinics is also being seen in Asia and Latin America.
More insurers globally, and especially in Europe,
indicated that providing an incentive to seek Delisting providers due to clinical or business A significantly larger number of insurers, especially
treatment on an outpatient as opposed to practices and setting reasonable and customary in the Middle East and Africa, are adopting medical
an inpatient basis is also part of their plan charging limits are becoming more prevalent second-opinion services and centers of excellence.
management approach. practices, especially in Europe.
Do you see the insurance industry in your country 0% 20% 40% 60% 80% 100%
taking responsibility for such a solution? 59% 25% 15% Global

72% 20% 8% Asia
Coinsurance 50% 32% 18% Europe
It is encouraging to see that over 60% of insurers 61% 21% 18% LATAM
53% 24% 24% MEA
across all regions agreed that some responsibility
for many cost management solutions lies with them. 70% 16% 13% Global
74% 15% 11% Asia
However, a meaningful shift in healthcare costs Deductibles/excesses 68% 19% 14% Europe
76% 15% 9%
will be achieved only if all stakeholders, including 59% 18% 24%
LATAM
MEA
employers, governments and healthcare providers,

78% 10% 12% Global
play a role in driving more cost effective care. 78% 11% 11% Asia
78% 9% 12% Europe
reasonableness of procedure/supply cost
79% 9% 12% LATAM
82% 6% 12% MEA
69% 16% 15% Global

Preauthorization, including assessment of 72% 14% 14% Asia
medical appropriateness of treatment
68% 16% 16% Europe
undertaken and active involvement in
determination of treatment 70% 18% 12% LATAM
Key 71% 18% 12% MEA
80% 10% 10% Global

Yes 72% 12% 15% Asia
Negotiated rates with health providers 84% 9% 7% Europe
No
94% 3%3% LATAM
Not applicable 71% 18% 12% MEA
57% 25% 18% Global

55% 26% 18% Asia
Coverage or incentive to seek treatment on
61% 19% 20% Europe
outpatient basis
67% 30% 3% LATAM
41% 35% 24% MEA
70% 18% 12% Global

68% 22% 11% Asia
Negotiated packaged/bundled pricing for
77% 14% 9% Europe
specific procedures
70% 15% 15% LATAM
59% 24% 18% MEA
74% 13% 13% Global

65% 15% 20% Asia
Preferred/narrow provider networks 80% 12% 8% Europe
82% 12% 6% LATAM

76% 12% 12% MEA
65% 20% 14% Global
62% 23% 15% Asia
Second opinion services 74% 16% 9% Europe

64% 21% 15% LATAM
47% 29% 24% MEA

0% 20% 40% 60% 80% 100%
51% 27% 22% Global

54% 20% 26% Asia
Centers of excellence 55% 26% 19% Europe

42% 42% 15% LATAM
41% 29% 29% MEA
29% 43% 28% Global
38% 32% 29% Asia
Support for medical tourism 28% 46% 26% Europe
18% 52% 30% LATAM
24% 47% 29% MEA
70% 19% 12% Global

83% 6% 11% Asia
Education to make plan members smarter
61% 27% 12% Europe
healthcare consumers
67% 24% 9% LATAM
59% 24% 18% MEA
52% 32% 16% Global

68% 18% 14% Asia
Provision of medical clinics near or onsite to
43% 39% 18% Europe
sponsoring employer sites
52% 36% 12% LATAM
41% 35% 24% MEA
53% 26% 21% Global

60% 20% 20% Asia
Influencing government around legislative
54% 27% 19% Europe
changes/health reform
36% 36% 27% LATAM
41% 35% 24% MEA
61% 23% 15% Global

62% 23% 15% Asia
Virtual health consultations/telemedicine 66% 22% 12% Europe

58% 24% 18% LATAM
41% 35% 24% MEA
63% 19% 18% Global

65% 15% 20% Asia
Delisting providers due to clinical or
business practices 66% 20% 14% Europe
64% 18% 18% LATAM
41% 35% 24% MEA
68% 16% 16% Global

65% 17% 18% Asia
Defining reasonable and customary
charging limits 69% 18% 14% Europe
73% 18% 9% LATAM
65% 12% 24% MEA

7
Strategic
Investments Into
the Future
We expect that rising costs, more Rank your insurance company’s top three strategic areas of investment relating to group medical insurance.
demanding customers and the changing
1%
industry landscape will shape the future 3% 2%
of health insurance. Key
9%
We have observed disruption across the insurance 33% Data analytics
and healthcare ecosystem, driven by digital

Quality care-focused benefit design
startups, innovation among established players
(delivering the right care at the right
and vertical integration across the supply chain. time in the right setting to achieve
Clinicians and consumers are benefiting from the the best possible result)
use of advanced analytics for many applications,
Plan member technology (e.g.,
such as increasing transparency in cost, care 23% online claims submission)
quality and greater access and choice.
Well-being
The survey results show that insurers are
making strategic investments in data analytics Other forms of claims management
and digitization.
Government and other
stakeholder engagement
Others
29%
Data analytics
Data analytics is the top strategic area of investment with regard to group medical insurance globally. We suspect this is for three reasons:
1. Insurers looking to collect various types of 2. Insurers trying to meet the needs of plan- 3. Insurers needing to obtain actionable insights
data to drive new experiences, solutions sponsor employers who want to identify/manage driven by real-time data from providers and
and revenue streams cost drivers and design plans that are relevant patients to better manage providers and
to the healthcare needs of their employees control healthcare costs
Digitization
Offering online member engagement is naturally expected, given the expectations of today’s workforce for a seamless consumer-
grade digital experience. We anticipate continued expansion of digital capabilities to support tasks like claims submission,
navigating healthcare providers, appointment booking and medical record management. The number of and, in many cases, value of
complementary digital health solutions provided by others in the value chain, including technology start-ups and giants, continue to
grow. Our point of view is that employer-sponsored or facilitated digital health programs will increasingly include elements that fall
outside the traditional insurance plan and need to be integrated into a cohesive experience for plan members.
Creating a
digital home
According to a global survey by It is important for employers to manage and deliver benefits
Thomsons Online Benefits, only have a digital home that integrates digitally as well as to communicate
38% of companies provide the multitude of health and well- and engage with employees
employees with access to being initiatives. Online platforms around how they use them.
benefits from mobile devices.1 make it easier for companies to
1
Thomsons Online Benefits. Global Employee Benefits Watch 2018/19, available at
https://www.thomsons.com/resources/whitepapers/global-employee-benefits-watch-201819.
The rise of digital health

Health insurers not only are focused on paying for sick care but are moving toward integrated offerings
ranging from preventive wellness measures to condition management. They are also increasingly funding
unconventional methods of care — virtual, home based and even machine learning or artificial intelligence,
such as AI “doctors” and symptom checkers. This Is Health | Point of View Series
03 The New Age of

Digital Benefits
We share below a flavor of the digital health innovations across the wellness to ill spectrum. Adopting
preventive and early intervention measures will help employers improve the health and productivity of
employees while controlling future increases in medical costs.
The Well The At Risk The Ill The Long-term
No health risk factors; Living with health risks Health issues; Health issues;
normal productivity (either consciously or productivity affected, productivity affected
1
unconsciously); productivity but largely on a for significant period

affected or potentially could temporary basis. At Mercer Marsh Benefits, we are
be affected. taking a closer look at the rewards
that come from companies
Integrated platform Holistic wellness Remote cardiac Engaging in stroke
prioritizing digital technology in the
that enables users solutions that monitoring and rehabilitation exercises
design and delivery of benefits.
to adopt healthier incorporate digital diagnosis that enables through smart games,
lifestyles through therapeutics, real-time tracking of with opportunity for
For more details, see the third
research-backed mindfulness apps, sleep vitals, communication therapists to monitor
paper in our This is Health | Point
behavioral economics solutions and so on to with patients and engagement and track
of View series, The New Age of
incorporating elements alter the behavior of ensuring medication progress in real time
Digital Benefits.
like gamification, social patients to prevent adherence
engagement and habit or delay the onset of
algorithms chronic conditions
Prevention Intervention
Making members smarter healthcare consumers
Insurers are continuously wrapping around value-added services that will

help plan members make smarter healthcare decisions. Globally, 63%
insurers — with a resounding 71% in the Middle East and Africa — indicated
that they are adopting approaches. These are currently offered in various
forms, including education sessions, case management, supporting wellness
content and programs.
However, a gap still lies in shifting from mass communication to creating

engaging, personalized and timely messaging to incentivize behavioral change
and alter healthcare buying habits. More needs to done for employee adoption
and sustained engagement of digital health.
Are you taking approaches to help plan members make smarter

healthcare decisions?
Global Asia Europe LATAM MEA

Yes 63% 64% 62% 58% 71%
No 37% 36% 38% 42% 29%
Below are some examples of how we have worked with clients in the area of
medical plan design, focusing on incentive-based and clinical approaches:
In Mexico, a client integrated its In Malaysia, a client designed and In Hong Kong, a client introduced tiered
prescription drug plan, major medical implemented a medical savings provider panels to drive responsible
plan, legally required occupational account for outpatient expenses. This member and provider behaviors and
health clinic and multiple other introduced flexible and consumerism partnered with vendors to develop
healthcare initiatives. The client restructured approaches, including limits and co-payments, cancer centers of excellence to deliver holistic
programs to cost control through standardized with the objective of incentivizing the right quality care to members at efficient cost levels.
processes; reduced overlap and complexity behavior and rewarding those that utilized the
of initiatives; introduced a wellness and health scheme responsibly.
management council and developed a well-being
strategy. Primary care consultations increased,
which decreased major medical levels of demand.
In India, a client introduced tiered In the Philippines, a client developed In the Middle East, a client addressed
coinsurance into the hospitalization and refined individual health risk supply and demand management
scheme to incentivize individuals to scores from the annual physical processes. This included designated
use hospitals that met certain quality exam to better assist employees in service providers for standardized
and cost standards. understanding their health conditions. The onsite tariffs, chronic disease management, prescription/
clinics were also moved from a statutory provision pharmaceutical benefit management and care
to a highly effective element of the overall health pathways (general practitioner versus specialist).
management strategy. These changes drove
increased care coordination and reduced insured
medical cost.
8
In Closing
The future of work demands healthy and engaged employees.

As global medical trends continue to rise, now is the time
for employers to consider proactively implementing plan
management measures. We encourage employers to review
their plans with both cost optimization and employee
engagement lenses.
To achieve cost savings while ensuring access to good-quality healthcare,

employers can consider the following:
1. P
ay for value: Review the plan design to ensure that it incentivizes the
right behavior and results.
2. D
rive to quality: This is about delivering the right care at the right time in
the right setting. Although employers may not have the expertise to do this
themselves, leveraging specialists who can (often virtually) help employees
decide whether to go to the emergency room or a local provider rather
than seek telemedicine or visit a center of excellence with the most cost-
effective care will be needed to improve quality and affordability.
3. P
ersonalize the experience: Employees expect personalization and support
anytime, and companies using a technology-enabled approach to achieve
this are having the greatest success in impacting well-being outcomes.
4. Embrace disruption: Collaborate with insurers, employers and other

internal stakeholders to drive change in the system. Increased adoption
of clinical consultations is making healthcare (from physicians to mental
health providers to physical therapy) more accessible and affordable.
Combine the rollout of these virtual-care initiatives with active
communication and engagement with employees.
Time to shift from cost management to

an employee-centric view? Can I afford to pay for Where should I
the treatment? go for care?
Take a holistic view that supports employees
through their whole health journey.
The Medical Trends Around the World report

traditionally takes a focused view on cost.
However, we are increasingly seeing employers
apply not only a cost lens but also an employee-
centric lens as they modernize the design and
delivery of their health programs.
Plan members are seeking choice, personalization

and support, and while role expectations vary from
country to country, many see their employers as a
source for these items.
We look forward to engaging with you further on

this topic; you can expect to see more viewpoints
from Mercer Marsh Benefits.
How can I stay fit Will my data stay safe if I

and healthy? share health records?
At Mercer Marsh Benefits, our mission is to change

health and benefits for the better — to improve Advice-Driven Broad and Deep
lives and build stronger organizations. Broking Consulting
We help clients design, deliver and finance health
and risk protection benefits that:
• Create a healthy and engaged workforce

• Optimize cost and manage risk
Changing
• Simplify and digitally enable program delivery Health and Benefits
for the Better
Engaging and
Empowering
Technology
9
About This
Survey
Countries by region
Region Country Region Country

Americas Argentina Europe Belgium
Brazil Bulgaria
Canada Denmark
Chile France
Colombia Greece
Costa Rica Hungary
Dominican Republic Ireland
El Salvador Italy
Guatemala Latvia
Honduras Lithuania
Mexico Norway
Nicaragua Poland
Panama Portugal
Peru Romania
Venezuela Russia
Asia Pacific Australia Serbia
China Spain
Hong Kong Sweden
India Switzerland
Indonesia Turkey
Malaysia Ukraine
New Zealand United Kingdom
Philippines Middle East Bahrain
Singapore and Africa (MEA) Egypt
South Korea Kenya
Taiwan Oman
Thailand Qatar
Vietnam Saudi Arabia
South Africa
United Arab Emirates
About This Survey Country Insurance company Country Insurance company

Argentina ASE Dominican
Humano Seguros
Argentina Galeno Argentina S.A. Republic
The following insurers have agreed to having
Argentina Medicus S.A. Egypt AXA
their name published as participants in the
Argentina Swiss Medical Medicina Privada Egypt MedGulf Egypt
survey. An additional 82 insurers participated on
Australia GU Health France Groupama Gan Vie
a confidential basis.
Bahrain Bahrain National Life Assurance Company France Swiss Life
Belgium Allianz Benelux Greece AXA Greece
Belgium DKV Belgium Greece Allianz Hellas S.A.
Brazil Care Plus Medicina Assistencial LTDA Greece Generali Hellas
Brazil Omint Saúde Guatemala Aseguradora General, S. A.
Brazil Seguros Unimed Honduras Davivienda Seguros
Bulgaria Bulgaria Insurance Hong Kong Blue Cross (Asia-Pacific) Insurance Limited
Bulgaria Generali Insurance AD Hong Kong Bupa (Asia) Limited
Canada Green Shield Canada Hong Kong FWD General Insurance Company Ltd.
Chile Bice Vida Hong Kong Liberty Mutual
China Aviva-COFCO Life Insurance Co., Ltd. Hong Kong MassMutual Asia Ltd.
China AXA TP Property & Casualty Insurance Co., Ltd. Hong Kong Sun Life Hong Kong Limited
Beijing Branch, CPIC Allianz Health Insurance Hungary Groupama Biztosító
China
Co., Ltd. Hungary Union Vienna Insurance Group Biztosító Zrt.
China Bupa Global India HDFC ERGO General Insurance
China Generali China Life Insurance Co., Ltd. Indonesia Lippo General Insurance
China ICBC–AXA Indonesia PT. Asuransi Reliance Indonesia
Ping An Health Insurance Company of China, Indonesia PT. Asuransi Sinar Mas
China
Ltd. Ireland Laya Healthcare
China ZhongAn Online P&C Insurance Co., Ltd. Ireland Vhi Healthcare
Colombia Allianz Seguros Italy AXA Assicurazioni
Colombia Colsanitas Italy AXA XL
Colombia Coomeva Medicina Prepagada Italy Generali Italia
Colombia Pan American Life de Colombia Italy Società Reale Mutua di Assicurazioni
Costa Rica Assa Compañia de Seguros Costa Rica Kenya Hollard Health International
Denmark Dansk Sundhedssikring Kenya Sanlam
Denmark Skandia A/S Latvia Seesam Insurance AS
Denmark Topdanmark
Country Insurance company Country Insurance company

Malaysia AIA Bhd. Serbia Triglav Osiguranje a.d.o.
Malaysia Allianz Life Insurance Malaysia Singapore AIA Singapore
Malaysia AXA Affin General Insurance Berhad Singapore Aviva Ltd
Mexico Grupo Nacional Provincial Singapore FWD Singapore
Mexico MetLife México Singapore Great Eastern Life
New Zealand Southern Cross Health Society South Africa Liberty
Norway DNB Livsforsikring South Korea Samsung Life Insurance
Norway Fremtind Spain AXA Seguros Generales
Norway Protector Forsikring ASA Spain DKV Seguros y Reaseguros SAE
Oman Al Madina Insurance Company SAOG Spain Sanitas
Panama Compañia Internacional de Seguros S.A.
Sweden Euro Accident Livförsäkring AB
Panama MAPFRE Panama
Sweden Länsförsäkringar
Peru Rimac EPS
Taiwan AIA
Peru Rimac Seguros Taiwan Fubon Life Insurance Co., Ltd.
Philippines First life Thailand Cigna Insurance
Philippines Generali Life Assurance Philippines, Inc. Thailand Generali Life Assurance (Thailand) Plc.
Philippines MediCard Philippines, Inc. Thailand Muang Thai Life Assurance
Philippines Pioneer Life Insurance Thailand Tokio Marine Life Insurance (Thailand) PCL
Philippines United Coconut Planters Life Assurance Corp. United Arab MetLife
Poland Medicover Emirates
Poland PZU Życie SA United AXA PPP Healthcare
Poland TU Allianz Życie Polska S.A. Kingdom
Portugal Allianz Portugal United VitalityHealth
Portugal Generali - Companhia de Seguros S.A. Kingdom
Portugal Seguradoras Unidas, S.A. Ukraine PJSIC INGO Ukraine
Portugal Una Seguros Ukraine The Private Joint-Stock Company "European
Russia AlfaStrahovanie PLC Insurance Alliance"
Russia Allianz Venezuela Mercantil Seguros
Russia JSIC "VSK" Venezuela Seguros Universitas, C.A.
Russia MetLife Vietnam Bao Viet Insurance
Russia RESO-Garantia Vietnam BaoMinh Insurance Corporation
Russia Rosgosstrakh (RGS) Vietnam Liberty Insurance Limited

ICD 10 listing for claims-related sample conditions data
1. Infectious diseases: intestinal infectious 7. Disease of the sense organs: blepharitis, 14. Osteomuscular diseases: arthritis, internal
caused by bacteria and parasites, viruses and cataract, retinal detachment, glaucoma, affections of the knee, disorders of
fungi; includes HIV infection blindness; otitis, hearing loss, vertigo intervertebral discs, back pain
2. Cancer: can include malignant tumors of all 8. Diseases of the circulatory system: 15. Congenital anomalies: congenital
body tissues, tumors “in situ” and benignant hypertension, acute myocardial infarction, malformations, deformations, chromosomal
tumors; consider in this group leukemia, rheumatic fever, cerebrovascular events abnormalities
myeloma and lymphoma
9. Respiratory conditions: respiratory tract 16. Newborn attention and complications:
3. Endocrine and metabolic diseases: affections infections, chronic obstructive pulmonary respiratory distress syndrome of the newborn,
of the glands, metabolic conditions (such as disease, emphysema, asthma newborn sepsis, congenital pneumonia
diabetes, obesity and lipid disorders)
10. Gastrointestinal diseases: gastroesophageal 17. Accidents, conditions derived from violence:
4. Blood diseases (hematological): all type of reflux disease, Crohn’s disease, ulcer, gastritis, injury, fractures, trauma, wounds, poisoning,
anemia, thrombocytopenia, immunodeficiency colitis, hepatic diseases, pancreatitis, certain other consequences of external causes
NOT related to HIV, coagulation, hemorrhagic cholelithiasis
disorders 18. Other (not classified in above groups)
11. Genitourinary conditions: chronic renal failure,
5. Mental conditions: organic mental disorders, urolithiasis, prostatic hyperplasia, pelvic
behavioral disorders, alcohol and substances inflammatory disease, infertility
abuse, eating disorders, developmental
disorders (such as mental retardation) 12. Obstetrics and pregnancy: abortion,
pregnancy, pregnancy-related complications,
6. Neurological conditions: meningitis, natural childbirth and termination of pregnancy,
encephalitis, Parkinson, degenerative diseases, postpartum complications
epilepsy, transitory cerebral ischemia, sleep
disorders, affection of peripheral nerves 13. Skin diseases: infections of the skin and
(including compression due to intervertebral subcutaneous tissue, acne, dermatitis,
discs), myopathy, cerebral palsy, hydrocephalus psoriasis
For further information, please contact your local Mercer Marsh Benefits office.
About Mercer Marsh Benefits Important Notices
Mercer Marsh Benefits provides clients with a This document does not constitute or form part
single source for managing the costs, people of any offer or solicitation or invitation to sell by
risks and complexities of employee benefits. The either Marsh or Mercer to provide any regulated
network is a combination of Mercer and Marsh services or products in any country in which
local offices around the world, plus country either Marsh or Mercer has not been authorized
correspondents who have been selected based or licensed to provide such regulated services
on specific criteria. Our benefits professionals, or products. You accept this document on the
located in 135 countries and serving clients in more understanding and agreement that it does not
than 150 countries, are deeply knowledgeable form the basis of any contract, and Mercer and
about their local markets. Through our locally Marsh shall have no liability in respect of any
established businesses, we have a unique common reliance on, or decisions based on, the content
platform that allows us to serve clients with global of this document.
consistency and locally unique solutions.
The availability, nature and provider of any services
or products, as described herein, and applicable
terms and conditions may therefore vary in certain
countries as a result of applicable legal and
regulatory restrictions and requirements.
Please consult your Marsh or Mercer consultants

regarding any restrictions that may be applicable to
the ability of Marsh or Mercer to provide regulated
services or products to you in your country.
Copyright 2019 Mercer LLC. All rights reserved.
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BENEFITS

2019 Medical Trends

1 Message From Mercer Marsh Benefits........................................................................................... 4

2 Key Trends Shaping Employer-Sponsored Medical Plans................................................................ 6

3 Medical Trend Rate Exceeds Economic Inflation ............................................................................ 8

4 Causes of Claims — Risks and Conditions ...................................................................................... 12

5 Supplier-Driven Pressure on Cost of Care.................................................................................... 16

6 Levers Being Employed for Cost Containment .............................................................................. 18

7 Strategic Investments Into the Future ......................................................................................... 24

9 About This Survey......................................................................................................................... 34

However, we all need to do more to ensure health Hervé Balzano

*Excludes the United States

Exploration is increasingly shifting Embrace digital disruption to make healthcare

2018 medical 2019 projected 2018 medical 2019 projected

Looking to the future

Global* Asia Europe LATAM MEA

Insurers are generally predicting further increases on the horizon in 2020.

While overall less than 10% of insurers globally 33% 7%

in Asia and Latin America reporting this compared

The next highest categories vary by region.

Key Global Asia Europe LATAM MEA

Lifestyle-related risks continue to contribute to declining health

Emotional/Mental Stigma remains a major hindrance to accessing

sponsored medical plans? 64% 3% 9% 24% LATAM

67% 9% 12% 12% Global

use of design and management of health providers

that coinsurance and deductibles, respectively, 62% 9% 12% 17% Global

deductibles, respectively. 91% 3%3%3% LATAM

47% 11% 17% 25% Global

40% 15% 20% 25% Asia

65% 6% 6% 24% MEA

60% 12% 19% 9% Global

49% 17% 25% 9% Asia

Key specific procedures

71% 12% 18% MEA

management approach 45% 12% 22% 22% Asia

We are currently considering this 54% 15% 15% 16% Global

40% 15% 23% 22% Asia

82% 12% 6% MEA

Note: Due to rounding, percentages may not total 100.

sponsored medical plans? (continued) 48% 15% 9% 27% LATAM

13% 9% 15% 63% Global

15% 8% 23% 54% Asia

Support for medical tourism 7% 8% 9% 76% Europe

48% 17% 19% 16% Global

36% 14% 16% 34% Global

27% 14% 20% 39% Global

38% 21% 19% 22% Global

Virtual health consultations/telemedicine 35% 26% 20% 19% Europe

Key 48% 12% 6% 33% LATAM

management approach 38% 11% 23% 28% Asia

to initiate this within the next 24 months 65% 24% 6% 6% MEA

We are currently considering this 63% 9% 13% 15% Global

Note: Due to rounding, percentages may not total 100.

Levers being employed for cost containment

taking responsibility for such a solution? 59% 25% 15% Global

Coinsurance 50% 32% 18% Europe

employers, governments and healthcare providers,

69% 16% 15% Global

Key 71% 18% 12% MEA

80% 10% 10% Global

Not applicable 71% 18% 12% MEA

57% 25% 18% Global

70% 18% 12% Global

4. Embrace disruption: Collaborate with insurers, employers and other