Picture credit: Tommyv580, via Wikimedia Commons

People who position themselves as intermediaries for transactions can open up the possibility for lucrative income streams, just ask Jeff Bezos. Healthcare is no different. But what’s the catch? In this blogpost Dr Benjamin Hunter draws on research from India to argue that intermediaries in healthcare also face a lot of challenges to stay relevant in what can be an unforgiving sector.

Commercial opportunities for brokerage

Commercial brokerage has been thriving for some time. Merchants made a living by brokering economic transactions, and now many of our day-to-day purchases are provided through a third party. From one perspective, intermediaries are being rewarded for reducing transaction costs to the benefit of all concerned, bringing together two groups who would otherwise find their exchange more difficult. From another perspective, they are rentiers who have monopolised a service and exploited it for personal gain.

In a previous blogpost I introduced the idea of brokerage in the healthcare sector. I explained how lay community health workers in Lucknow’s slum areas were able to use their knowledge and health vouchers to assist families in accessing healthcare. They also took payments from healthcare users and from the hospitals they visited. In current work I am looking at very different settings, but nonetheless characterised by brokerage relationships: burgeoning markets for healthcare facilitation in Delhi and London provided by agents and companies in these cities.

Precarity in the intermediary space

For all the potential commercial benefits of facilitating healthcare, it can be marked by significant precarity and volatility. There are strong commercial incentives for hospital marketing teams to try to bypass facilitators to save on facilitator commissions, and an energetic set of rival facilitator companies looking to undercut competitors. For companies relying on inflows of medical tourists, their business can be disrupted by war, economic crises and currency fluctuations. Changes in legislation can undermine brokerage too – whatever your views on India’s ban on commercial surrogacy, it has sapped demand for the systems of brokerage that had emerged serving that market.

Facilitator companies are therefore engaged in a seemingly endless pursuit of new clients, connections and countries, hoping to maintain and grow streams of healthcare users. Many companies engage closely with incoming clients, what one facilitator in Delhi called ‘intensive hand-holding’, with regular and detailed information ahead of their visit complemented by daily visits or calls after arrival. Calls to patients or family members are another way to gauge client satisfaction and ameliorate problems.

Physical and mental demands of facilitator work

But this close attention comes at a cost. The frenetic pursuit of new contacts and settings can be tough for those expected to perform these activities. Directors and business development managers in Delhi have told me about regular international travels and the challenge it can create for their personal lives. One cited a prolonged trip of 17 visits in other countries in a row without returning to Delhi.

For case managers and interpreters there is the challenge of satisfying users’ needs in this service industry. This might include calls and airport pick-ups during the night, and the draining hops between multiple clients on a given day. It might include accompanying a client for lunch, dinner, shopping and trips to the Taj Mahal. One case manager described having to survive on just a few hours’ sleep each night during peak periods.

Stuck in the middle

Perhaps the most challenging activity for facilitators is the need to mediate communications and tensions between hospitals and users. Interpreters face the difficult task of breaking bad news when treatment fails, bills go up, or a user dies. I have been told reports of case managers having to resolve arguments between users and hospitals over hospital fees. These workers are the frontline of healthcare facilitation, performing some of its most unpleasant tasks in the service of an unforgiving healthcare industry.

Mediation activities can leave facilitators facing blame for non-payment of fees by users, with a typical punishment involving the withholding of the facilitators’ commission as hospitals try to re-coup lost fees. Meanwhile facilitators may also be blamed by users for problems with the care they received. In the Medical Tourism Facilitator’s Handbook, Maria Todd highlights the importance of managing expectations throughout the process, and Snyder et al. (2011) noted the use of disclaimers by facilitators to try to avoid litigation. As Todd (p. 47) notes: ‘The last thing you want is an upset client Tweeting about their experience with your service because of a bad outcome that was not in your care or control.’

These individualised relations, and the tensions they create, are by no means confined to healthcare, and there is a growing wealth of sociological literature on intermediaries, brokerage and the platform economy. It’s really worth thinking about how the growth of healthcare brokerage fits within wider trends for outsourcing labour and judging performance digitally, and what it means for how we understand and access healthcare.

The research described in this blog has been funded by the Wellcome Trust.