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The MTA Advisory Board includes<br />

ROBERT K. CRONE<br />

MD, President & CEO of Harvard <strong>Medical</strong> International;<br />

Boston, Mass.<br />

JOHN F. P. BRIDGES<br />

PhD, Assistant Professor at Johns Hopkins Bloomberg<br />

School of Public Health; Baltimore, Maryland<br />

PRADEEP THUKRAL<br />

Head of International Marketing at Wockhardt<br />

Hospitals Group; Mumbai, India<br />

THOMAS JOHNSRUD<br />

Senior Consultant, N.A., Parkway Hospital; Singapore<br />

BRAD COOK<br />

International Benefits Director at Hospital Clinica Biblica;<br />

Costa Rica<br />

KAMALJEET SINGH GILL<br />

GM, International Business Development Unit of National<br />

University Hospital; Singapore<br />

JONATHAN EDELHEIT<br />

President, <strong>Medical</strong> <strong>Tourism</strong> Association, Inc.;<br />

Palm Beach, Florida<br />

RENEE-MARIE STEPHANO<br />

Esq., General Counsel for <strong>Medical</strong> <strong>Tourism</strong> Association<br />

and Editor of The <strong>Medical</strong> <strong>Tourism</strong> <strong>Magazine</strong><br />

STEPHEN M. WEINER<br />

Esq., Chairman of the Health Law Practice of Mintz, Levin,<br />

Cohn, Ferris, Glovsky & Popeo, P.C.; Boston, Mass.<br />

SCOTT A. EDLESTEIN<br />

Esq., of Counsel at Squire, Sanders & Dempsey, LLP;<br />

Washington D.C.<br />

DANIEL BONK<br />

Executive VP ~ Central Region, Aurora Healthcare; Wisconsin<br />

FREDERIC J. ENTIN<br />

Esq., Partner at Foley & Lardner, LLP; Chicago, Ill.<br />

MARY ANN KEOUGH<br />

Professor at Eastern Washington University;<br />

Washington State<br />

DALE C. VAN DEMARK<br />

Esq., Member of Epstein, Becker & Green,<br />

PC; Washington, D.C.<br />

KEVIN RYAN<br />

Esq., Member of Epstein, Becker & Green, PC;<br />

Washington D.C.<br />

LAURA CARABELLO<br />

Principal of CPR Communications,<br />

Publisher of <strong>Medical</strong> Travel Today Newsletter; New York<br />

RUBEN TORAL<br />

Proprietor of MedNet Asia, Ltd.; Bangkok, Thailand<br />

DAVID C. KIBBE<br />

MD, MBA, Principal of The Kibbe Group LLC;<br />

North Carolina<br />

Editorial<br />

America is viewed as the land of the great and the land of opportunity.<br />

Unfortunately, that is painting a pretty rosy picture that isn’t exactly true. At the<br />

end of the day our health care system is broken. It really upsets me that Americans<br />

are so disenchanted with our U.S. health care system that some have to travel<br />

overseas. The fact that hard working taxpaying Americans, whether white, black,<br />

Hispanic, Indian, or Asian or any race have no access to affordable healthcare in the<br />

U.S., while in some cases illegal immigrants get free and better care than Americans is<br />

very frustrating.<br />

The reality is, at the end of the day, almost 50 million Americans have no access to<br />

healthcare, 120 million do not have dental insurance, and the number is growing each<br />

day. Working in the healthcare industry the trend is simple, more and more<br />

employers are canceling their group health insurance because the cost is too high,<br />

and more and more individuals can no longer afford medical insurance.<br />

It gets really bothersome to see the politicians constantly talking about Health Care<br />

being broken in the U.S. Some offer no solutions. The rest offer unrealistic solutions -<br />

Nationalized healthcare, mandatory health care, etc. The politicians talk, but don’t do<br />

anything. Massachusetts passed a law, which soon will go into effect and requires<br />

people to have mandatory health coverage or pay penalties. Hillary Clinton has<br />

proposed mandatory health care also with the possibility of Tax credits. If our health<br />

care system is broken and costs are too high, then why do politicians believe forcing<br />

people to buy health care will solve our problem. It will only continue us down a<br />

negative path, as each year goes by Americans are forced to pay higher prices for ever<br />

increasing cost of health care. Eventually everyone will have mandatory health<br />

insurance they can’t afford.<br />

Why isn’t anyone attacking the actual problem? Why has not one politician<br />

actually stood up and acknowledged the problem. Some of the major costs of our<br />

U.S. health care system today are medical malpractice, high costs of labor, and<br />

inflated costs of medical supplies and prescription drugs. Why do parts for a surgical<br />

procedure in the U.S. cost almost $9,000, while the same parts by the same U.S.<br />

manufacturer for a procedure in India cost only about $2,000? Why does a<br />

prescription drug that costs $1,600 in the U.S. cost $800 in Costa Rica? How is it<br />

that a U.S. trained and board certified doctor in the U.S. can perform a procedure in<br />

India and Thailand for almost up to 80% less than the United States? Why is it that<br />

for certain heart procedures in Asia, American patients spend almost 5 times longer in<br />

the hospital to recover than American patients in American hospitals? Have we given<br />

up on providing quality care in America, and instead race to send the patient home?<br />

When will Politicians stop putting band aids on our health care problem and really<br />

try to fix it? When will everyone in America stand up and say enough is enough and<br />

band together? Obviously not yet! Because on October 2nd a U.S. farmer traveled to<br />

India for surgery he couldn’t afford in the United States. In October a single mother<br />

of two, who hasn’t been able to hold down a job for two years because of a broken<br />

back and tremendous pain, is going to India for surgery she can’t afford in the U.S.<br />

Apparently, no one cares that we are sending Americans overseas for surgery. Since<br />

no one cares, then that leaves us one option. We are in a Global Health Care world,<br />

and we all need to come together to focus on the best quality of care and best<br />

outcomes for Americans going overseas. We need to pull together, because <strong>Medical</strong><br />

<strong>Tourism</strong> is the only real viable solution to America’s health care crisis. Am I ashamed<br />

that we are sending hard working Americans overseas and in<br />

some cases around the world, because that is the only place<br />

they can receive affordable, quality care? Yes, I am. Do I<br />

believe that Americans can get care equal to or in some cases<br />

better care than here in America? I absolutely do.<br />

I hope everyone can come together within this industry and<br />

show everyone how amazing <strong>Medical</strong> <strong>Tourism</strong> is, and the<br />

cutting edge medicine and care available globally.<br />

By JONATHAN EDELHEIT<br />

President<br />

<strong>Medical</strong> <strong>Tourism</strong> Association


EDITORIALS<br />

Time to Rally Around <strong>Medical</strong> <strong>Tourism</strong><br />

FEATURES<br />

Costa Rica: The Great Opportunity<br />

Vice-Minister of the Costa Rican Council on<br />

24<br />

Competitiveness, Jorge Woodbridge Gonzalez speaks<br />

out about the challenge of competitiveness in medical<br />

services and international accreditation.<br />

BY JORGE WOODBRIDGE GONZALEZ<br />

Who are Those Masked Men?<br />

The physicians of Costa Rica undergo educational<br />

requirements comparable to those in the U.S.<br />

26<br />

Costa Rica: Big Trip Little Country<br />

Traveling to a foreign country can be intimidating, so in<br />

38<br />

order to assure a good trip, you should do your research<br />

ahead of time.<br />

BY RENEE-MARIE STEPHANO<br />

Deep Venous Thrombosis:<br />

The Traveler’s Disease<br />

Decreasing your time in flight could provide for better<br />

32<br />

medical travel, but if you must fly far, here are some<br />

precautions to take.<br />

BY Dr ELLIOT GARITA JIMINEZ<br />

5 Elements to Choosing<br />

an International Hospital<br />

There are no perfect doctors and no perfect hospitals,<br />

19<br />

but sifting through the available information increases<br />

your odds of a perfect experience.<br />

BY BERNAL ARAGON BARQUERO<br />

Got a Passport? Gain a Smile.<br />

The dental possibilities in Costa Rica are endless and<br />

affordable.<br />

BY EUGENIO J. BRENES, DDS<br />

34<br />

Patient Processing, Clinica Biblica Style<br />

As the draw to Costa Rica accelerates for medical<br />

36<br />

tourism, Clinica Biblica has created their in-house<br />

medical tourism company to provide excellent service to<br />

international patients. We live a day in the life of an<br />

international patient.<br />

4 DECEMBER 2007<br />

December 2007<br />

<strong>Medical</strong> <strong>Tourism</strong><br />

AT A GLANCE<br />

Costa Rica<br />

Ecotourism to World Class Healthcare<br />

The road looks promising as Costa Rica reinvents itself as a global<br />

healthcare arena.<br />

20 COLUMNS<br />

BY WILLIAM COOK<br />

JCI CORNER<br />

The Value of Accreditation<br />

President and CEO of JCI, Karen Timmons, speaks about the<br />

12<br />

characteristics and the value of promoting safety and quality<br />

of care in international medical facilities.<br />

BY KAREN TIMMONS<br />

LEGAL ISSUES<br />

Surrounding <strong>Medical</strong> <strong>Tourism</strong><br />

Understanding the nature of potential liability requires first an<br />

16<br />

underlying basic understanding of the American Legal System. Can<br />

Americans even bring a claim against foreign providers in US Courts?<br />

BY FREDERIC J. ENTIN, ESQ.<br />

BINA BUZZ<br />

Unaffordability Ebola Spreading Throughout Healthcare<br />

Driven by the number one concern of adults and businesses in the<br />

48<br />

US, an insatiable, immutable “Unaffordability Ebola” is attacking<br />

another compliant US host: the American healthcare system.<br />

BY MICHAEL BINA


December 2007<br />

<strong>Medical</strong> <strong>Tourism</strong><br />

AT A GLANCE<br />

ECONOMICS<br />

What are the True Financial Savings<br />

in <strong>Medical</strong> Travel?<br />

Are the numbers you hear regarding savings on<br />

healthcare abroad truly an accurate depiction of<br />

what you can keep in the bank?<br />

BY MICHAEL D. HOROWITZ, MD<br />

14<br />

Self-Funding Your <strong>Medical</strong> Travel<br />

<strong>Medical</strong> <strong>Tourism</strong> is a perfect fit for American<br />

Employers with self-funded health plans.<br />

BY JONATHAN EDELHEIT<br />

54<br />

The Boomers are Coming!<br />

The Boomers are Coming!<br />

Every day, almost 11,000 baby boomers turn<br />

50 – one every eight seconds. How are we<br />

going to pay for their healthcare?<br />

BY BOB MEISTER<br />

60<br />

Pay for Performance:<br />

Here Today…Here Tomorrow?<br />

Why are physicians so fearful about P4P and how will<br />

this be affected by the rise in medical tourism?<br />

BY DAN BONK<br />

50<br />

The Fully Insured Myth<br />

Hospitals should not expect massive amounts of fully<br />

insured Americans to travel overseas for healthcare.<br />

BY JONATHAN EDELHEIT<br />

42<br />

NEWS & INSIGHTS<br />

Selecting a <strong>Medical</strong> Travel Destination<br />

Making a list and checking it twice, the 4 D’s in<br />

selecting a destination that is more than meets<br />

the eye.<br />

BY DARREN TAM & DR JEREMY LIM<br />

10<br />

Psychological Barriers to<br />

<strong>Medical</strong> <strong>Tourism</strong><br />

Dr John Bridges of Johns Hopkins takes a look at the<br />

three barriers to understanding medical tourism.<br />

BY JOHN F. BRIDGES, PH.D.<br />

46<br />

Planning Your <strong>Medical</strong> Trip Abroad:<br />

Recovery Retreat or Hotel?<br />

While both have their advantages, the medical tourist<br />

needs to do their homework to find their home away<br />

from home. An interview with Jim Holt of<br />

Intercontinental Hotel Group.<br />

BY LOURDES GASPARONI<br />

56<br />

Copyright <strong>Medical</strong> <strong>Tourism</strong> Association<br />

Engaging Your Family Physician in <strong>Medical</strong> Travel<br />

The concerns of returning home after surgery are plentiful.<br />

How do you bring your doctor onboard?<br />

BY THOMAS C. JOHNSRUD<br />

44<br />

What is Your Country’s Ranking?<br />

The World Health Organization surveyed the international<br />

healthcare systems in 2000 and ranked the quality of care.<br />

Where does your destination fall?<br />

60<br />

The Lure of <strong>Medical</strong> <strong>Tourism</strong> in Asia<br />

What makes Americans travel thousands of miles for healthcare?<br />

6<br />

The first world treatment at third world prices is just<br />

part of the puzzle.<br />

BY GERALDINE CHEW & NORZILAWATI MT<br />

Editor-in-Chief<br />

Renée-Marie Stephano, Esquire<br />

10130 Northlake Boulevard<br />

Suites 214-315<br />

West Palm Beach, Florida 33412<br />

866-756-0811 Fax<br />

Renee@<strong>Medical</strong>TravelAuthority.com<br />

DECEMBER 2007 5


MEDICAL TOURISM<br />

By GERALDINE CHEW & NORZILAWATI MT<br />

Would you travel across the globe for a heart bypass if it will only cost you a<br />

tenth of the usual US $122,000?<br />

The concept of medical tourism started thousands of years ago. People have been<br />

traveling across the continents in search of cures for any imaginable illnesses and<br />

making therapeutic trips for health wellness. In ancient Greece, pilgrims and patients<br />

came from all over the Mediterranean to the sanctuary of the healing god, Asklepios at<br />

Epidaurus, and from the 18 th century wealthy Europeans have been traveling to spas<br />

from Germany to the Nile.<br />

In recent years, medical tourism is becoming more popular with patients seeking<br />

treatment for health and well-being purposes abroad.<br />

Why Are People Traveling?<br />

If you can get your ailing heart cured or get your flat-nose fixed at home, why bother<br />

to travel across the globe for medical treatment?<br />

Patients seeking treatment abroad are motivated to do so by various reasons. Many<br />

are attracted by the low cost factor or they are simply dissatisfied with the existing<br />

medical care in their home country. Frustrated by the long waiting times, inadequate<br />

medical care and exorbitant medical expenses, many go abroad in search of medical care.<br />

The steep medical costs in America have contributed to many Americans flying to<br />

other countries in search of cheaper alternatives. According to the Census Bureau, as<br />

many as 46.6 million Americans were uninsured in 2005. As these uninsured Americans<br />

are not able to afford the costly medical care, many will jump at the opportunity of<br />

getting treatment abroad at a fraction of the price at home.<br />

6 DECEMBER 2007<br />

In the UK it is not uncommon to hear patients grumbling from<br />

having to wait for as long as six months to get treated by the<br />

public health service due to the system being too stretched to<br />

cater to everyone. Otherwise they will have to opt for private<br />

health services which is very expensive.<br />

The Guardian wrote a classic case example on the medical care<br />

hiccups in Britain. George Marshall, a violin repairer<br />

from Bradford was diagnosed with coronary heart disease.<br />

He was told that he could either wait for up to<br />

six months for a heart bypass operation on the National Health<br />

Service or pay $38,000 to go under the scalpel immediately.<br />

He chose to outsource his operation to India instead. He went<br />

for an operation at the Wockhardt Hospital and Heart Institute<br />

and paid only $9,763.24 for surgery including travel expenses.<br />

Research and studies have shown support on the increasing<br />

trend in medical tourism.<br />

Dr Arnold Milsein, medical director of the United States based<br />

medical group Pacific Business Group, told a U.S. Special<br />

Committee on Ageing in 2006 that the typical combined<br />

hospital and doctor’s charges for operations in “technologically<br />

advanced hospitals in lower-wage countries” such as Thailand<br />

were 60 to 85 percent lower than charges in the US hospitals.<br />

An independent survey on medical tourism prices in 2006 by<br />

European Research Specialists commissioned compiled data from<br />

108 clinics, hospitals and healthcare providers in 30 countries.<br />

Research revealed that patients from UK can save up to 80<br />

percent by going overseas for surgery and medical treatment<br />

<strong>Medical</strong> <strong>Tourism</strong> Takes off the Runway<br />

<strong>Medical</strong> tourism is made possible and has gained popularity<br />

due to the advancement in medical technology, more affordable<br />

travel and the availability of information provided by the mass<br />

media.<br />

As medical costs accelerate, patients are finding alternatives<br />

for low-cost treatment, and going abroad to get healthy seems<br />

very appealing. Lured by the promise of high quality,<br />

reliable medical care at a lower cost, patients are<br />

flying across the globe for medical treatment that they<br />

otherwise would not have access to easily due to prohibitive<br />

costs, long waiting time or unavailability of treatment in their<br />

home country.<br />

The promise of medical care and the attraction of<br />

exotic places are taking people places for medical care.<br />

First World Treatment at Third World Prices<br />

International patients are flocking to Asia for elective and<br />

cosmetic procedures, an increasing pool of patients are getting<br />

their ailing heart fixed or have hip replaced in countries such as<br />

Singapore and India.<br />

Choices are also not limited to medicine or western treatment;<br />

there are growing interests in alternative medicine providing<br />

holistic therapy to patients. Alternative medicine such as


Ayurveda, acupuncture, osteopathy,<br />

chiropractic and homeopathy etc. are gaining<br />

popularity among medical tourists. Countries<br />

such as China and India are promoting alternative<br />

medicine to international patients searching for<br />

holistic cures.<br />

Hospitals in Asia are carving out an outstanding<br />

reputation for themselves, drawing overseas<br />

patients with top-notch doctors, low cost,<br />

high-tech equipments and high quality patient<br />

care. Countries such as Thailand, Singapore,<br />

India, Philippines, South Korea and Malaysia<br />

see a combined 1.3 million tourists each year for<br />

medical treatment. This move is expected to<br />

contribute at least US $4 billion by 2012 to the<br />

Asia medical tourism industry and US $40 billion<br />

globally.<br />

Experience Asia’s Best<br />

Amazing Thailand<br />

Thailand better known among foreigners as a<br />

popular destination for leisure tourism has<br />

earned for itself a name in the medical tourism<br />

industry. The Thai government is quick in<br />

realizing and identifying the great opportunities<br />

that medical tourism will bring. They have made<br />

significant inroads as an early investor in medical<br />

tourism with strong support from the healthcare<br />

institutions in the country, making Thailand into<br />

one of the leading medical tourist destination in<br />

Asia. The medical tourism industry is expected<br />

to attract two million medical tourists into<br />

Thailand by 2012.<br />

Hundreds of hospitals and clinics catering to<br />

foreigners are establishing themselves across the<br />

country like mushrooms on a rainy day. They<br />

offer everything from dentistry and cosmetic<br />

surgery to heart operations and sex change<br />

procedures to preventive care and health<br />

treatment.<br />

Catering to the alternative medicine market,<br />

Tria, the new kid on the block introduced into<br />

the market by the Piyavate Hospital is a<br />

specialist spa promising to bring wellness to a<br />

new level. Equipped with the latest in modern<br />

science combined with homeopathic and other<br />

treatments to provide preventive care and health<br />

treatments, the four storey complex boasts 19<br />

consultation rooms, four detoxification rooms<br />

and two colonic-hydrotherapy rooms.<br />

Incredible India<br />

<strong>Medical</strong> tourism is not new to India – housing<br />

some of the world’s best medical care providers<br />

that are equipped with technological<br />

sophistication and infrastructure, India drew an<br />

estimated 150,000 overseas patients last year.<br />

Coupled with its vast experience in dealing with<br />

overseas patients, medical tourists have no<br />

qualms about traveling to India to receive medical<br />

treatment.<br />

The Escorts Heart Institute and Research<br />

Centre ranks as having the best cardiac hospital<br />

in India. Equipped with state-of-the-art<br />

infrastructure and equipment, the 332-bed<br />

Institute has nine operating rooms and carries<br />

out nearly 15,000 procedures every year.<br />

The Wockhardt Hospitals Group has an<br />

association with Harvard <strong>Medical</strong> International,<br />

the global arm of the Harvard <strong>Medical</strong> School<br />

and is the first super specialty hospital in South<br />

Asia to achieve accreditation from Joint<br />

Commission International (JCI), USA. This<br />

established Group has a chain of super specialty<br />

hospitals such as Wockhardt Brain & Spine<br />

Hospital, Wockhardt Hip Resurfacing Centre<br />

and Wockhardt Liver & Kidney Institute,<br />

Kolkatta, catering to specific needs of their<br />

patients.<br />

Uniquely Singapore<br />

SingaporeMedicine, a multi-agency<br />

government initiative, aims at developing<br />

Singapore into one of Asia’s leading destinations<br />

for international patients. Looking at the<br />

visibility that Singapore has gained as a top<br />

destination for medical travelers, Singapore<br />

Medicine is fast on its way to achieving this<br />

objective. Through their aggressive campaigns,<br />

Singapore is expected to attract over one million<br />

foreign patients annually by 2012.<br />

Singapore’s efforts in promoting medical<br />

tourism have shown success. According to recent<br />

reports, Parkway Group Healthcare received<br />

170 Russian patients last year with average bill<br />

between $10,000 and $60,000 for each patient,<br />

and Raffles Hospital, for example, boasted a 36<br />

percent of its occupancy by foreign patients.<br />

DECEMBER 2007 7


WOW Philippines<br />

MEDICAL TOURISM<br />

The Philippines has also jumped on the medical tourism bandwagon. It<br />

has become so popular and successful in driving its medical tourism effort,<br />

officially known as the Philippine <strong>Medical</strong> <strong>Tourism</strong> Program (PMPT),<br />

that the country’s medical directors and government officials met in<br />

California in May this year to discuss the health tourism industry and how<br />

to effectively promote it.<br />

Prominent hospitals like St. Luke’s <strong>Medical</strong> Center, Asian Hospital and<br />

<strong>Medical</strong> Centre and Philippine Heart Centre etc. are active participants and<br />

advocates for this program.<br />

Jade del Mundo, Health Undersecretary of the Philippines said that a<br />

total of 200,000 foreigners came to the Philippines for medical treatment<br />

such as cosmetic surgery and eye or dental treatments. He said that the<br />

bustling medical tourism program of the Philippines is expected to<br />

contribute between US $300 million and US $400 million next year. The<br />

Philippines health department, estimates as much as US $200 million has<br />

been generated from medical tourism alone.<br />

<strong>Medical</strong> <strong>Tourism</strong> Whetting Appetites<br />

The spurt in the industry has created a vacuum that is quickly being filled<br />

with organizations or professionals eager to capture a share of the pie.<br />

Everyone from finance, insurance, travel, hospitality as well as health<br />

professionals, who have seen the potential of this industry with its<br />

growing audience, are looking for opportunities to fill in the gap in the<br />

medical tourism puzzle.<br />

Though many are eager to be the right pieces in the puzzle, many are still<br />

struggling to get the right fit. There are a number of concerns and risk<br />

factors for patients getting treatment much less seeking them abroad.<br />

Some additional concerns for patients include a consistent quality of care,<br />

lack of extensive dialog between the patient and the doctor, lack of<br />

post-op follow up, cultural differences and difficulty in obtaining<br />

sufficient insurance coverage.<br />

Packages to India<br />

At the first meeting of the Private Sector Advisory Group (PSAG) of<br />

the US-India Trade Policy Forum held in New York in<br />

September, Indian Commerce Minister Kamal Nath said that the US<br />

was “keen to ask its insurance companies to work with<br />

hospitals in India.” Evidently the US is pushing insurance<br />

companies to come up with medical tourism packages with<br />

Indian hospitals, some offering up to forty percent discounts on<br />

annual premiums for those people who will go to India for<br />

treatment. Others are adding tourism to their package offerings and<br />

financial incentives for their family and friends to stay at nearby<br />

hotels. Have the insurance companies really started taking this leap?<br />

We could not confirm that any major medical carrier is doing this, but<br />

we got the picture that it is not too far off.<br />

8 DECEMBER 2007<br />

As this industry is driven by patients or travelers who become patients,<br />

it will be interesting to see whether the industry will meet their<br />

expectations.<br />

<strong>Medical</strong> <strong>Tourism</strong> – The Other Side of the Story<br />

Much have been said and claimed about the surging medical tourism<br />

industry and how its players are benefiting from it, however, not much is<br />

known about the other side of the story – the patients themselves.<br />

The <strong>Medical</strong> Tourist<br />

There are many testimonies supporting the claim of quality medical care<br />

and low cost expenses by those who have been there and done that,<br />

however what about the potential medical tourists.<br />

Where can they find quality information on the services provided abroad?<br />

How do they know who’s good and who’s not. Although there are a few<br />

indisputable medical centers who have already carved their name in the<br />

industry, there are a great many more that are less well known. Should this<br />

have a bearing on whether they are capable of providing quality healthcare?<br />

Take for example India; there are thousands of hospitals sprawling across<br />

the country. Some have already been identified as the place to go for<br />

medical treatment, however, there are still many that are below the radar.<br />

The richer hospitals are able to afford to provide patients with the luxury<br />

of five star accommodation and service with equally advanced treatments<br />

and services, but the hospitals that are less well funded are only able to<br />

provide medical care minus the other peripherals. So how do the medical<br />

tourists choose?<br />

<strong>Medical</strong> <strong>Tourism</strong> Riding on the Waves<br />

The term and concept of modern medical tourism may have been around<br />

for the last decade but it is still in its infancy stage. There are many<br />

challenges and obstacles ahead as with any burgeoning industry.<br />

There are a few players who are already paving the way and leading<br />

from the front but there is significantly more who are jumping onto the<br />

bandwagon. It is crucial that in this race to be the best and offer the most,<br />

the travelers/patients do not get ‘marginalized’ in the industry.<br />

Continuous training for healthcare workers to ensure consistent quality<br />

of care is essential as is consistency in the service that a patient receives<br />

before and after deciding on their doctor or the medical centre where they<br />

will be receiving treatment. <strong>Medical</strong> referrers and those providing<br />

concierge services need to have a strict understanding of the quality of<br />

medical care provided by those that they are affiliated with and ensure<br />

that that information as well as the risks is clearly brought across to the<br />

travelers.<br />

Each player must play their part in ensuring that the medical tourism<br />

industry will continue to grow and benefit those that are in it – both<br />

patients and providers.<br />

Both Authors work for Avail Corporation, which had put<br />

on a conference called International <strong>Medical</strong> Travel Conference<br />

(www.<strong>Medical</strong>Travelconference.com), in November 2007 at<br />

Manila, Philippines.


MEDICAL TOURISM<br />

SELECTING A MEDICAL<br />

TRAVEL DESTINATION<br />

With advertorials from international healthcare providers increasingly commonplace, it can be challenging to distinguish<br />

bona fide foreign hospitals from fly-by-night outfits which are out to make a quick buck. Offered here is a consumer decision-making<br />

checklist that ensures you board the plane knowing that you will get the care you need at a price you are comfortable with.<br />

10 DECEMBER 2007<br />

According to the National Coalition on Health Care,<br />

approximately half a million Americans travelled<br />

internationally to seek surgical treatment in 2006. This<br />

trend looks set to continue increasing with the population<br />

aging and the prospect of lower healthcare costs in America<br />

nowhere in sight.<br />

There are 4 D’s one should consider in selecting a medical<br />

travel destination which have been described by Dr Rome<br />

Jutabha of UCLA: “Domain, Doctors, Data and<br />

Disaster.” Let’s deal with each one in turn, but before that,<br />

a few words about the importance of the country of<br />

destination.<br />

COUNTRY-SPECIFIC INFORMATION<br />

Being left hanging high and dry is the last thing you<br />

would want while you are convalescing. Thus, it is<br />

important to assess if the country that you would be<br />

visiting is generally safe and has an adequate regulatory<br />

framework to protect you, the consumer. Good sources of<br />

information include the US State Department’s regular<br />

travel advisory for US citizens and a recent World Bank<br />

By DARREN TAN & DR JEREMY LIM<br />

publication – Governance Matters 2007: Worldwide<br />

Governance Indicators 1996-2006. The latter ranks<br />

countries in terms of their political stability, government<br />

effectiveness, regulatory quality and rule of law, and<br />

control of corruption.<br />

Another important consideration would be on who the<br />

main driver of medical tourism in the country is. If it were<br />

driven primarily or regulated strongly by the government,<br />

then there would be greater assurance that the<br />

international consumer would be adequately protected<br />

because the country’s reputation would be at stake.<br />

Lastly, as most blood banks are run by national or<br />

regional governments, it would be prudent to check the<br />

quality of the blood supply and the rigor with which blood<br />

is tested for infectious diseases such as HIV and hepatitis.<br />

HOSPITAL-SPECIFIC INFORMATION<br />

Domain- What is the hospital’s clinical focus? Is the<br />

hospital really a specialist in the procedure you are<br />

undergoing? There is little point travelling thousands of<br />

miles if the attending physician is not an expert.


Doctors and Hospitals- The qualifications<br />

of the doctors are important but as U.S. board<br />

certification requires specialist training to be<br />

undertaken in the U.S. and not anywhere<br />

else, there would be relatively few doctors<br />

in the world having American board certified<br />

qualifications compared to the number of<br />

overall physicians. Membership and fellowship<br />

of the Royal Colleges in the United<br />

Kingdom are the main specialist<br />

qualifications for much of the<br />

Commonwealth countries in the world such<br />

as Singapore which is a major medical travel<br />

destination. Accreditation with Joint<br />

Commission International (the<br />

international arm of the Joint<br />

Commission) is the usual ‘mark of quality’<br />

for hospitals outside the United States but<br />

there are many other accrediting bodies such<br />

as Trent Accreditation Scheme in the United<br />

Kingdom.<br />

Experience is probably more relevant given<br />

the diversity of medical qualifications and<br />

accrediting bodies globally. The doctors<br />

treating you should have a good track record<br />

in the procedure and be able to tell you their<br />

own personal results as well as that of the<br />

hospital. While scientific publications and<br />

conference presentations are not essential to<br />

clinical expertise, they are a useful measure<br />

of peer recognition and the standing of your<br />

attending physician in his or her medical<br />

specialty.<br />

Being left hanging high<br />

and dry is the last thing<br />

you would want while<br />

you are convalescing.<br />

The number of clinical trials the doctor or<br />

hospital is involved in can also be telling.<br />

Pharmaceutical and medical devices<br />

companies will only work with doctors and<br />

hospitals that meet their stringent standards<br />

to be trial sites and you can capitalize on the<br />

background checks done by them to<br />

double-check the standards of the hospital<br />

you are about to enter. For example,<br />

www.clinicaltrials.gov (a website hosted by<br />

the National Institutes of Health<br />

documenting clinical trials worldwide)<br />

records that the Singapore National Eye<br />

Centre is currently involved in 18 clinical<br />

trials (Site accessed on Sept 12, 2007).<br />

Data- Nothing beats knowing the doctors’ and<br />

hospital’s results are publicly available.<br />

However, while many hospitals publish online<br />

their own results, it is often unclear how the<br />

data is collected and whether the data has been<br />

subject to external audit for accuracy. It would<br />

be much more reassuring if an independent<br />

body such as the government centrally<br />

collates and publishes this information and this<br />

is already happening. In New York City, the<br />

New York City Health and Hospitals<br />

Corporation has begun to put online the<br />

outcomes of certain diseases such as<br />

pneumonia and heart attack including<br />

complications such as infections. In Singapore,<br />

the Ministry of Health regularly publishes not<br />

only the clinical outcomes of procedure, e.g.<br />

Lasik and cataract surgery, but also the price<br />

patients pay for them. Another measure of<br />

reliability of data is the publication of results<br />

in peer reviewed publications such as the New<br />

England Journal of Medicine and the Lancet.<br />

Disaster- Despite the best efforts of<br />

everyone, disasters can and do happen in<br />

healthcare and you want to know you will<br />

receive the best possible care if something<br />

unfortunate occurs. As mentioned above, check<br />

that the blood supply is safe. If you are<br />

seeking treatment at a hospital that adopts a<br />

‘focused factory’ approach, i.e. it only<br />

manages heart diseases or orthopedic<br />

conditions, then make sure that the hospital<br />

has ready access to all the specialists you<br />

might need in a medical disaster, e.g.<br />

nephrologists in case of post-operative<br />

kidney failure requiring dialysis, infectious<br />

disease physicians for post-operative wound<br />

infection etc.<br />

Traveling outside the United States is<br />

something Americans are seriously<br />

considering in ever-increasing numbers. Like<br />

any other overseas venture, there will always<br />

be uncertainty, but the savvy patient can<br />

minimize risk by carrying simple checks and<br />

asking the right questions before leaving the<br />

U.S<br />

Darren Tan. MHS (Mgt), BSc (Biology)<br />

leads the Outcomes Research team at the<br />

SingHealth Centre for Health Services<br />

Research. He and his team works<br />

extensively on evaluating clinical<br />

interventions, which forms the bridge<br />

linking the endpoints of practices<br />

and interventions with their effectiveness.<br />

Dr Jeremy Lim. MBBS, MPH, MRCS<br />

(Edin), MMed (Surg), a surgeon by<br />

training, Jeremy leads the SingHealth<br />

Centre for Health Services Research. He<br />

has written and lectured widely on health<br />

policy and maintains a personal and<br />

professional interest in public healthcare<br />

quality and accessibility for all, especially<br />

the poorest segments of society.<br />

DECEMBER 2007 11


MEDICAL TOURISM<br />

The<br />

Value of<br />

Accreditation<br />

12 DECEMBER 2007<br />

Why Americans Needing Health Care<br />

Abroad Should Choose JCI-Accredited<br />

Facilities<br />

By KAREN TIMMONS<br />

President and Chief Executive Officer<br />

of Joint Commission International<br />

As Americans seek care in other countries, they look<br />

for reassurance that health care organizations abroad meet<br />

certain quality and safety standards they have come to<br />

expect. Therefore, hospitals abroad who hope to attract<br />

Americans to their institutions often seek Joint<br />

Commission International (JCI) accreditation, which is<br />

endorsed by the World Health Organization, because it<br />

demonstrates to the international community that the<br />

hospital has voluntarily sought an independent review of<br />

its commitment to safety and quality, and has met<br />

standards that contribute to good patient outcomes.<br />

But in addition, overseas hospitals tell us that they seek<br />

our consulting services and accreditation because our<br />

standards help them learn a common language – like that<br />

used by air traffic controllers – which ensures safety and<br />

consistency in the delivery of health care. Every hospital<br />

earning JCI accreditation must also set up parameters for a<br />

safe organization and meet JCI’s International Patient Safety<br />

goals.<br />

JCI is part of Joint Commission Resources (JCR), an affiliate<br />

of the U.S.-based Joint Commission. The Joint Commission<br />

accredits over 90% of hospitals in the United States.<br />

JCI extends the Joint Commission’s mission, which is to<br />

improve the quality and safety of patient care, into the<br />

international arena through international consultation, publications,<br />

education, and accreditation.


JCI is Different from JC Accreditation in the US<br />

JCI accreditation standards are comparable to Joint<br />

Commission accreditation standards, but they are different. The<br />

difference is that the JCI standards and survey process were adapted<br />

for the international community and designed to be culturally<br />

applicable and in compliance with laws and regulations in countries<br />

outside the United States. For example, informed consent by<br />

patients is a JCI requirement, but different cultures handle this in<br />

different ways. In some cultures, patients fill out a form in front of<br />

a witness, while in others a family member may be the only one<br />

allowed to give consent. JCI accreditation allows for these<br />

differences.<br />

JCI accreditation standards are<br />

comparable to Joint Commission<br />

accreditation standards, but they<br />

are different.<br />

JCI standards were developed by an International<br />

Standards Subcommittee made up of experts representing five major<br />

regions of the world. These standards address important topics such<br />

as the qualifications of doctors and nurses, properly assessing<br />

patients to match care to their identified medical needs, anesthesia<br />

procedures, and safe use of medicines.<br />

In addition to accreditation, JCI has extensive international<br />

experience working with public and private health care<br />

organizations and local governments in more than 60<br />

countries. Part of meeting JCI’s mission is helping individual<br />

countries develop their own accreditation programs. In many<br />

countries, JCI works with the ministries of health to develop their<br />

own standards and establish their own accrediting bodies. JCI’s<br />

standards have also become a model for standards developed by<br />

governments around the world.<br />

Canadian Firms Pushing Cuban Healthcare<br />

Two Canadian-based medical tourism companies are offering overseas<br />

medical care to Cuba. That’s right, even though the US embargo makes it<br />

illegal for Americans to spend money there for treatment, these firms believe<br />

that the rising costs of healthcare may make some Americans take the<br />

plunge. Cuba currently boasts patients from Spain and Italy and many<br />

other countries and is known for high standards of care. While the issue of<br />

high standards is often disputed, no one can dispute the cost savings,<br />

with prices at about one third of the cost in the US for some procedures.<br />

Nevertheless, with Latin and Central America rising in the industry of medical<br />

tourism, and waiting times for some surgeries in Canada of up to 18 months,<br />

there will likely be a great rise in the numbers of Canadian patients heading<br />

to socialist Cuba.<br />

We believe Americans can receive high quality care<br />

internationally, but first, patients needing care abroad must carefully<br />

research the physicians and health care organizations they are<br />

considering using and visit our website to determine if the hospital is<br />

accredited by JCI. Using a JCI-accredited hospital is basically a<br />

risk-reduction activity because when hospitals improve patient care<br />

and safety, patients are more likely to have good outcomes.<br />

Americans using JCI-accredited hospitals will also find other<br />

advantages. JCI accreditation requires that every patient is spoken<br />

to in a language and manner they can understand and that patients<br />

are involved in their care decisions. Patient rights must be protected,<br />

including confidentiality and privacy. When a patient prepares to<br />

leave the hospital and return home to his country, we<br />

require that the hospital transfer information to the patient and<br />

provide recommendations for follow-up care at home. All of these<br />

steps make it less likely the medical traveler will have some type of<br />

error or problem with his care.<br />

How Accreditation Works<br />

JCI accreditation is a rigorous process for which most hospitals<br />

prepare at least a year, if not longer. JCI accreditation is for a period<br />

of three years. After three years, JCI will conduct a full, onsite<br />

survey. Before accrediting a hospital, JCI sends in a team, usually<br />

including a doctor, nurse, and administrator, for a period of 3 to 5<br />

days. Although at this time, the JCI surveys are announced visits,<br />

JCI may move to unannounced visits in the future.<br />

Our surveyors use a tracer methodology, which is a<br />

systems approach, rather than just examining each<br />

department within a hospital. We believe the best way to gauge the<br />

quality of care provided by an institution is to trace the journey of<br />

patients as they move through the institution and examine how<br />

various departments work together to provide the care they need.<br />

Typically we trace 8 or more patients during our site visits.<br />

JCI has approximately 300 standards which hospitals must meet<br />

and 1200 measurable elements which is what surveyors examine and<br />

score. Before leaving, surveyors conduct an exit interview with<br />

administrators, and hospital leadership is given a copy of the<br />

preliminary report, which allows them to know whether or not they<br />

will likely receive accreditation. All reports are confidential; all we<br />

share with the public is a list of the hospitals currently accredited by<br />

our organization.<br />

There are approximately 140 JCI-accredited hospitals in 26<br />

countries. For the names of these hospitals or more information on<br />

JCI accreditation, you can visit our website at<br />

www.jointcommissioninternational.com.<br />

DECEMBER 2007 13


MEDICAL TOURISM<br />

Financial Savings in<br />

MEDICAL TOURISM?<br />

American patients pursue health care in medical<br />

destinations primarily to save money. Employers and<br />

insurance companies are exploring offshore healthcare<br />

options for the same reason. Although there has been<br />

much discussion about low costs in medical tourism,<br />

the magnitude of financial savings actually realized by<br />

patients and third-party Payors is not always clear.<br />

Insurance Company Savings<br />

For insurance companies, determination of<br />

potential savings is fairly straightforward. Third party<br />

Payors already know exactly how much they pay for<br />

their beneficiaries to have care in the domestic<br />

marketplace. First, they must establish what the<br />

charges would be for their beneficiaries to have<br />

equivalent care in medical tourism destinations. In order<br />

to make offshore arrangement acceptable to<br />

employers and beneficiaries, third party Payors will<br />

also have to assume some costs that they would not<br />

generally cover when care is obtained within the United<br />

States, including travel and certain accommodations<br />

in destination countries. Calculating potential savings<br />

for any given patient is a simple undertaking for<br />

insurance companies with core competency in<br />

collecting and analyzing data. However, projecting<br />

which segments of their beneficiaries can have – and<br />

will agree to – offshore care is a much more<br />

challenging issue.<br />

Patient Savings<br />

For patients who pay for their own care,<br />

determining the potential savings available in the<br />

medical tourism marketplace is a more complicated<br />

undertaking. Interestingly, the difficulty is not<br />

determining charges for offshore care but, rather,<br />

establishing what a patient’s expenses would be in<br />

their own hometown. To say what the financial<br />

savings are we must have this latter figure. Although<br />

it is easy and attractive to use stated charges, I believe<br />

that this practice leads to erroneous overestimation of<br />

potential savings. This practice also disregards the<br />

fact that a substantial proportion of the posted charge<br />

for procedures done here in the US is never paid due<br />

to either discounts or defaults.<br />

Getting to Best Price and Terms<br />

The number we should use for the cost of care in the<br />

domestic marketplace is the best price that patients<br />

can reasonably get if they are willing to ask for a<br />

discount and commit to clear payment terms.<br />

14 DECEMBER 2007<br />

In healthcare there is a chaotic relationship between<br />

the prices that providers charge and the payment they<br />

will actually accept. Most providers are willing to<br />

accept payment of less than posted charges from<br />

self-pay patients – they already do just this for<br />

Medicare, Medicaid and commercial insurance plans.<br />

In order to get such a discount, a patient must commit<br />

to reasonable terms and a clear payment arrangement<br />

before having treatment. (In the context of medical<br />

tourism, a patient who can arrange care in a foreign<br />

country has the wherewithal to try to do this.)<br />

Providers are much more agreeable to any<br />

arrangement if a patient makes a meaningful deposit<br />

at the time terms are discussed. The increasing<br />

number of firms that provide financing for medical<br />

and surgical care may allow patients to negotiate even<br />

better prices because this frees providers from<br />

collection costs and eliminates the risk of default. The<br />

price that a patient can likely get will probably fall<br />

below the quoted charge but above the payment<br />

provided by commercial insurance plans.<br />

My analysis compares the total out-of-pocket<br />

payments for unilateral hip replacement surgery in<br />

the US, India and Costa Rica. The data was obtained<br />

from the public web sites of several medical tourism<br />

agencies, supplemented by information provided by<br />

an experienced agent during a telephone interview. The<br />

quoted price for this operation in the United States<br />

ranges from about US$ 44,000 to US$ 62,000. For<br />

the reasons explained above, I am using the figure<br />

US$ 40,000 for this analysis. In order to make useful<br />

conclusions, it is necessary to control for<br />

uncertainties by making certain assumptions in this<br />

analysis. First, I assume that there are no additional<br />

MICHAEL D. HOROWITZ, MD, MBA<br />

Dr Horowitz has been researching<br />

medical tourism and international<br />

medical travel since 2005. A<br />

graduate of the University of Miami<br />

School of Medicine, Dr Horowitz<br />

practiced Cardiothoracic Surgery<br />

for more than 15 years and obtained<br />

his MBA from Goizueta Business<br />

School of Emory University.<br />

He can be contacted at<br />

michael_horowitz@mac.com.


charges for postoperative complications in any of the groups. Second,<br />

American patients having care within the United States incur no charges<br />

for travel and accommodations. Third, patients travel offshore in economy<br />

class with one other party – a spouse or other companion.<br />

This analysis shows that the medical savings for unilateral hip<br />

replacement are 86.5% and 83.5% in India and Costa Rica, respectively.<br />

The calculated savings are actually quite close to the commonly cited<br />

number of 90%. But American patients are not particularly interested in<br />

medical savings. They really want to know what their total savings will<br />

be since this is what truly affects them. For this analysis of hip<br />

replacement, the total cost savings are 75% for both India and Costa Rica,<br />

as compared to what a patient would really pay in the United States,<br />

presuming reasonable efforts to get a discounted price. Although medical<br />

costs are US$ 1200 less in India than in Costa Rica, much of the savings<br />

are consumed by the greater cost of travel to Asia than to Central America.<br />

Opportunity Cost: the Overlooked Factor<br />

Opportunity cost is a very important issue that has not been<br />

addressed in any analysis of savings in medical tourism that I have seen.<br />

If a patient has surgery in their own hometown, their spouse might miss<br />

a day or two of work. But a trip to a foreign country may well result in<br />

prolonged unpaid absence from fruitful employment. Furthermore, if a<br />

patient and partner are away for several weeks there may be expenses for<br />

childcare and/or elder care. On the other hand, in certain situations,<br />

offshore health care allows some patients to enhance their savings by<br />

combining their medical travel with previously considered or planned<br />

tourism activities. Opportunity costs, the expenses created by absence<br />

from home and the enhanced savings are extremely variable and not well<br />

suited to quantitative analysis. Nevertheless, they clearly have a great<br />

impact on the financial decision for patients considering offshore health<br />

care.<br />

In summary, this analysis indicates that patients who have hip<br />

replacement surgery in India or Costa Rica realize total savings of<br />

approximately 75%, compared to estimated best prices that patients<br />

could reasonably get in the United States.<br />

Cost for Hip Replacement at US and Offshore <strong>Medical</strong> Centers.<br />

Destination United States India Costa Rica<br />

Cost Date<br />

Cost of <strong>Medical</strong> Care<br />

Physicians<br />

Facilities<br />

Cost to Arrange Care<br />

Commission to agent<br />

Pre-travel evaluation<br />

Pre-operative labs<br />

Cost of Travel<br />

(Patient plus 1 companion)<br />

Air travel<br />

Travel insurance<br />

Cost at Destination<br />

Concierge services<br />

Hotel ( 5 nights)<br />

Meals at destination<br />

Analysis<br />

<strong>Medical</strong> Cost<br />

<strong>Medical</strong> Cost (% of US Value)<br />

<strong>Medical</strong> Savings ($)<br />

<strong>Medical</strong> Savings (% of US Value)<br />

Total Cost<br />

Total Cost (% of US Value)<br />

Total Savings ($)<br />

Total Savings (% of US Value)<br />

$ 40,000<br />

n/a<br />

n/a<br />

n/a<br />

$ 40,000<br />

100%<br />

$ 0<br />

0.0 %<br />

$ 40,000<br />

100%<br />

$ 0<br />

0 %<br />

$ 5,400<br />

$ 800<br />

$ 2,700<br />

$ 1,100<br />

$ 5,400<br />

13.5%<br />

$ 34,600<br />

86.5 %<br />

$ 10,000<br />

25.0%<br />

$ 30,000<br />

75.0 %<br />

$ 6,600<br />

$ 1000<br />

$ 1,200<br />

$ 1,050<br />

$ 6,600<br />

16.5%<br />

$ 33,400<br />

83.5 %<br />

$ 9,850<br />

24.6%<br />

$ 30,150<br />

75.4 %<br />

For clarity of presentation, some data are aggregated and rounded up or down to<br />

the nearest $50 increment. Travel costs are based on quotes by a medical tourism<br />

agent and confirmed using an online travel web site. Travel costs are for the<br />

patient and one confirmed, in economy class from Atlanta to New Delhi, India/<br />

San Jose, Costa Rica.<br />

2007 Michael D. Horowitz


So you manage a hospital or work with a hospital outside of<br />

the United States and you just cannot ignore the fact that the U.S.<br />

health care system is not readily available to just about one-third<br />

of all Americans. It seems like every day you see the same statistics<br />

quoted in the news media, cited by candidates running for political<br />

office or in the trade press, that as many as 50 million Americans<br />

have no health insurance and that at least another 50 million are<br />

inadequately insured. You read the complaints of U.S. businesses<br />

that the cost of providing health care benefits is increasing at a<br />

rate that threatens global competitiveness, if not corporate<br />

viability altogether. You see Michael Moore’s documentary, Sicko,<br />

and you know that you just might have an affordable option for<br />

care and treatment to many of these Americans. Finally, you think<br />

you understand enough of the public policy debate in the United<br />

States over health care to conclude that fundamental change to<br />

the current system is a long way off.<br />

Wow! A market of at least 100 million potential patients,<br />

employers looking for relief, political paralysis and you have a<br />

product that is of better or equal quality and far less expensive to<br />

offer to U.S. citizens. Why not go for it?<br />

Appropriately, you hesitate and wonder what risks are<br />

associated with this great opportunity. Although health care in<br />

the United States is heavily regulated, raising tax, ERISA, privacy,<br />

licensing and insurance issues, more likely than not, the first thing<br />

you think about is medical liability. If you are a provider, you<br />

correctly wonder if engaging in the care of American citizens<br />

exposes your organization and the individuals who provide clinical<br />

and other services to liability in United States courts. If you help<br />

facilitate obtaining care for American citizens in foreign hospitals,<br />

you also wonder if you will find yourself in court. And if so,<br />

what does that mean and can the risk of liability in US courts be<br />

managed sufficiently to justify a business decision to go after the<br />

American market?<br />

The American Judicial System<br />

No doubt you already know that the United States is the most<br />

litigious country in the world and you expect that you might get<br />

sued. Inevitably, some US citizen will experience a bad result and<br />

you wonder if your healthcare facility has adequate defenses to<br />

protect you from liability in our courts. Defenses and postjudgment<br />

realities such as personal jurisdiction, waiver, choice of<br />

law and forum selection clauses, theories of medical liability,<br />

16 DECEMBER 2007<br />

MEDICAL TOURISM<br />

The United States Court System<br />

and Liability for Treatment of<br />

American Patients Overseas<br />

~ Challenging Jurisdiction ~<br />

By FREDERIC J. ENTIN, ESQUIRE<br />

liability insurance, service of process and enforcement of judgments<br />

will be adjudicated in American courts of law.<br />

To best understand how these issues will be resolved, it is helpful<br />

to note which aspects of the United States legal system have and<br />

will affect medical malpractice litigation. In the United States,<br />

different jurisdictions with different principles of law, aggressive<br />

and creative lawyers, and the unpredictability of individual judges<br />

will have a profound affect on the success of a medical malpractice<br />

claim. As care is delivered outside of the United States, poor<br />

outcomes will inevitably occur. Patients will quickly realize that<br />

legal recourse outside of the U.S. courts is unattractive and<br />

inadequate by our standards. Once retained by the patient, their<br />

lawyers can be expected to examine every step in the process from<br />

initial patient contact to discharge to follow up care at home, to<br />

find a way to get jurisdiction in a U.S. court and to have that court<br />

apply U.S. law. The same creativity and aggressive lawyering that<br />

has made for large judgments and broad liability here will be applied<br />

to these new factual circumstances. A careful examination of our<br />

system by those looking to facilitate and provide care for American<br />

citizens may influence decisions about who is treated, how the<br />

patient is treated and how the services of the provider are marketed.<br />

51 American Court Systems<br />

LEGAL ISSUES<br />

Unlike other countries, the United States does not have a unified<br />

single body of law for the entire country. Although there is a<br />

Federal Court System, liability of the type commonly alleged when<br />

a patient has a bad outcome is covered by state law. Each state has<br />

its own legislature that makes the law and courts that interpret and<br />

enforce the laws. Including the District of Columbia, that makes<br />

for 51 separate jurisdictions with sometimes subtle and sometimes<br />

significant differences in substantive law and procedure. In the<br />

early part of this decade, the medical malpractice insurance crisis<br />

caused many state legislatures to reexamine state medical<br />

malpractice law. What resulted is typically American. Some states<br />

did nothing, many states passed reforms and plaintiff’s lawyers<br />

immediately started challenging the constitutionality of the reforms.<br />

The differences from state to state may be substantial enough to<br />

influence where the foreign provider markets its care.<br />

The incentives to sue are high and the barriers to the courts are<br />

low in America. While the law continues to vary from state to<br />

state, it is clear that judgments and settlements are much higher in<br />

all of the 51 jurisdictions than in other country. This is largely<br />

attributable to the ability in almost all states to recover


non-economic damages and the high cost of care that cause actual<br />

damages to be so high. No matter which state the patient decides<br />

to sue in, access to the courts is easy because each side pays its<br />

own legal fees and this type of case is almost always taken on a<br />

contingency basis thus, requiring no legal fees to be paid by the<br />

injured patient until the case is resolved.<br />

Lawyers and the Search for Deep Pockets<br />

The expansion of liability theories in medical malpractice law in<br />

the U.S. can be attributed to the constant creativity of plaintiff’s<br />

lawyers. Physicians typically carry no more than $1,000,000 of<br />

liability insurance for any one claim. As lawyers seek to increase<br />

the size of judgments, they look for other defendants to share the<br />

burden of paying for judgments that exceed the amount of<br />

insurance of any single physician defendant. <strong>Medical</strong> malpractice<br />

attorneys have responded aggressively and resourcefully by<br />

advocating new theories of liability which open up the pockets of<br />

others in the continuum of care to joint and several liability for<br />

the same injury.<br />

Starting with the 1967, Illinois Supreme Court decision in<br />

Darling, hospitals have been independently liable under an<br />

increasing number theories for the care delivered to patients. Injured<br />

patient’s lawyers have successfully applied theories of direct and<br />

apparent agency to expand the number of defendants against whom<br />

liability could be imposed, even when the care is delivered in the<br />

doctor’s office. And in the quest for even larger awards and<br />

settlements, plaintiffs’ attorneys have convinced courts and juries<br />

of the viability of pain and suffering and new basis upon which<br />

their clients can be compensated for non-economic damages. Faced<br />

with a client allegedly injured as a result of care in a foreign<br />

provider, it is not unreasonable to expect the same persistence<br />

and ingenuity to be applied to finding a way to bring the claim to<br />

a U.S. court under U.S. law. Anyone arguably involved in the care<br />

of the patient can be a target.<br />

Judges are People Too<br />

Just as the law may be different from state to state, the<br />

interpretation and application of the law can be highly influenced<br />

by the judge before whom the case is tried. In many states, judges<br />

are elected by the citizens of the county or region in which the<br />

judge will preside. While judges are bound to follow the law and<br />

the precedent from prior cases, the application of the facts of any<br />

single case to the law can be somewhat subjective even in the<br />

same state. Some judges sit in areas of the same state which are<br />

vastly different in culture and perspective. In Illinois for example,<br />

Cook County could not be any different than its immediate neighbor<br />

to the west, Du Page County. Judges and juries in Cook County<br />

are generally known to be more inclined to side with a plaintiff<br />

and if so, the size of the judgment is likely to be higher than in Du<br />

Page County. Further, as will be discussed later, a judge facing a<br />

ruling on whether he has jurisdiction over a defendant may be<br />

more inclined to find some basis to take the case if the alternative<br />

is that a member of his community is left with no adequate legal<br />

recourse if injured in another country.<br />

Assuming the business proposition is compelling enough to<br />

encourage you to go forward, what are the defenses that can be<br />

raised in the event a lawyer wants to get his client’s claim decided<br />

in an American court of law and what can be done to put the<br />

providers in the best position to defend?<br />

Personal Jurisdiction<br />

A court must have personal jurisdiction over a defendant before<br />

it can enter a valid judgment imposing a personal obligation on the<br />

defendant. Therefore, first line of defense for a foreign hospital or<br />

provider will be to challenge the court’s jurisdiction. Will the fact<br />

that you are located outside of the United States, that you have<br />

no offices or employees in the state where the suit is filed, that<br />

you have not consented to jurisdiction, and the alleged injury<br />

DECEMBER 2007 17


MEDICAL TOURISM<br />

occurred outside of the United States, immunize you from<br />

liability? It depends! But it is clear that over the years, starting<br />

with a case called International Shoe Co. v Washington, the United<br />

States Supreme Court, has allowed state courts to assert personal<br />

“long-arm” jurisdiction over a nonresident even though the<br />

defendant is not personally served within the state, provided the<br />

defendant has certain “minimum contacts” and the action “does<br />

not offend traditional notions of fair play and substantial justice.”<br />

Long-arm jurisdiction can be general or specific.<br />

Specific Personal Jurisdiction<br />

A court can exercise specific personal jurisdiction over a non-resident<br />

defendant when the defendant’s activities within the state serve as or<br />

are related to the basis of the lawsuit. For example, a patient calls a<br />

medical tourism facilitator in another state acting as a representative<br />

of a foreign health care provider, and the representative assists the<br />

patient in the selection of a hospital and the patient alleges he has been<br />

the victim of negligent care. In addition to suing the hospital and<br />

physicians for negligence, the patient might also allege that the decision<br />

to travel abroad for the procedure and the referral to the specific<br />

hospital or physician was the proximate cause of the injury. Before<br />

the defendants are forced to defend the claim on the merits, they can<br />

first challenge whether there is proof of the requisite connection<br />

between the act allegedly occurring in the state in which suit is sought,<br />

the recommendation or referral and the injury. An inquiry of this<br />

nature would not extend to the actual merits of the negligence claim,<br />

but if the court believes there is a connection, it will exercise specific<br />

personal jurisdiction and force the defendant hospital and physicians<br />

to defend or face a default judgment. Even if the defendants are<br />

successful in getting the matter dismissed for lack of personal<br />

jurisdiction, it will cost time and money to defend.<br />

With extensive use of the Internet to reach out to prospective patients,<br />

claims of specific personal jurisdiction are likely to arise. Developing<br />

case law tells us that the interactivity of the website consulted by and<br />

used by the patient and the hospital, may give a court sufficient<br />

grounds to find specific personal jurisdiction.<br />

It is important to remember that specific personal jurisdiction is for<br />

18 DECEMBER 2007<br />

that case only and other claims involving the same defendant and the<br />

same state are subject to fresh analysis of the underlying facts.<br />

General personal jurisdiction<br />

As opposed to specific personal jurisdiction, general personal<br />

jurisdiction exposes a defendant to the jurisdiction of the courts<br />

for all actions. A court can exercise general jurisdiction over a person<br />

if the defendant’s conduct in the state is “continuous and<br />

systematic”. Because a plaintiff bears a higher burden of proof to<br />

establish general jurisdiction, even the use of a highly interactive<br />

web site on the internet would be less likely to constitute the kind<br />

of continuous and systematic presence in the state to give a court<br />

the basis to assert general personal jurisdiction. However, the<br />

more the website becomes a virtual transactional workplace,<br />

developing legal precedents might encourage a judge to conclude<br />

that the website is no different than a physical office, that the<br />

presence of the foreign defendant is “continuous and systematic”<br />

and that there is jurisdiction for all purposes.<br />

Conclusion<br />

Bad results and poor outcomes occur whenever patients receive<br />

health care. This will be true whether the patient receives treatment<br />

in the United States or abroad. Methods of compensation for<br />

medical injuries in other countries are likely to be viewed as<br />

inadequate when compared to the American system. Some patients<br />

will understand that limited compensation in the event of a poor<br />

outcome is one of the tradeoffs for going abroad for medical care.<br />

Other patients may not be as forgiving. Those who choose to help<br />

arrange for care and those who engage in the treatment of Americans<br />

abroad must prepare to defend against clever, resourceful and<br />

aggressive lawyers and sympathetic judges.<br />

This article has discussed the first line of defense, challenging<br />

jurisdiction. While a future article will go into more detail about<br />

jurisdictional pitfalls, other articles will discuss how to manage<br />

risk in the event a sympathetic judge takes jurisdiction and requires<br />

the foreign health care provider to defend itself.<br />

Fredric J. Entin is a partner with Foley & Lardner LLP. A member of the<br />

firm’s Health Care Industry Team, he served as chair of the former Health<br />

Legislation/Associations Practice. Mr. Entin has broad experience representing<br />

hospitals and other health care providers focusing on compliance with a wide<br />

variety of issues including antitrust, Medicare and Medicaid, medical staff<br />

and exempt tax law. He has also represented trade associations and their<br />

subsidiaries for many years. Prior to joining the firm, Mr. Entin served as<br />

senior vice president and general counsel for the American Hospital<br />

Association (AHA) for more than eight years. Fred is an Advisory Board<br />

Member of the <strong>Medical</strong> <strong>Tourism</strong> Association.


Choosing an<br />

International Hospital<br />

5 Elements<br />

to Consider When Making Your Selection<br />

By LIC. BERNAL ARAGON BARQUERO<br />

General Director of Hospital Clinica Biblica, Costa Rica.<br />

We live in a generation of information overload. With so many choices available to us, it is sometimes difficult to discern truth from<br />

fiction and make sense of the mountain of information that is coming our way. This is especially true when it comes to choosing and<br />

trusting the right hospital for our particular needs.<br />

You and I have the opportunity and the capability to interact with thousands of people and organizations via the internet. With the<br />

development of the worldwide web, experts and non experts alike are filling up web pages of blogs and vlogs, having found an interactive<br />

space to share their lives and experiences with the rest of the world.<br />

As far as hospitals go, the internet also allows us the advantage of “visiting and experiencing” a hospital before physically traveling there.<br />

Additionally, sites such as MySpace, Facebook, Hi5 or LinkedIn, help us to find information that will assist us in making a sound decision<br />

about which hospital to choose. The downside is - these sites also expose us to a variety of opinions and criteria that are hard to verify and<br />

could skew reality. In other words, how do we sift through this mountain of information and ultimately make the correct decision about<br />

the best hospital for our needs? Below are some tips to make sense of all that information:<br />

LOOK FOR JCI ACCREDITATION<br />

The Joint Commission is a non governmental agency that certifies US hospitals. The International branch of the Joint Commission<br />

certifies hospitals outside the US health system that have comparable standards to a US hospital. A list of accredited institutions<br />

can be found at www.jointcommissioninternational.com/23218/iortiz.<br />

LOOK FOR EXPERIENCE<br />

Many hospitals outside the United States have been providing services to the local population for a long time. Local reputation<br />

is a good indicator of good quality. Look for institutions that have been in the market for over 50 years. This would give you<br />

confidence that things would run smoothly since they have experience. Some hospitals care only for locals, some others care for<br />

tourism alone. Seek hospitals that provide a healthy combination of locals and tourists.<br />

CHOOSE SHORT TRAVEL DISTANCES OF LONG ONES<br />

Air travel increases the risk of certain complications like deep venous thrombosis (DVT). DVT is the formation of blood clots in<br />

your legs. These clots can migrate up to your lungs and create a Pulmonary Embolism, The risk of DVT increases by 2.93 times<br />

when flights are over 8 hours and the risk of Pulmonary Embolism is 1.07 times greater in flights over 8 hours. Health tourists who<br />

undergo surgery, are pregnant, smoke, take birth control or suffer from cancer are at higher risk of suffering this condition than the<br />

rest of the population. There are many ways to reduce the risk. There are other complications from long haul air traveling, like jet<br />

lag, changes in air pressure, humidity, oxygen concentrations. A healthy conversation with your local doctor and your physician<br />

at the destination of your care can help diminish your specific risk. The World Health Organization has published a segment on<br />

International Health and Travel that includes a segment on the health considerations of air traveling. This segment is available at<br />

their website, www.who.int.<br />

SEEK PHYSICIANS THAT SPEAK YOUR LANGUAGE<br />

Communication has been the weak point of humanity ever since it came to existence. The risk of communication failure increases<br />

if two people do not speak the same language. Make sure you ask what percentage of staff and doctors speak English or your<br />

language at the Hospital. Avoid surprises.<br />

COMPARE YOUR OPTIONS<br />

We have been mentally trained to trust our doctors. No matter who we are, the white coat has a halo effect that blinds our<br />

consumer oriented mentality. Comparing hospitals and doctors is a healthy practice since past performance is the best predictor<br />

of future outcomes. Google your procedure and educate yourself about the complications and risk of the surgery or treatment.<br />

Ask specific questions about these risks and complications including hospital based risk like infection control. If these are being<br />

measured and they are willing to compare, it is a good sign of quality management at that institution.<br />

Overall, there are neither perfect hospitals nor perfect doctors, but being able to find one that fits our expectations of healthcare is a<br />

task that we can only do for ourselves.


MEDICAL TOURISM<br />

Costa Rica:<br />

From Ecotourism Leader<br />

to World Class Healthcare Provider<br />

Mention Costa Rica to someone and invariably you’ll hear<br />

words such as eco-friendly, misty rainforests and picture-perfect<br />

volcanoes to name just a few. Costa Rica is well known around the<br />

world as a premier ecotourism destination. Its proximity, stunning<br />

scenery and friendly locals have been luring North American travelers<br />

for at least three decades, long before the term “ecotourism” became<br />

popular. With all the focus on Costa Rica’s natural attractions, many<br />

people are not aware that the country is also a popular destination for<br />

top quality health care at very affordable prices.<br />

That is now changing. According to Costa Rica’s <strong>Tourism</strong> Bureau,<br />

the number of visitors to the country coming in search of medical<br />

treatment has doubled since 2003 1 . Although exact numbers are hard<br />

to come by, (a 1991 study by the University of Costa Rica suggested<br />

that nearly 14% of visitors came for medical purposes; other surveys<br />

put this number much lower), there is no doubt that more and more<br />

North Americans are finding Costa Rica a very attractive destination<br />

for their healthcare needs.<br />

20 DECEMBER 2007<br />

By WILLIAM COOK<br />

Why Costa Rica?<br />

PRICE<br />

If you have done any research, you will quickly discover that the<br />

price of medical procedures in Costa Rica tends to be at least 40-70%<br />

less than what you would pay in North America. This is due in part to<br />

lower wages, a favorable exchange rate and<br />

lower malpractice insurance. Price is no<br />

doubt the principal reason why patients<br />

choose Costa Rica and other foreign<br />

destinations.<br />

LOCATION, LOCATION, LOCATION<br />

Located just two and a half hours from<br />

Miami, Florida, Costa Rica is one of the<br />

closest off-shore medical care destinations<br />

for people living in North America. If you<br />

choose, you can literally fly to Costa Rica’s


capital city of San José on one day, have your surgery that same day,<br />

and be on your way home the following day. This, by the way, is not<br />

recommended, but it is an attractive option for less invasive<br />

procedures. For many, however, the advantage of a relatively short<br />

flight home is what puts Costa Rica at the top of their list of medical<br />

tourism destinations.<br />

Coupled with the fact that Costa Rica is a favored vacation destination<br />

for American travelers, the country is a convenient option for people<br />

who are looking to combine a regular vacation with a health check-up<br />

or surgery procedure. I mean, who wouldn’t want to slide into bubbling<br />

thermal springs or explore an emerald-green rainforest and then take<br />

care of an ailing health problem all on the same trip?<br />

Add to this picture the luxury of a wide variety of recovery retreats,<br />

a feature unique to Costa Rica, and it is easy to see why this country<br />

is such an attractive destination for plastic surgery as well as other<br />

medical procedures.<br />

A LITTLE HISTORY<br />

Even back in the early 1980’s there was already a healthy flow of<br />

North American patients coming to Costa Rica for cosmetic surgery<br />

procedures. The low cost of cosmetic and dental procedures is still<br />

one of the main attractions for patients abroad.<br />

Increasingly however, travel to Costa Rica and other countries for<br />

medical care is being driven by North Americans who don’t have<br />

health insurance or have only minimal coverage. According to the<br />

New England Journal of Medicine, “These patients are not ‘medical<br />

tourists’ seeking low-cost aesthetic enhancement but middle-income<br />

Americans who need life saving surgeries and want to evade<br />

impoverishment by succumbing to expensive healthcare options in<br />

America.” 2 This trend of traveling abroad for life-saving medical<br />

treatments is expected to increase dramatically over the coming years<br />

due to rising health care costs, higher deductibles and insurance<br />

premiums that are well beyond the reach of many middle income<br />

Americans.<br />

In a typical scenario, Tom, a self-employed roofing contractor, is<br />

told by his U.S. doctor that he requires knee replacement surgery.<br />

The price he’s quoted is close to $40,000, and, as one of America’s 47<br />

million uninsured, Tom has no way of footing the bill.<br />

Through a friend, Tom<br />

hears that there may be<br />

more inexpensive options<br />

abroad. A Google search<br />

brings up a hospital in<br />

Costa Rica where Tom<br />

learns that the exact same<br />

procedure costs only<br />

$9,500. After carefully<br />

researching the site and<br />

talking to doctors and<br />

former patients, Tom<br />

decides to use the hospital<br />

to arrange his surgery and<br />

logistics. During this time<br />

Tom speaks several times<br />

with his Costa Rica<br />

physician and is impressed<br />

by his warmth and<br />

knowledge, as well as by<br />

his credentials and fluency<br />

in the English language.<br />

Tom arrives in Costa Rica a few days before his surgery and takes<br />

advantage of the hospital’s concierge services to visit an active volcano and<br />

relaxing hot springs. A few days later, Tom is picked-up at his hotel by a<br />

hospital representative and taken to the hospital for surgery. The hospital’s<br />

caring staff and ultra-modern facilities quickly put Tom at ease. After<br />

surgery, Tom spends three days in the hospital and an extra week in a<br />

recovery retreat before heading back home. Total expenses including<br />

round-trip air-fare? $10,700.<br />

ARE WE FORGETTING ABOUT QUALITY?<br />

Sure, soaking it up at a tropical paradise may sound all fine and dandy.<br />

But who’s to say the masked man hovering over me is a qualified medical<br />

professional and not some quack that just stayed at a Holiday Inn Express?<br />

Is there any kind of government regulation? How does one weed out the<br />

good doctors and hospitals from the bad ones?<br />

First off, just as in life, things usually aren’t so black and white. Whether<br />

in the United States, Canada or Costa Rica, some doctors and hospitals<br />

simply have more experience in certain procedures and are therefore more<br />

likely to have better outcomes. Here or abroad you’ve got many good<br />

DECEMBER 2007 21


MEDICAL TOURISM<br />

doctors and then a small few that are not so good. It pretty much<br />

comes down to doing the research and using common sense. In Costa<br />

Rica, all practicing medical professionals must be registered with the<br />

“Colegio de Médicos” (the College of Physicians) www.medicos.sa.cr,<br />

a good place to start your research.<br />

To its credit, Costa Rica also has a long tradition of offering high<br />

quality medical care to all it citizens through a national public healthcare<br />

system. Besides the public health system, the country has a strong<br />

private health system with hospitals and clinics of great prestige and<br />

reputation.<br />

FACTS TO CONSIDER:<br />

• The World Health Organization’s most recent survey of healthcare<br />

systems published in the World Health Report 2000, ranks Costa<br />

Rica’s health system among the top three in Latin America ahead of<br />

154 other countries including the United States, New Zealand and<br />

Thailand<br />

• In 2004, Costa Rica’s infant mortality rate was nearly as low as<br />

the United States (9.25 deaths for every 1000 born live in Costa Rica,<br />

against 6.5 deaths for every 1000 born live in the United States). This<br />

is especially relevant considering that the United States has more<br />

neonatologists and neonatal intensive care beds per person than<br />

Australia, Canada and the United Kingdom (not to mention Costa<br />

Rica) and a per capita income nine times more than that of Costa Rica.<br />

• According to the World Bank, Costa Rica has the highest life<br />

expectancy in all of Latin America. With 78.7 years of life expectancy<br />

at birth, Costa Rica equals Canada, and beats the United States life<br />

expectancy by one year.<br />

Additionally, many of the country’s doctors have trained in the United<br />

States or Europe and a significant percentage speak English or another<br />

second language.<br />

THE FUTURE<br />

Traditionally in Central and South America (as well as many other<br />

parts of the world), most medical services have been marketed abroad<br />

through individual doctors and small clinics. Recently, however, larger<br />

hospitals have begun to actively solicit foreign patients. A case in point<br />

is Thailand, which boasts several hospitals that have successfully<br />

marketed their services to an international clientele.<br />

In Costa Rica, the Hospital Clinica Biblica has taken a leading role in<br />

positioning itself as the region’s premier medical institution for<br />

international patients. This privately owned, non-profit institution<br />

boasts one of Costa Rica’s most technologically advanced medical<br />

facilities and will soon be the region’s first JCI accredited hospital. The<br />

JCI accreditation is a world-renown seal of approval that indicates a<br />

hospital meets high performance standards comparable to hospitals in<br />

the United States and Europe.<br />

Founded in 1927 by North American protestant missionaries, Hospital<br />

22 DECEMBER 2007<br />

As Patient Coordinator for Hospital Clinica Biblica<br />

International Department in Costa Rica, Bill Cook oversees<br />

operations and customer relationship management<br />

initiatives aimed at increasing customer loyalty and<br />

satisfaction. Bill also overseas web content development<br />

and marketing strategy for <strong>Medical</strong> Tours Costa Rica, a<br />

locally based medical tourism operator. Bill can be reached<br />

at www.hospitalbiblicamedicaltourism.com.<br />

Clinica Biblica has a long tradition of catering to resident aliens and more<br />

recently to medical tourists. It recently opened an international department<br />

and is considering dedicating an entire hospital wing solely for the use of<br />

international patients. Presently over fifteen percent of its patients are<br />

foreigners and this is only expected to increase.<br />

It is initiatives such as these and others like it that bode well for Costa<br />

Rica’s incursion into this exploding market. With no end in sight to the U.S.<br />

healthcare crises, aging baby boomers and the number of uninsured continuing<br />

to grow, the road ahead looks promising as this country reinvents itself<br />

from solely a top ecotourism destination to a leading player in the global<br />

healthcare arena.<br />

References<br />

1 Milstein and M. Smith, “America’s New<br />

Refugees-Seeking Affordable Surgery<br />

Offshore,” New England Journal of Medicine<br />

2006; 355(16): 1637–1640<br />

2 ICT: Llegadas de turistas internacionales<br />

por LA VIA AEREA 2001-2006


Costa Rica<br />

The Great Opportunity<br />

Costa Rica is the country of sunny beaches<br />

on the Pacific Ocean and Caribbean rhythm on its<br />

Atlantic Coast. It is the country with the best<br />

coffee in the world, of tasty bananas,<br />

pineapple and melon consumed on the tables in<br />

five continents. It is also a country that<br />

manufactures microchips, develops software and<br />

where corporate services of important<br />

multinationals like Intel, Panasonic, Hewlett<br />

Packard and others are outsourced. Finally, it is<br />

the oldest democracy in Latin America, a country<br />

whose President, Dr Oscar Arias Sánchez, was<br />

awarded the Nobel Peace Prize.<br />

The closeness of Costa Rica to the United States<br />

at just two hours and thirty minutes from Miami<br />

lures thousands of Americans to its beaches and<br />

volcanoes for ecotourism. However, the quality<br />

of its medical professionals, the guaranteed<br />

international level of service in its clinics, the<br />

hospitability of its people and its natural beauty<br />

and excellent hotel infrastructure lure thousands<br />

of patients to its shores, making Costa Rica the<br />

new convenient destination for medical tourism<br />

where patients can recover in full and relaxing<br />

comfort.<br />

Competitiveness in <strong>Medical</strong> Services<br />

The strengthening of a cluster of medical<br />

services is one of the priorities of the<br />

competitiveness program being developed by the<br />

Government of Costa Rica. It is estimated that in<br />

2006 about 4,500 medical procedures were<br />

performed on non-Costa Rican patients. The<br />

immediate goal for the country is to provide an<br />

opportunity for at least 0.5% of Americans<br />

without medical insurance to travel to Costa Rica<br />

to get treatment, which would mean at least<br />

230,000 patients.<br />

To achieve this challenge, we are betting on the<br />

24 DECEMBER 2007<br />

MEDICAL TOURISM<br />

By JORGE WOODBRIDGE GONZÁLEZ,<br />

Vice-minister Costa Rican National Council on Competitiveness<br />

The immediate goal for<br />

the country is to<br />

provide an opportunity<br />

for at least 0.5% of<br />

Americans without<br />

medical insurance to<br />

travel to Costa Rica to get<br />

treatment, which would<br />

mean at least 230,000<br />

patients.<br />

Jorge Woodbridge González may be<br />

reached at jorgewg@racsa.co.cr<br />

competitiveness of the whole system. The most<br />

effective way to accomplish this goal is first and<br />

foremost to safeguard the quality of physicians<br />

and hospitals. In terms of marketing, Costa Rica<br />

is developing the potential of receptive offers,<br />

particularly from specialized recovery centers,<br />

promoting agreements with large international<br />

insurers, and promoting medical and nursing<br />

careers in both public and private universities.<br />

The Challenge of International<br />

Accreditation<br />

Undoubtedly, the main challenge the country<br />

faces is to promote the international<br />

accreditation of its hospitals. Some Costa Rican<br />

structures have already started certification<br />

processed before the Joint Commission<br />

International (JCI), the international arm of the<br />

Joint Commission (JC), an organization endorsed<br />

by the U.S. Department of Health and Human<br />

Services. In the short term, we want all hospitals<br />

in Costa Rica to be duly accredited, since we are<br />

aware that only in this way we can guarantee the<br />

positioning and sustainability of an industry with<br />

a lot of added value.<br />

In past months, all agents related with the medical<br />

services cluster were called by the National<br />

Competitiveness Council to work on a strategic<br />

development plan for the sector. Hospitals,<br />

physicians, hoteliers, and different Government<br />

entities (among them the Ministry of Health,<br />

Ministry of <strong>Tourism</strong>, Ministry of Foreign<br />

Affairs, Ministry of Economy, Industry and<br />

Commerce) have committed to make our<br />

country a world-class medical center within the<br />

next 10 years.<br />

We trust Costa Rica will be able to succeed in<br />

this challenge, becoming a regional leader in health<br />

care tourism, so we can again be referred to as the<br />

“Switzerland of Central America.”


MEDICAL TOURISM<br />

Costa Rica<br />

Who are those Masked Men?<br />

Costa Rica not only has universal health care,<br />

but Costa Rica is considered to have one of the<br />

best health care systems in all of Latin America<br />

The government runs more than 30 hospitals<br />

and 250 clinics. The Costa Rican health care<br />

system has been in existence for almost 60 years.<br />

Most Americans are shocked to find out that<br />

Costa Rica has been rated higher by the World<br />

Health Organization than the US, and in the last<br />

2000 WHO report the United States rated 37,<br />

below Singapore and Costa Rica.<br />

Requirements to become a doctor<br />

What exactly does one have to do to become a<br />

physician in Costa Rica? Like doctors in the<br />

US, medical doctors in Costa Rica receive formal<br />

university training followed by a postgraduate<br />

residency program. The latter ensures that they<br />

have extensive practice knowledge in their<br />

specialty. In addition, all medical physicians<br />

must meet general requirements to be a member<br />

of the Costa Rican Doctors’ and Surgeons’<br />

26 DECEMBER 2007<br />

More than Cosmetic & Dental Surgery<br />

Association (Colegio de Médicosy Cirujanos ~<br />

medicos@racsa.co.cr). Dentists, on the other<br />

hand, are certified by the Costa Rican Surgeons<br />

and Dentists Association (dentista@racsa.co.cr).<br />

Obtaining a medical degree in Costa Rica<br />

requires some undergraduate studies in the<br />

medical field and a graduate degree in medicine.<br />

It takes six years at the National University of<br />

Costa Rica to obtain a graduate medical degree,<br />

but even then a doctor is not ready for practice.<br />

A prospective doctor must complete a Doctorate<br />

Title in Medicine and one year of social service<br />

at one of the Social State Hospitals.<br />

For postgraduate residency, the amount of time<br />

spent in the various programs depends on the<br />

specialty field. For instance, plastic surgeons<br />

are required to complete an extra eight years of<br />

post-graduate residency study. Four of those<br />

years are spent in general surgery and the<br />

following four years in plastic surgery. That<br />

means a plastic surgeon has totally fourteen years<br />

of study, comprising of graduate study and post<br />

graduate residency study, before they can<br />

practice. Endocrinologists must perform an<br />

additional two to four years post graduate<br />

residency study to become a specialist, and a<br />

doctor must spend five to seven years in post<br />

graduate residency study just to qualify in<br />

general medicine.<br />

Requirements to become a nurse<br />

The University of Costa Rica requires students<br />

who are applying for a nursing degree to perform<br />

aptitude exams with a score of 700 or more to<br />

qualify. The private universities, however, do<br />

not require this exam. It takes from three to four<br />

years for a nurse to graduate from the University<br />

and four to five years in total to graduate as a<br />

licensed nurse. To qualify with a masters in<br />

nursing, a nurse will spend another one and a<br />

half years on top of the license nurse<br />

requirements. In order to work, nurses need a<br />

Costa Rican Accreditation Title and must be<br />

affiliated with the School of Nurses of Costa<br />

Rica. All other nurse titles require accreditation<br />

from the Nurses School of Costa Rica.<br />

While Costa Rica has a public healthcare<br />

system, it has a growing private health care<br />

system which is starting to focus on attracting<br />

Americans to Costa Rica for medical care above<br />

and beyond the prior reputation for inexpensive<br />

cosmetic and dental surgery. Costa Rica is now<br />

becoming known for surgeries such as Hip<br />

replacements, back or spinal surgeries and knee<br />

replacements. In fact, laboratory materials are<br />

all FDA approved and shipped in from the<br />

United States.<br />

For Americans traveling to Costa Rica for<br />

medical care the healthcare is quite affordable.<br />

Many of their doctors not only speak English<br />

but also have received training in the United<br />

States, Canada or Europe.<br />

The Two main hospitals in Costa Rica are<br />

Clinica Biblica and CIMA. Unfortunately, at the<br />

time of writing this article, CIMA hospital had<br />

not finished completing its hospital floor<br />

specifically for medical tourists. CIMA also did<br />

not provide written information to the <strong>Medical</strong><br />

<strong>Tourism</strong> Association regarding its hospital and<br />

other items such as infection rates. We hope to


include more information about CIMA once their<br />

new wing has been opened. In the interim, we<br />

have provided some information provided by New<br />

York raised, Costa Rican CEO, Carole Velosa.<br />

CIMA is an impressive complex of buildings,<br />

two of which are high rises, home to 400<br />

physicians on a campus and 1500 on staff. Most<br />

of the physicians at CIMA are trained outside of<br />

Costa Rica. CIMA has erected two new medical<br />

towers, laid stylish like in New York. Nearby, a<br />

developer plans on building condominiums, a<br />

shopping center and even an Imax theater to cater<br />

to its hospital staff. CIMA can handle 120<br />

inpatients per day and has all the modern<br />

technology of MRIs, ultrasounds, a 9 bed<br />

emergency room and trauma center. The hospital<br />

has its own helipad for the “five people per week<br />

who fall and need to be airlifted,” according to<br />

Carole Velosa.<br />

Carole Velosa indicated that last year she saw a<br />

shift from plastic surgery as the primary sought<br />

after medical treatment from foreigners to now<br />

about only fifty percent of foreigners coming for<br />

plastic surgery. The other fifty percent are looking<br />

for general medical care and surgery found in<br />

American hospitals. Of this fifty percent, patients<br />

are seeking heart bypasses, lap bands,<br />

knee replacements, hip replacements and<br />

hysterectomies.<br />

The third floor of the hospital is intended to be<br />

the “Tourist Unit,” Velosa described, “with six<br />

beds and four suites, all English speaking with a<br />

separate staff, computer room and common area.<br />

The unit will have an all American menu and WiFi<br />

access. CIMA just began their process for JCI<br />

Accreditation.”<br />

Hospital Clinica Biblica, on the other hand, has<br />

a dedicated <strong>Medical</strong> <strong>Tourism</strong> Department of 5<br />

full time employees, who speak both English and<br />

Spanish, and also a newly dedicated floor for<br />

medical tourists. The two brothers, Brad and Bill<br />

Cook, who run the international department,<br />

spent some time growing up in the United States<br />

and so there clearly is no culture barrier here in<br />

dealing with them.<br />

Hospital Clinica Biblica is a private hospital<br />

established by American missionaries and built<br />

in 1929. The hospital is affiliated with Tulane<br />

University in Louisiana with a capacity of 5000<br />

Costs of Surgeries In Costa Rica vs United States<br />

<strong>Medical</strong> Procedures<br />

Heart Bypass<br />

Heart Valve Replacement<br />

Angioplasty<br />

Hip Replacement<br />

Hysterectomy<br />

Knee Replacement<br />

Spinal Fusion<br />

Cosmetic Surgery<br />

Facelift<br />

Rhinoplasty<br />

Breast Lift<br />

Breast Augmentation<br />

Blepharoplasty (Eyelid Surgery)<br />

Tummy Tuck<br />

Dental Surgery<br />

Bridges<br />

Crowns<br />

Implants<br />

Porcelain Veneers<br />

Root Canal<br />

USA<br />

$130,000<br />

$160,000<br />

$57,000<br />

$43,000<br />

$20,000<br />

$40,000<br />

$62,000<br />

$7,000 - $13,000+<br />

$3,000 - $12,000+<br />

$4,000 - $9,000+<br />

$5,000 - $9,000+<br />

$1,500 - $7,000+<br />

$5,000 - $9,000+<br />

$1,000 - $3,000+<br />

$500 -$900+ per tooth<br />

$1,000 - $5,000+<br />

$1,000 + per tooth<br />

$360 - $900+<br />

Costa Rica<br />

$24,000<br />

$15,000<br />

$9,000<br />

$12,000<br />

$4,000<br />

$11,000<br />

$25,000<br />

$4,600-$5,000<br />

$3,500 - $3,900<br />

$3,000-$3,400<br />

$2,700-$2,900<br />

$2,000 -$2,200<br />

$3,900 - $4,200<br />

$250-400 per tooth<br />

$250 - $400 per tooth<br />

$700 - $900<br />

$300 - $500 per tooth<br />

$125 - $250<br />

<strong>Medical</strong> <strong>Tourism</strong> Association August 2007 Survey. Prices in US vary by many<br />

factors, including but not limited to, zip code, location, and provider experience.<br />

outpatients and 120 inpatients per day. Most of<br />

the non-Costa Rican patients come from the US,<br />

Canada and Europe, making up a generous<br />

percentage of the 14,400 procedures performed<br />

at the hospital each year. At least ten percent of<br />

the physicians at Clinica Biblica are US board<br />

certified in specialties such as general surgery,<br />

orthopedics, cardiac and urology. With its 800<br />

employees, this hospital boasts that all of its<br />

nurses are registered nurses and the nurse to<br />

patient ratio is approximately four to one, and all<br />

rooms are private and some are suites.<br />

Clinica Biblica has almost completed the lengthy<br />

and arduous process of JCI accreditation. It has<br />

spent thousands of dollars in training all its<br />

employees in resuscitation techniques approved<br />

by the American Heart Association. Even the<br />

janitors are certified. There are state of the art<br />

voice activated video surgery rooms, and high<br />

tech infection prevention architecture reducing<br />

the infection rate at Hospital Clinic Biblica to<br />

less than three percent .<br />

What was interesting about Hospital Clinica<br />

Biblica was the atmosphere of the facility and its<br />

employees. The whole hospital is painted in blue<br />

and green because research suggests that those<br />

colors are indicative of emoting calmness, and<br />

suitable for patient healing. There are also TVs<br />

located in ICU rooms which has been shown to<br />

create good patient outcomes.<br />

The attitude of the physicians is not one of<br />

superiority and it is common that patients have<br />

access to their doctor’s cell phone numbers. As<br />

one doctor stated, “We are just people helping<br />

people.” That being said, your overall experience<br />

at a hospital in Costa Rica may be more than you<br />

expected, especially at the lower costs for<br />

services. If the surgeon is the right one for your<br />

particular medical condition and the hospital<br />

meets your approval, we suggest you go for it!<br />

DECEMBER 2007 27


MEDICAL TOURISM<br />

ORTHOPEDIC SURGERY IN<br />

COSTA RICA<br />

Although Costa Rica is known for its excellence in cosmetic and dental surgery,<br />

the specialties found in most American hospitals can be found in Costa Rica.<br />

Many of the surgeons are board certified and trained in the U.S. and their<br />

medical practices overseas are second to none.<br />

They care for the whole patient, not just the medical problem.<br />

By OSCAR OEDING B, MD<br />

When I was asked to write an article for publication in a <strong>Medical</strong> <strong>Tourism</strong> related<br />

journal, I thought of giving a medical report including statistics of results obtained in Total Knee<br />

Replacement, Total Hip Replacement, Reconstruction of the Anterior Cruciform Ligament,<br />

Rotator Cuff Plasty, etc.<br />

New York Health Crisis<br />

Reuters reported that one out of 6 New Yorkers lacks health insurance, even though<br />

almost two thirds of these individuals are employed. Forty one percent of those<br />

without insurance did not seek medical care due to not having health insurance. New<br />

Yorkers without health insurance were four times more likely to not seek medical care<br />

as those with health insurance. Dr Frieden, New York City’s health commissioner<br />

stated “All of this adds up to people landing in emergency rooms with costly,<br />

devastating health problems that could have been prevented or treated.”<br />

28 DECEMBER 2007<br />

All these are procedures we do in the branch of<br />

orthopedic surgery. Instead, I asked some of my former<br />

overseas patients for advice as to what they would like<br />

to read about in regards to <strong>Medical</strong> <strong>Tourism</strong> in Costa<br />

Rica. Almost all agreed their attention was called<br />

primarily to the type of care they had received in our<br />

Clinic, including my care, the care provided by the medical<br />

team, as well as the entire staff in charge of their care.<br />

We are a group of professionals devoted to solving<br />

your medical problems without forgetting to care for<br />

the person behind the ailments. We want to see that<br />

you recover well from your surgery, but also feeling<br />

emotionally well throughout the entire process. Unlike<br />

in America, patients are not just numbers in a<br />

production line. Fortunately, thus far, we have achieved<br />

this commitment. All our patients not only leave<br />

satisfied with the medical result obtained, they leave<br />

thankful for having found a different way of medical<br />

care.<br />

From the medical point of view, it behooves just to<br />

mention that in Costa Rica we have the highest<br />

longevity index of Latin America, comparable with USA<br />

and Canada. This compels us to have extensive practice<br />

in procedures frequently performed on patients beyond<br />

age sixty as are joint replacements. With a Social<br />

Security institution giving coverage to 100% of the<br />

population and offering highly efficient services, we<br />

have experience in handling implants from the best<br />

manufacturers, both American and European (Biomet,<br />

Zimmer, Depuy, Johnson & Johnson, Synthes, etc.)<br />

In sports, our national soccer football team ranks around<br />

the 35 th place worldwide. This is the most practiced<br />

sport in our country, bringing us frequent injuries such<br />

as Meniscus Tear, Anterior Cruciform Ligament<br />

Rupture, Damaged Cartilage, etc. Needless to say, we<br />

have quite a bit of experience resolving orthopedic<br />

problems.<br />

For years, Costa Rica has been a strong medical<br />

tourism destination with Plastic, Dental and <strong>Medical</strong><br />

Surgery. Accordingly, we have plentiful experience with<br />

private hospital infrastructure and patient recovery and<br />

we have excellent rehabilitation centers that our<br />

orthopedic patients now are using.<br />

I look forward to some day showing you the Costa<br />

Rican way we care for patients.<br />

OSCAR OEDING B, MD is an orthopedic<br />

surgeon at the Hospital Clinica Biblica in<br />

Costa Rica


MEDICAL TOURISM<br />

Deep Venous Thrombosis<br />

The Traveler’s Disease<br />

As the world becomes more globalized and traveling becomes easily<br />

accessible to most people, we face diseases that may result from travel.<br />

Deep Venous Thrombosis (DVT), also referred to as Venous<br />

Thromboembolism (VTE), is undoubtedly a disease that can be deadly for<br />

an individual. It is therefore important for patients intending to travel<br />

abroad and medical tourism companies assisting patients abroad to<br />

understand the risks and take measures to prevent them.<br />

DVT results from many factors that can easily occur in travelers during<br />

flights lasting longer than 3 hours. Although the risk of DVT is not very<br />

high, occurring generally in about one in every six thousand people,<br />

risk factors such as age, obesity, pregnancy, smokers or people who have<br />

had certain surgical procedures like hip or knee replacements, or<br />

abdominal surgeries may increase the risks of DVT. Some cancers such as<br />

lung, ovarian and breast cancers have been shown to increase the risks as<br />

well as anyone having undergone chemotherapy. Certain heart<br />

conditions, high blood pressure or cardiovascular disease, bowel<br />

diseases and other gastrointestinal conditions can increase the risk as well.<br />

32 DECEMBER 2007<br />

By DR ELLIOTT GARITA JIMENEZ<br />

Cardio-Vascular Surgeon, Hospital Clínica Bíblica<br />

A prime candidate for DVT might be also be a person with varicose veins<br />

who takes a flight longer than 3 hours in an air-conditioned<br />

environment that causes dehydration, who failed to ingest liquids, thereby<br />

avoiding frequent bathroom visits.<br />

DVT results from a blood clot in the deep veins of the lower extremities,<br />

producing intense pain in the calves and extreme swelling in the limbs.<br />

This swelling may progress from the feet up to the thighs. This phenomenon<br />

may not appear for up to 48 hours after a trip. Although there is an<br />

immediate concern of pain and swelling, blood clots are not the real causes<br />

of concern per se. However, if a clot in a vein breaks off and travels to the<br />

arteries of the lung in the form of a pulmonary embolism, this may quickly<br />

lead to death or may result in many serious complications that require<br />

immediate hospitalization in the Intensive Care Unit.<br />

Preventing this and many other diseases is much more effective and<br />

economical than treatment. The following recommendations are<br />

specifically designed to prevent DVT:


The day before traveling:<br />

� Make sure you walk throughout the day. This should not be difficult<br />

since you likely have many errands to run before your trip.<br />

� Do not forget to take the medications you usually take.<br />

� If you regularly use a diuretic, ask your doctor if you can skip it just for<br />

this day before travel in order to avoid dehydration.<br />

� Take a lot of fluids 24 hours before the trip.<br />

� The use of anti-clotting agents (anticoagulants) or anti-platelet agents<br />

must only be used as indicated by the treating physician.<br />

The day of travel:<br />

� Make sure you use comfortable, loose-fitting clothing that is not tight<br />

around the waist.<br />

� Avoid using high-heeled shoes to prevent swollen feet.<br />

� Make sure you take liquids throughout the day so your bloodstream can<br />

become thinner, forcing you to get up and walk to the bathroom during the<br />

flight.<br />

� Avoid postures that obstruct blood flow back from your legs such as<br />

sitting with your legs bent or crossed.<br />

� Make sure that you walk frequently along the aisle at least every 3-4<br />

hours.<br />

� If your legs are prone to swelling, elastic socks are recommended (avoid<br />

bandages, since it is difficult to measure the pressure being applied).<br />

Socks pulled up to your knees should have a tension between 15 to 20<br />

mm and may be purchased at any pharmacy.<br />

� Stretching exercises are recommended, such as standing on your heels or<br />

toes.<br />

� If you have suffered previously from leg thrombosis, ask your doctor if<br />

you should take any additional precautions.<br />

And remember, if you want to enjoy your stay after a long trip, make sure you follow<br />

these simple tips and avoid unnecessary pain. Taking shorter flights or connecting<br />

flights might well be worth your while.<br />

Illegal Practices in Australia<br />

The Sydney Morning Herald reported that the New South Wales <strong>Medical</strong><br />

Board is trying to crack down on medical tourism companies that are<br />

performing illegal practices of paying Malaysian and Thai doctors to come<br />

to Australia to provide consultations in hotels. Thus far, the only report of<br />

such events comes against Gorgeous Getaways which advertised on its<br />

website for free consultations in Australia with overseas doctors before<br />

surgery. The <strong>Medical</strong> Practice Act, Section 105, states that “It is an offense<br />

for a person who is not a registered medical practitioner to advertise or hold<br />

themselves out to be qualified…or to give surgical advice and service.”<br />

Therefore the surgeons flying to Australia and giving consultations to<br />

patients in New South Wales are in violation of the <strong>Medical</strong> Practice Act.<br />

The NSW <strong>Medical</strong> Board threatened action against Gorgeous Getaways,<br />

but they are still promoting the service. What is the experience of some of<br />

these medical tourism companies? In some cases, none. One company is<br />

run by a former carpet cleaner, and many have no medical background or<br />

experience. It is very important to research the medical tourism operator<br />

and assure that you are not being misled by false promises.<br />

DECEMBER 2007 33


Got a Passport?<br />

Get a smile!<br />

There is currently a trend in the United<br />

States, where more and more Americans travel<br />

abroad for various medical and dental<br />

procedures offered by specialists around the<br />

globe.<br />

It is not a secret that a great number of<br />

Americans are not covered by dental<br />

insurance. For those who have dental<br />

insurance, their insurance generally does not<br />

cover cosmetic or aesthetic procedures, such<br />

as veneers, crowns, bleaching or dental<br />

implants. Even though these procedures offer<br />

superior treatment results, and provide<br />

patients with an improvement in their quality<br />

of life, insurance companies do not consider<br />

them basic dental treatments, and usually<br />

reject any claims filed by the patients.<br />

The only solution for some patients is to<br />

pay out of pocket for dental treatments at<br />

typically very high prices. The underlying<br />

factors creating the high cost of dental<br />

procedures in the U.S. include the high cost of<br />

materials that are used, unusually high cost of<br />

malpractice insurance, overpriced labor and the<br />

unaffordable cost of living in the U.S.<br />

Additionally, the number of years of training<br />

34 DECEMBER 2007<br />

MEDICAL TOURISM<br />

By EUGENIO J. BRENES, DDS & JAVIER QUIROS, DDS<br />

that are required by the dental doctors<br />

providing these types of procedures is very<br />

high in order to provide their patients with<br />

predictable and successful treatments.<br />

People often may ask themselves why travel<br />

abroad? Which procedures can be done in<br />

foreign countries? How does one choose the<br />

right Doctor? How does one contact these<br />

professionals?<br />

In order to answer these questions, it is<br />

important to understand that a very<br />

important factor that drives people to travel<br />

outside the U.S. for dental treatment is<br />

finances. As emphasized, dental treatments<br />

in the U.S. can be extremely expensive,<br />

leaving most procedures out of reach for a<br />

great percentage of the population.<br />

As a result, Americans are traveling abroad<br />

seeking more affordable dental care. One of<br />

the countries that is fast becoming a Mecca<br />

for dental treatments is Costa Rica. Costa Rica<br />

has a large number of dental specialists, many<br />

of whom are trained in the U.S. at the highest<br />

levels and standards, and they provide dental<br />

treatment at a fraction of the cost in the U.S.<br />

In my case, I had five years of dental<br />

training in Costa Rica, followed by four years<br />

of post graduate training and residency in<br />

aesthetics, restorative, and prosthodontics<br />

procedures at Loma Linda University, in<br />

California. Dr Quiros on the other hand,<br />

studied in Costa Rica for six years and<br />

continued his post graduate education in<br />

Dallas, Texas with a Fellowship of two years<br />

in Esthetic Dentistry, and a three year<br />

Residency in Advanced Prosthodontics.<br />

We both speak perfect English and perform<br />

the same treatments that are performed in the<br />

U.S. We both decided to return to our<br />

country and open our practice using all the<br />

knowledge and experience we gained, training<br />

at some of the top ranked dental schools in<br />

the U.S., to help the people in our country.<br />

One may wonder how U.S. trained<br />

specialists in Costa Rica can charge a third of<br />

what a U.S. based specialist will charge.<br />

There are a number of reasons for this. First,<br />

Costa Rica has a lower cost of labor and fees<br />

charged by dental labs (labs that custom make<br />

crowns, veneers, dentures, etc.). Costa Rican<br />

dental labs provide excellent quality of work


and some of the biggest American commercial dental labs outsource a great<br />

percentage of their U.S. business to Costa Rica. That means that a lot of<br />

crowns, veneers, and partial dentures, and all sort of dental work used by<br />

U.S. doctors in the United States, are manufactured in Costa Rica.<br />

Another factor is that the cost of living in Costa Rica is almost one third<br />

of what it is in the U.S. When one considers states such as California and<br />

Florida, Costa Rica is about one fourth less expensive, and this shows in<br />

the final price of the dental treatments.<br />

Some people wonder about the<br />

quality of the materials used in dental<br />

clinics in Costa Rica. Most of the<br />

materials used in Costa Rica are<br />

manufactured by multinational<br />

corporations that sell the same<br />

products in the U.S. These<br />

manufacturers distribute their products<br />

worldwide, but they have variable<br />

pricing in order to be competitive in<br />

different markets. Our clinics in Costa<br />

Rica use state of the art equipment and<br />

the highest quality in all of our clinical<br />

and laboratory materials. This gives us<br />

the certainty that the final results and<br />

treatments are at the same level as those<br />

performed in the best clinics anywhere<br />

in the world.<br />

Another question commonly asked is which dental treatments can be<br />

done in foreign countries. Well, this is a question that is closely related with<br />

the question of how to choose the right dentist. In the U.S., the association<br />

that regulates dentistry is the American Dental Association (www.ADA.org).<br />

It recognizes Prosthodontics as the only specialty in dentistry that deals<br />

with aesthetics, function, and oral rehabilitations. In other words, the name<br />

of the specialty that deals in full detail with the appearance of your smile is<br />

called Prosthodontics.<br />

How do I know if my dentist is a Prosthodontist? The easiest way is<br />

asking them directly, or by doing a little research on your own. The<br />

American Association that certifies dentists with the proper training to<br />

become a Prosthodontist is called the American College of Prosthodontics<br />

(www.Prosthodontics.org). On their webpage, you can find Prosthodontists<br />

in specific areas, both in the U.S. and other countries.<br />

It is important to do your research because the Prosthodontist is trained<br />

as “a quarterback of dental treatments.” He is the best person to coordinate<br />

a treatment plan, he knows about the results and outcomes of the different<br />

dental specialties and their procedures such as periodontics, endodontics,<br />

orthodontics, oral surgery, and he can guide you in order to achieve your<br />

goals, and expectations regarding your smile.<br />

It is important to do your research<br />

because the Prosthodontist is trained as<br />

“a quarterback of dental treatments.” He is<br />

the best person to coordinate a treatment<br />

plan, he knows about the results and<br />

outcomes of the different dental<br />

specialties and their procedures...<br />

Dental treatments that are done and supervised by a Prosthodontist can<br />

go from aesthetic concerns, crooked teeth, missing teeth due to different<br />

factors such as accidents, congenital oral defects, or other reasons, to helping<br />

you improve your quality of life by having a healthy, functional and<br />

beautiful smile.<br />

Why choose Costa Rica and not another country? Besides having world<br />

class professionals and state of the<br />

art hospitals and clinics, Costa Rica<br />

has become one of the most sought<br />

after places for travel. Costa Rica<br />

has luscious jungles, breathtaking<br />

beaches, amazing volcanoes and<br />

everything in between. Visitors to<br />

Costa Rica have increased form<br />

784,610, in 1995 to 1,452,926 in<br />

2004. Along with the increase in<br />

the number of tourists, is the<br />

development of tourist<br />

infrastructure. Another factor is the<br />

social and economic stability of the<br />

country. Since abolishing its army<br />

over fifty years ago, Costa Rica has<br />

become one of the most developed<br />

countries in Latin America, having<br />

redirected previously budgeted military funds to furthering education. It is<br />

known for its high rates of literacy and the warmth of its people and their<br />

love for their country. As an independent country, Costa Rica has excellent<br />

economic and diplomatic relationships with the U.S. Costa Rica is very<br />

American friendly, and is a preferred country for American expatriates,<br />

with over 8,000 Americans permanently living in Costa Rica, making it the<br />

country with the most U.S. citizens per capita in Latin America.<br />

And finally, you might wonder how to get in contact with the right<br />

professionals. A good way of getting appointments set and procedures<br />

done are by solid institutions, and always look for the right accreditations<br />

of such establishments. Look to the top hospitals first for their specialized<br />

dental departments to find the right professional for you.<br />

Eugenio J. Brenes, DDS, Advanced Prosthodontics, certified at<br />

Loma Linda University, School of Dentistry, Loma Linda, CA.,<br />

and Javier Quiros, D.D.S, Advanced Prosthodontics, certified at<br />

Baylor College of Dentistry, Dallas, TX are both Prosthodontists<br />

at Hospital Clinica Biblica, San Jose, Costa Rica.<br />

DECEMBER 2007 35


We interviewed Brad Cook,<br />

Managing Director of the<br />

International Department of<br />

Clinica Biblica Hospital in<br />

Costa Rica to find out just<br />

what it is like to be a patient<br />

looking for medical treatment at<br />

their hospital and what a patient<br />

might expect from beginning to end.<br />

By RENÉE-MARIE STEPHANO<br />

36 DECEMBER 2007<br />

MEDICAL TOURISM<br />

Processing the Patient<br />

CLINICA BIBLICA STYLE<br />

Generally most patients looking for<br />

healthcare overseas start their search on the<br />

Internet. Milling through the web pages, some<br />

in English, some not, performing your own due<br />

diligence can be very wearing. In an effort to<br />

make this process easier, Clinica Biblica Hospital<br />

established an international patient department<br />

specifically dedicated to making life a little easier<br />

for the foreign patient. We interviewed Brad<br />

Cook, Managing Director of this Department<br />

to learn a little more about what their role is in<br />

the lives of their patients.<br />

“We receive a call or Web form from the<br />

prospective patient and based on the<br />

information received, we then put together a<br />

price estimate for the requested procedure<br />

together with a brief description of the<br />

procedure, details concerning recommended<br />

arrival date, length of the procedure, inpatient<br />

or outpatient, and how many days are<br />

recommended for recovery,” says Cook. “We<br />

also request additional information such as<br />

photos, medical records and require the patient<br />

to complete a detailed medical questionnaire.”<br />

Cook went on to explain, “The scheduling<br />

process includes a pre-operative consultation<br />

with the physician and the procedure itself, with<br />

follow-up care, if required.” Generally,<br />

scheduling of these appointments may be made<br />

on the day the patient first contacts the<br />

international department, depending on the<br />

availability of medical records and the particular<br />

health conditions of the patient. Wait times are<br />

almost non-existent at Clinica Biblica as they<br />

run a tight ship. “It is not unheard of for a<br />

patient to contact us on Monday and schedule<br />

his or her surgery for Thursday,” says Cook.<br />

However, most patients have a long list of<br />

questions and are usually not so quick to commit<br />

to the surgery on such short notice. They


typically have questions they would like answered by the physicians<br />

usually relating to the doctor’s qualifications, questions about the<br />

hospital, the type of pre-op tests involved, accommodation issues,<br />

and what the price estimate involves. “We are seeing patients taking a<br />

much more proactive approach to their medical care and performing<br />

their due diligence since they are traveling out of their comfort zone,”<br />

says Cook. “Patients traveling abroad for healthcare are in some cases<br />

asking more questions and doing more research on their physicians<br />

than they would actually do at hospitals in the U.S. and this is a very<br />

good thing, as they are taking control of their healthcare,” he added<br />

Over the course of several days many emails and calls are exchanged<br />

between the international department staff of Clinica Biblica in order<br />

to make the patient feel completely at ease about the decision. The<br />

staff generally will make arrangements for the doctor to speak with the<br />

patient by phone or by web cam from their office.<br />

Once the decision to travel to Costa Rica for the surgery has been<br />

made, the staff sends the patient a formal itinerary confirming all medical<br />

services. If the patient desires, staff will meet the patient and any<br />

companions at the airport and assist them through Customs. From<br />

there, air-conditioned vans driven by bilingual guides deliver the patient<br />

to their prearranged hotel accommodations.<br />

“On the day of the pre-operative consultation we arrange for patient<br />

pick-up and transfer to the hospital and personally assist the patient<br />

every step of the way,” affirms Cook. A staff member escorts the<br />

patient through pre-operative tests and doctor’s appointments, assisting<br />

with translation if required. The international staff generally matches<br />

a prospective patient with an English speaking physician, unless, of<br />

course, the patient requests a specific surgeon based upon referral,<br />

specific experience of qualifications for a certain procedure, or if the<br />

patient is bilingual. Costa Rica receives a large number of Spanish<br />

speaking patients from the United States.<br />

On the day of the surgery the patient is picked up and transported to<br />

the hospital where our staff meets the patient for admission. After the<br />

surgery, staff periodically visit the patient to assure all needs are being<br />

met and will then transport the patient to a hotel with a bilingual<br />

registered nurse escort. This registered nurse will then continue to visit<br />

the patient periodically over the next few days to assist with bandages<br />

or injections if required, administer medications, and to monitor the<br />

patient’s recovery process.<br />

A day or so before the intended departure, the patient is escorted to<br />

the hospital for final evaluation before returning home. A complete<br />

medical examination is performed to assure the patient is ready to<br />

travel. Then, on the day of departure, the patient is transported to the<br />

airport where the staff assists with procuring a wheel chair, if needed.<br />

Cook says that even after the patient returns home, their staff continues<br />

with a close follow-up to make sure the patient is recovering according<br />

to plan.<br />

The international staff can also schedule tourism events for friends<br />

and family traveling with the patient if requested. “Arrangements and<br />

transportation can be provided to visit some of Costa Rica’s exotic<br />

attractions,” says Cook, “but generally this is done before the surgery.”<br />

Cook informs patients that their surgery procedure can be scheduled<br />

very quickly. Once the decision is made, and unless there are extenuating<br />

circumstances such as the need for extensive medical records or<br />

X-rays, the surgery can usually be scheduled in a matter of days.<br />

All surgery procedures require a medical consultation where the patient<br />

is present with the surgeon before the actual procedure is done. For<br />

very delicate procedures such as open heart surgery, a long distance<br />

consultation with the surgeon may be requested. What are the recovery<br />

times suggested by the international staff? “It all depends on the<br />

medical procedure and the health condition of the patient,” states Cook.<br />

“We recommend the following general guidelines which may be adjusted<br />

according to each patient health situation. Cosmetic surgery may take<br />

7-14 days, Bariatric surgery 5-7 days, Orthopedics 7-10 days, dental<br />

procedures require usually no more than 24 hours,” he added.<br />

Does this mean you can get a new smile in less than two days?<br />

“Definitely,” says Cook.<br />

Brad Cook, is founder and director of <strong>Medical</strong> Tours Costa<br />

Rica and Segrupex S.A. Brad has more than 13 years experience<br />

coordinating medical services for international patients at<br />

Clinica Biblica Hospital in Costa Rica where his company runs<br />

the International Department for the hospital.<br />

Under his direction, the International Department has been<br />

instrumental in forging relationships with insurance companies<br />

throughout the world positioning Clinica Biblica Hospital as a<br />

premier destination for international travelers. Mr. Cook is<br />

frequently contacted by local hospitals and international billing<br />

agencies for assistance and services in regards to international<br />

insurance billing.<br />

Mr. Cook launched the <strong>Medical</strong> <strong>Tourism</strong> initiative for Clinica<br />

Biblica Hospital orchestrating an aggressive service oriented<br />

model that has helped position Clinica Biblica Hospital as one<br />

of the premiere destinations in the region for medical services.<br />

His marketing efforts have been successful in attracting local<br />

and international media outlets for segments and stories<br />

regarding <strong>Medical</strong> <strong>Tourism</strong>. He has also been proactive<br />

contracting with and hosting medical tourism companies from<br />

around the world.<br />

DECEMBER 2007 37


Costa Rica<br />

Big Trip, Little Country<br />

In the heart of Central America, bridging the gap between the Pacific and Caribbean Seas,<br />

Costa Rica provides an ecotourism for anyone, just a two and a half hour flight from Miami.<br />

From die hard backpackers to patients coming for facelifts and lap band procedures, Ticos (as<br />

the locals are called) have their thumb on the pulse of attracting Americans. People can get a<br />

taste of their days of adventure without going too far or spending too much money.<br />

The only problem you might have in Costa Rica is that you might strain yourself trying to do<br />

it all before tucking yourself into a hospital bed for a medical procedure. To get the best bang<br />

for your buck, you should consider for your trip a series of a few shorter diversions from the<br />

jungle covered volcanoes to the cactus hills of Guanacaste. The important thing to remember<br />

is that you can take the perfect trip to Costa Rica in about a week and then allow yourself<br />

ample time to recover from whatever procedure you might be having. What’s more, with the<br />

relatively small size of Costa Rica, the rest of your family can continue to explore while you<br />

are recovering.<br />

The President of the <strong>Medical</strong> <strong>Tourism</strong> Association, Jonathan Edelheit and I planned a trip to<br />

visit some of the hospitals in Costa Rica for our research and for this issue of the magazine. We<br />

wanted something different, something exciting during our trip to Costa Rica. We wanted an<br />

adventure trip since this was my first time to the ecotourism paradise, and that is just what we<br />

did. We stayed at two eco-friendly lodges with toucans, monkeys and hummingbirds.<br />

Downtown Reality<br />

We arranged for a several day tour of Hospital Clinica Biblica through their special international<br />

patient department. Managers Brad Cook and Bill Cook, and their staff took care of all the<br />

38 DECEMBER 2007<br />

MEDICAL TOURISM<br />

By RENÉE-MARIE STEPHANO<br />

Decades ago, Costa Rica<br />

was a pioneer in ecotourism.<br />

Now it is also a pioneer in<br />

medical tourism. Oh how far<br />

it has come.


arrangements. Getting off the plane and going through customs, we<br />

were lured into excitement by the large flat screens depicting exotic<br />

photographs of volcanoes, toucans and poison dart frogs. Soon thereafter,<br />

we were greeted by a nice woman with our names on a sign showing us<br />

where to get our baggage and where we should go to meet Luis, of<br />

Tropical Expeditions (www.tropicalexpeditions.com). Luis took us on<br />

a driving tour of downtown San Jose, the capital city of Costa Rica,<br />

pointing out some of the notable monuments, art centers, museums and<br />

of course, the international icons of McDonalds and Taco Bell. The<br />

majority of the population speaks Spanish, but then again, living only<br />

one and a half hours from Miami, I felt right at home.<br />

We finally ended at our destination, the Holiday Inn – Aurora, owned<br />

by the Intercontinental Group. This had to be one of the nicest Holiday<br />

Inns I had ever stayed in. We met Bill and Brad Cook for dinner in the<br />

restaurant of the hotel to discuss our upcoming tour of their hospital and<br />

also our prearranged ecotour. The upscale dining and piano<br />

accompaniment was a relaxing way to end our first day in this exotic<br />

country. The next few days were spent touring the city and the hospital<br />

facilities.<br />

Rafting the Pacuare River<br />

Following our desire to be adventurous, the Cooks arranged an overnight<br />

rafting tour through Tropical expeditions and the Pacuare Lodge. Class<br />

four to five rapids we were told…the adventure was on. We were picked<br />

up by shuttle that made several stops at other hotels to pick up some<br />

Americans and some British folk, one couple on their honeymoon, a<br />

father and son seeking bonding time and another couple on a one month<br />

vacation through Central America. Clearly, we had very little concern<br />

that our Spanish was not up to par.<br />

Our tour guide was a lively fellow named Tito, employed by the Pacuare<br />

Lodge, our ultimate destination. During the one and a half hour shuttle<br />

tour through some of the most exhilarating and picturesque countryside,<br />

Tito gave us a detailed history of Costa Rica, its people, towns, folk<br />

lure, architecture and personal stories about his experience working in<br />

the coffee fields. Surely, he must have been handpicked for our tour. His<br />

charisma and sense of humor made the long journey at such an early hour<br />

very invigorating. We made a stop for breakfast, where we were served<br />

local foods at a restaurant located at the top of a hill overlooking the<br />

valley. It was a nice break and great photo taking opportunity, not to<br />

mention the last toilet break for the whole rafting trip, we were told.<br />

Okay, so they did tell us to travel light for the one night stay and I thought<br />

that was just to prevent you from bringing your valuables and extra your<br />

necessities. What I failed to realize was that our luggage was going to be dry<br />

bagged and then rafted down by another brave soul with two paddles in an<br />

oversized raft. Fitted up in life preservers, helmets and a paddle, we were<br />

instructed to get in the Pacuare River and learn how to swim towards the raft<br />

in the event we were tossed out. This was the adventure we were looking for!<br />

The raft ride into the Pacuare Lodge was not that intense, only Class 3 and<br />

4 Rapids I was told. Not bad at all. With six people and a guide, the raft was<br />

comfortable and the company was terrific with Tito also as our river guide,<br />

pointing out natural flora and fauna, wildlife and waterfalls, when spotted.<br />

The ice cold water quickly dissipated with the heat of the sun and I found<br />

myself curiously comfortable in my Florida-thin skin. We stopped for lunch<br />

on the river bank, which was prepared by the rafting guides as well. They raft<br />

and they prepare food? You cannot ask for more than that!<br />

We were warned about the frequent rains in the rainforest, where the river<br />

was guiding us, and fortunately we just barely missed the downpour that<br />

came through just after we arrived at the Pacuare Lodge<br />

(www.pacuarelodge.com).<br />

The Lodge itself is environmentally responsible inasmuch as there is no<br />

electricity, no lights and you do not flush toilet paper. We were greeted by<br />

the staff and led to our bungalows by our river tour guides. Tito carried our<br />

luggage to our new home away from home and told us dinner was to be served<br />

in about an hour. This was like no other bungalow I had stayed in. The place<br />

was huge, private and definitely romantic. Minimalist but large<br />

accommodations featured a large main bedroom with a small step down hallway<br />

and inspired bathroom with rainforest water showers. Our friends were staying<br />

in the honeymoon suite, which was worth the long hike to view its privacy,<br />

its own swimming pool, magnificent view and outside porch with hammocks.<br />

Dinner consisted of five star dining, tables located in the main lodge area<br />

where you can sit with anyone staying at the lodge. We ended up sharing our<br />

meals with the same people on our raft. After all, we were devoted to saving<br />

each others lives out there on the rapids. Interestingly, Tito was also our<br />

server and the raft guides were the chefs of our meal. We were able to relax<br />

and kickback with backgammon and cocktails under the candle chandeliers<br />

until dark. I even indulged myself in an in-bungalow massage.<br />

DECEMBER 2007 39


The next day, we all took a wonderful, yet intimidating<br />

hike up the mountain terrain to get to the start of the<br />

zip-line tour. Capped in hardhats and lining harnesses,<br />

we zipped from one tree to another, overlooking the<br />

rainforest and all of the beauty Costa Rica has to offer.<br />

When you take a zip-line tour, you’re basically as high<br />

as the clouds. You go along the top part of the rain<br />

forest, also known as a canopy. It is terrifying, yet<br />

incredible. There’s only a wire hanging between two trees<br />

and you are really high. The natural American in me<br />

leads me to think, “Who inspected these things?” Our<br />

guide Alex, also a rafting guide assured me that I was not<br />

the first person to stop myself just a little bit short of<br />

the end so I had to sort of monkey-crawl to finish.<br />

Once landed back at the lodge, we prepared ourselves<br />

for the big day. Today we would raft on Class 4 and<br />

Class 5 rapids. Would we flow through this one like we<br />

did the day before? Tito retaught the method of “getting<br />

down” in the raft during certain rapid areas, presumably<br />

so we would not go flying out of the raft. No problem<br />

40 DECEMBER 2007<br />

MEDICAL TOURISM<br />

there, as I was more than willing to be the first down in the raft. Surprisingly, the words of<br />

my mentor Tito rang in my ear before each rapid, “okay good position now…get down get<br />

down!” This was a piece of cake. After each pass through conceivably deadly rapids, Tito<br />

encouraged us with the tapping of our paddles in the air yelling “Pura Vida!” I had developed<br />

a strange and deep confidence in this person who had taught me to raft, housed me, fed me<br />

and directed me each step of the way. Overall, we only had one person fall out of the raft<br />

during the whole trip. He fell over twice, but….we did not hold that against him. After<br />

spending the whole day on the water fighting the rapids, we were ready to hit land. The trip<br />

overall was unforgettable.<br />

After two days of intense physical workout, we decided to spend a couple of days at a<br />

place called Peace Lodge. Who could have a bad time at a place called the “Peace Lodge?”<br />

The drive to get there was picturesque with views of the coffee fields and volcano rainforest.<br />

When we arrived it was raining, but it did not taint the exotic flair of the Peace Lodge with its<br />

rooms named after butterflies. The Peace Lodge has established a fantastic series of walkways,<br />

hiking paths and stairs that weave you in and around the volcano area to expose three of the<br />

most powerful waterfalls I have ever seen this close up.<br />

It would seem that the Peace Lodge must have its sufficient share of guests since they did<br />

not respond to our request for photos for the <strong>Magazine</strong>, however, we have included some of<br />

our own. Some of the unique charm of the peace lodge is the privacy and the unique care<br />

taken to create the rooms, which are very large. Each room has a fireplace, as the rainforest<br />

and the elevation makes for chilly evenings. The large bathrooms include a tub with a<br />

waterfall backdrop and even a natural rainfall shower that seems to emanate from the wall<br />

and ceiling. The stained glass separating from the bathroom and the main bedroom emanates<br />

romanticism and who does not appreciate a balcony with a hot tub and its own hummingbird<br />

feeder? Although I must say, watch your eyes, those hummingbirds mean business.<br />

Costa Rica is truly an amazing and beautiful country. It’s people are friendly, it’s medical<br />

facilities state of the art, and it gives medical tourists a wide range of activities to choose<br />

from. Even if you don’t choose an eco-adventure, it is still a beautiful country to go to.<br />

TAIWAN TRIAD<br />

Under a new program, the Grand Hotel, the Taiwan Hospital Association and<br />

the Asia-Pacific Society of Travel Medicine (ASTM) out of Taipei has gotten<br />

together for the first time to promote medical tourism in Taiwan. Patients will<br />

spend four days and three nights at Taipei’s Grand Hotel visiting local tourist<br />

spots and get a three hour health checkup, anti-oxidation treatment, skin care<br />

and a magnetic wave face lift. At a news conference, ASTM Director Shieh<br />

Ying-hua stated that Taiwan has an excellent chance of developing medical<br />

tourism due to its superior medical care even despite its late start in this industry.


MEDICAL TOURISM<br />

Understanding the<br />

American<br />

Healthcare<br />

System<br />

Understanding the American Health Care<br />

System is a four part series with a focus on<br />

which aspects of the American Health Care<br />

System will readily access overseas medical<br />

care.<br />

Part I:<br />

The Fully Insured American Patient<br />

~ Dispelling the Myth<br />

The most common question asked when you explain the concept<br />

of medical tourism is, “What kinds of Americans are going to get onto<br />

a plane to travel to a foreign country for healthcare?” Surprisingly,<br />

most overseas hospitals have very little idea about what segment of the<br />

population their future health care clients come from. Therefore,<br />

hospitals seeking to attract medical tourists to their country have no<br />

idea who their audience or core market is, providing for futile marketing<br />

efforts.<br />

If international hospitals are to succeed in attracting Americans they<br />

first need to succeed in narrowing their marketing efforts to those<br />

where they will generate the greatest returns. Just as many hospitals<br />

have been misled into believing Medicare will soon be approving<br />

overseas medical treatment, still more hospitals are misled about the<br />

types of American patients that will be traveling overseas for health<br />

care.<br />

Many international hospitals and medical tourism companies are<br />

thrilled about the possibility of fully insured health carriers such as<br />

Blue Cross Blue Shield, Aetna, CIGNA, Humana, United HealthCare<br />

and other insurance carriers affording their fully insured members the<br />

opportunity to go overseas for health care rather than receiving care<br />

domestically in the United States. In fact, many hospitals have been<br />

told that the fully insured American health insurance carriers are about<br />

to approve medical tourism, opening the flood gates to swarms of<br />

Americans going overseas.<br />

Here is a reality check. It’s not going to happen, but if it does, it is not<br />

going to happen anytime soon.<br />

If an American can go to their local U.S. hospital for the same cost<br />

that they can go to an overseas hospital, why would the American go<br />

overseas for surgery? Especially if by going overseas the American<br />

would incur travel costs, such as airfare, hotel, meals, etc., and having<br />

42 DECEMBER 2007<br />

By JONATHAN EDELHEIT<br />

to spend a good amount of time far away from home. Many people in<br />

the industry are keeping the myth alive that these Americans will<br />

magically appear abroad. This is simply not true.<br />

And then you hear another rumor. Okay, maybe regular fully insured<br />

members won’t go, but what about Americans on high deductible plans?<br />

Even if someone has a $10,000 deductible on their U.S. health insurance<br />

policy, for most procedures worth going overseas, the cost for the<br />

American patient could be the same or comparable to the total costs for<br />

having the procedure performed here in the US. For example, if a heart<br />

procedure is almost 80% less overseas at a cost of about $9,000, if you


factor in medical expenses, plus the cost of travel<br />

for you and a companion or family, hotel and/or<br />

recovery center, meals and entertainment, lost<br />

wages, possibly child care or missed opportunity<br />

in some cases, there may be no savings for the<br />

American patient to going overseas, and instead<br />

higher costs.<br />

So, why would an American with a fully insured<br />

health policy decide to go overseas for treatment<br />

versus getting it done domestically here in the U.S.?<br />

Certainly the average patient has very little interest<br />

in saving the insurance carrier any money after the<br />

patient has paid the ridiculously high and everincreasing<br />

insurance premiums. Moreover, the<br />

innate concerns about safety, quality of care and<br />

inconvenience are not going to be easily dispelled<br />

when the fully insured patient could just as easily<br />

be treated domestically for similar out of pocket<br />

costs to that patient.<br />

Then why would a fully insured patient go<br />

overseas for care? Here are two possible reasons.<br />

First, the fully insured carrier is going to give<br />

incentives to an insured, such as waiving a<br />

deductible or coinsurance, and in some cases, picking<br />

up travel expenses. Some may go so far as to give<br />

cash incentives. If an insured had a $5,000<br />

deductible or a Health Savings Account in the United<br />

States, but no deductible overseas, all travel<br />

expenses paid, plus a cash incentive of several<br />

thousands of dollars, American patients would<br />

blink, and clearly would look into the option of<br />

getting treatment overseas. Currently, no U.S. health<br />

insurance carrier is offering cash incentives for an<br />

insured to go overseas. Many health insurers are<br />

still focusing on the evaluation of liability and<br />

determination of risk involved in sending patients<br />

overseas, and especially the risk involved in<br />

providing incentives to do so.<br />

The second reason a fully insured patient would<br />

go overseas would be quality of care. At this time,<br />

it is very difficult to determine and compare the<br />

quality of care overseas. Several of the largest<br />

health insurance carriers in the U.S. have said they<br />

are not comfortable with being able to evaluate and<br />

determinate the level of quality of care. Many of<br />

the fully insured carriers feel there needs to be an<br />

extremely high standard for overseas hospitals.<br />

Some have off the record even stated that they feel JCI, the most well-known and sought after<br />

accreditation system for the larger overseas hospitals isn’t good enough for them and they wish to<br />

see a higher standard, however they just don’t know what that is right now. And until they know<br />

what they want and what they are comfortable with, these U.S. insurers are not going to move<br />

forward with sending Americans overseas.<br />

A real problem with determining the quality of medical care overseas, especially for fully insured<br />

health carriers, but more particularly for patients, is obtaining full disclosure of accurate and detailed<br />

information on quality of care and outcomes. As long as hospitals hold this information tight to their<br />

chest, American companies will be hesitant to look overseas for health care. Those hospitals willing<br />

to progressively move towards transparency, allowing full disclosure of quality of care and outcome<br />

data will be more readily embraced by the U.S. health care system.<br />

In conclusion, it is extremely important for international hospitals seeking to expand their facilities<br />

in the area of medical tourism to realize who their target audience is. Before spending thousands of<br />

marketing dollars to attract the insurance carriers and fully insured patients, international hospitals<br />

should focus on globalizing their data to allow for full disclosure of quality of care and outcome data.<br />

Hospitals need to understand that fully insured carriers will not be sending many patients overseas<br />

until quality of care can be confirmed in a way they are comfortable with.<br />

DECEMBER 2007 43


MEDICAL TOURISM<br />

Change is the only constant. And because it is often accompanied by<br />

stressful and sometimes difficult adjustments and decisions, we often go<br />

to greater lengths to resist rather than embrace change. So how does one<br />

make change a little easier? Oftentimes having choices and options makes<br />

the transition bearable, and even rewarding.<br />

The challenges we face in health care today are certainly no exception. As<br />

leaders and employers address the need to manage the rising costs of care<br />

in the U.S., consumers have more options than ever. From multiple offerings<br />

of plan options, Health Savings Accounts (HSAs) and Flexible Spending<br />

Accounts (FSAs) to seeking medical treatment abroad, both insured and<br />

uninsured health care consumers now need to research how to spend their<br />

own resources. One such option is medical tourism, or as the qualityconscious<br />

refer to it, medical travel – traveling abroad expressly for high<br />

quality medical care at a lower cost.<br />

Traveling to another country for medical care, however, is not without<br />

some significant challenges of its own. One of particular importance is<br />

exactly how to involve your local physician and ensure that they will have<br />

access to the necessary resources when you return home. <strong>Medical</strong> travel<br />

will be more successful with the support of physicians and ancillary<br />

providers once back in the United States. A critical component in the<br />

success of one’s treatment is the availability and coordination of followup<br />

care with the patient’s domestic physician.<br />

The consensus among many U.S. physicians is that this is fast becoming<br />

a reality of today’s health care market and more and more patients will<br />

have choices when it comes to deciding where to seek care – especially for<br />

more complex, high-cost treatments and procedures. There are several<br />

recommendations you can follow to help smooth out the transition from<br />

treatment abroad to after-care at home.<br />

First, and most important, locate a provider and physician that support<br />

and encourage collaboration with the primary physician in the U.S. and<br />

vice versa. This should be viewed as a partnership between your doctor at<br />

home and the clinician abroad. It’s not enough to simply discuss the plan<br />

of treatment with your attending physician at home, but encourage them<br />

and the destination specialist to communicate. Effective communication<br />

between all individuals, services, programs and organizations will likely<br />

improve the quality of care and level of functioning. According to the<br />

March 31, 2007 sentinel event statistics published by The Joint<br />

44 DECEMBER 2007<br />

Engaging Your Family Physician in<br />

<strong>Medical</strong> Travel<br />

By THOMAS C. JOHNSRUD,<br />

<strong>Medical</strong> Travel Consultant, Parkway Hospital<br />

Locate a provider and<br />

physician that support and<br />

encourage collaboration<br />

with the primary physician<br />

in the U.S., and vice versa<br />

Commission, communication was cited as the root cause of the event in<br />

nearly 70% of the reported cases.<br />

Also, share ALL of your medical history, medications, allergies and any<br />

other relevant indications that you and your physician deem important to<br />

share. If you are working through a medical travel agent, they should be<br />

able to facilitate the transfer of appropriate medical records including<br />

current x-rays, diagnostics, etc. In fact, some agents have access to webbased<br />

repositories that enable medical records and documentation to be<br />

easily shared between authorized providers. Contrary to the more familiar<br />

referral process, this is a more complex partnership that requires all involved<br />

physicians to work together for the patient to receive the best and safest<br />

care.<br />

The total plan of care also should include ensuring that the potential<br />

resources needed after the initial treatments are available upon your return.<br />

Although the acute portion of the recovery may occur at the treatment<br />

destination, medical travelers may require the need for several weeks of<br />

rehabilitation at home post-treatment. Make sure you and both physicians<br />

are aware of what these requirements are before completing your travel<br />

plans.<br />

The collaborative link between the physicians facilitates a much more<br />

comprehensive treatment plan to follow you through your recovery and<br />

helps to ensure a better outcome. <strong>Medical</strong> treatment overseas serves as a<br />

complement to, not a replacement for, health care in the U.S.


JOIN<br />

THE MEDICAL TOURISM ASSOCIATION<br />

Info@<strong>Medical</strong>TravelAuthority.com


In recent years medical tourism has become<br />

somewhat of a buzzword in the USA – it might<br />

even be worth calling it a bubble, given both its<br />

links and likeness to the dot-com investment<br />

bubble. Although one could view this evolving<br />

industry as a manifestation of globalization and<br />

more liberal trade common in all sectors of the<br />

economy, some have attempted to classify this<br />

as a unique phenomenon – often considering it<br />

a “disruptive” technology that could<br />

revolutionize health care, both here and abroad.<br />

Others paint a more sinister picture, claiming<br />

that healthcare tourists are “refugees” escaping<br />

the high prices of the U.S., displaced from the<br />

comfort and quality of American health care<br />

systems in order to afford care (with the natural<br />

extension that they are sacrificing both comfort<br />

and quality by doing so).<br />

In reality, the U.S. plays a minor role in the<br />

international market for healthcare tourism.<br />

The American market is dominated by the<br />

Asian market, and both Asia and the Americas<br />

are minuscule compared to the size of the<br />

European market. This disparity is in part<br />

46 DECEMBER 2007<br />

MEDICAL TOURISM<br />

Psychological<br />

barriers to<br />

understanding<br />

the market for<br />

<strong>Medical</strong> <strong>Tourism</strong> By JOHN F.P. BRIDGES, Ph.D.<br />

This disparity is in part due<br />

to the misconceived<br />

definition of “health tourist,”<br />

which focuses on national<br />

borders rather than<br />

state borders.<br />

due to the misconceived definition of “health<br />

tourist,” which focuses on national borders<br />

rather than state borders. If we focused on the<br />

E.U. and just looked at its collective exterior<br />

border, much of the internal trade amongst its<br />

member countries would be omitted. Similarly,<br />

if the focus in the U.S. were to shift to patients<br />

crossing state borders for healthcare, the<br />

numbers would be much higher. In fact,<br />

Americans cross state borders for healthcare<br />

every day in search of better quality of care,<br />

better physicians, greater convenience of<br />

scheduling and even better pricing. What is<br />

surprising about the American market is that<br />

most of the current discussions focus on<br />

exporting patients to other nations, rather than<br />

the traditional market of attracting wealthy<br />

foreigners to our elite hospitals systems. It is<br />

clear, however, that the debate on health<br />

tourism is being manipulated for political<br />

means (e.g. healthcare reform in the USA is<br />

hard to sell if you focus on the positive<br />

elements) and such manipulation is being made<br />

possible by a lack of data on health care


tourism (both coming and going). For example, health care statistics<br />

in the USA, such as the percentage of GDP devoted to healthcare,<br />

are distorted by foreigners who seek health care – quite often at any<br />

cost – but who are just added to the statistics for the domestic<br />

market.<br />

If we are going to truly understand healthcare tourism in America,<br />

then there are at least three barriers that we have to overcome.<br />

Unlike most trade barriers, these barriers are in many respects<br />

psychological ones or relate to historical biases or have been generated<br />

by misinformed media coverage of the issue. Like many trade issues,<br />

there are vested interests looking at the market for medical tourism<br />

either as an opportunity, (particularly those that want a quick buck<br />

out of exploiting this market), or a threat to the status quo. To date,<br />

there has not been a rigorous discussion concerning the potential<br />

gains from trade associated with the internationalization of health<br />

care services.<br />

The first barrier to understanding health tourism is realizing that it<br />

is not dominated by flows of patients from the developed to the<br />

developing world per se. Many health care tourists come from<br />

developing countries that lack specialist care or infrastructure. For<br />

example, many health care tourists in Singapore come from Indonesia.<br />

In fact, when one assesses international trends, two assertions can<br />

be made. Generally, patients travel to countries with relative similar<br />

levels of development and patients normally seek care in their own<br />

region. Of course, many exceptions can be found to these rules, but<br />

it is important to note them as exceptions.<br />

The second barrier to understanding the market relates to the push<br />

and pull of patients. In the U.S. we need to stop focusing on the<br />

push factors that are leading people to consider healthcare tourism<br />

and focus on mechanisms to pull patients towards our facilities.<br />

This will be difficult as the notion of push is so engrained into the<br />

American health care system. (When has your surgeon ever said,<br />

“Let’s schedule the surgery when it is best for you?”) Managed care<br />

engrained the notion of push, and pay-for-performance will do little<br />

to make care more patient-centered. In reality, many Americans<br />

choose foreign providers because they are attracted by the quality<br />

of facilities, customer service and a holistic approach to care.<br />

Finally, to understand healthcare tourism one has to realize that it<br />

is more than just travel for medical procedures, rather, it incorporates<br />

a broad range of lifestyle and wellness factors. While many hospitals<br />

in the U.S. are venturing into the realm of complementary and<br />

alternative medicine, the environment of the typical aging hospital<br />

infrastructure of the U.S. might negate some of the benefits of these<br />

therapies. An example of how medical tourism enhances wellness<br />

relates to dedicated recovery time. In the U.S., it is common for a<br />

patient to return to work or return to their day to day grind before<br />

they physically are ready. By travelling abroad, patients are spending a<br />

dedicated amount of time for recovery – often by combining holiday time<br />

with their health care - in order to achieve a better state of wellness. The<br />

ability to combine holiday with health care is obviously a lure for patients to<br />

go overseas.<br />

John FP Bridges Ph. D. ~ John is an Assistant Professor in the<br />

Department of Health Policy and Management at Johns Hopkins<br />

Bloomberg School of Public Health (www.jhsph.edu/dept/hpm)<br />

and a Senior Fellow at the Center for Medicine in the Public<br />

Interest (www.cmpi.org). He is an advocate for the scientific<br />

study of patient preference in the area of Pharmacoeconomics,<br />

Outcomes Research and Technology assessment and is the founding<br />

editor of a new journal titled “The Patient – Patient Centered<br />

Outcomes Research.” He is also a co-author (with Percivil<br />

Carrera) of a study titled “Globalization and Health care: Understanding<br />

health and medical tourism,” published in the Expert<br />

Revue of Pharmacoeconomics Outcomes Research<br />

(2006;6(4):447-453). He can be contacted via email on<br />

jbridges@jhsph.edu.<br />

Patient with chronic back pain given life back<br />

Canadian 48-year old Jill Misangyi left Canadian waitlists to the wind, traveling<br />

thousands of miles to eliminate sixteen years of chronic back pain. Jill returned<br />

to her work of a registered nurse just five weeks after her spinal decompression<br />

surgery abroad. She only spent $12,000 for the surgery, airfare for her and a<br />

companion, hospital stay, hotel stay and other expenses where just the procedure<br />

alone in Canada would have cost $40,000. Jill described waiting lists for back<br />

specialists of up to six months and wait times for surgery up to two years after<br />

that. “It was a wonderful experience. I got my life back. The medical team, the<br />

doctors, the nurses and everybody right down to the housekeeping staff, is just<br />

wonderful. They make you feel very warm,” says Jill regarding her Indian<br />

medical team. Jill used Healthbase, a medical tourism firm out of Boston,<br />

Massachusetts.<br />

DECEMBER 2007 47


By MICHAEL BINA<br />

Driven by “The Number One<br />

Concern of Adults and<br />

Businesses in the U.S.,”<br />

an insatiable and immutable<br />

‘Unaffordability Ebola’ is<br />

attacking another compliant<br />

48 DECEMBER 2007<br />

U.S. host: The U.S.<br />

Healthcare System.<br />

MEDICAL TOURISM<br />

PART - 1<br />

Unaffordability<br />

Ebola<br />

According to experts at Harvard, Johns<br />

Hopkins and Mercer, the US System is sick;<br />

its prognosis, poor.” We’re reaching the outer<br />

limits of affordability,” said Arnold Milstein,<br />

MD, <strong>Medical</strong> Director of Pacific Business<br />

Group on Health (PBGH) and Chief<br />

Physician at Mercer Human Resource<br />

Consulting (MHRC). Milstein was<br />

addressing an international conference of<br />

providers, educators, brokers and facilitators<br />

on Global Health when he said, “We’re<br />

seeing an upward spread of the<br />

‘Unaffordability Ebola’.”<br />

What Happens in Vegas...<br />

At the first International <strong>Medical</strong> <strong>Tourism</strong><br />

Conference in Las Vegas this year, Milstein<br />

was one of the prominent canaries singing an<br />

early warning of a virus attacking the<br />

seemingly immune U.S. Healthcare System<br />

– (formerly known as “The Best System in<br />

the World”). The Canaries were singing at<br />

all venues in ‘Vegas, but it WON’T stay in<br />

It killed Manufacturing, put Software on life<br />

support and is now infecting U.S. Healthcare<br />

Vegas. The Ebola is spreading across a Flat<br />

World faster than people will admit...<br />

500,000 U.S. Patients Abroad<br />

The National Coalition of Healthcare<br />

estimates 500,000 people left the US for<br />

treatments last year; 500,000 international<br />

patients will visit India this year infusing $2.2<br />

Billion into its economy; 200,000 patients<br />

visited Singapore in 2005; 100,000 visited<br />

Malaysia that same year. It’s a $60 Billion<br />

Global Business that’s growing 20% a year.<br />

At a presentation titled: “Leveling the<br />

Global Healthcare Playing Field,” Harvard<br />

<strong>Medical</strong> International President and CEO,<br />

Dr Robert Crone argued: 1.) Regional Health<br />

Systems have achieved quality services at<br />

lower cost than U.S. systems; 2.) Global<br />

Standards and Benchmarks of quality are<br />

emerging; 3.) <strong>Medical</strong> <strong>Tourism</strong> is growing,<br />

and global insurers will participate. Privately,<br />

he said, “They’re going to eat our lunch.”


Bark and Bite!<br />

Dr Crone knows what’s going on. He has the<br />

credentials one would expect of a guy who’s at<br />

the top of the food chain at Harvard <strong>Medical</strong>.<br />

He’s lectured and implemented health education<br />

and delivery system programs in more countries<br />

than the average American could name, spell or<br />

find on a map! A Top Dog in global healthcare,<br />

Crone has the bedside manner of a Junk Yard<br />

Dog: both the bark and the bite hurt!<br />

”In the Flat Medicine World, US facilities may<br />

be seriously disadvantaged; adversely impacted<br />

in the global marketplace. “Oh well,” he said<br />

smugly, “we had our Century.”<br />

Crone rattled off the maladies running rampant<br />

throughout the system today, then piled on<br />

several scary scenarios ahead. It was a foreboding<br />

message for anyone planning to access US<br />

Healthcare today, or tomorrow.. (Meaning<br />

everyone; every single American; rich, poor,<br />

healthy, sick!)<br />

Like other industries, healthcare has globalized<br />

and the new, uber competitive marketplace is<br />

introducing unimagined (some say impossible)<br />

features and benefits to consumers of healthcare:<br />

Cheap; Comparable Outcomes; Outstanding<br />

Customer Service…What’s not to like?<br />

Let’s say you’re uninsured and need a new<br />

knee? What if you needed something less invasive<br />

like your annual physical? What if you wanted<br />

a face lift; breast reduction; tummy tuck or, sex<br />

change? Since you’re responsible for the full<br />

price on these latter procedures, you’re<br />

probably going to shop around, (after you’ve<br />

self-diagnosed your problem, of course.)<br />

As you’re shopping, you’re probably trying<br />

to find other important things to look at and<br />

measure. Unfortunately, there is little accessible,<br />

comparable consumer information on cost,<br />

quality and care in the U.S.! As a result, even<br />

the most unsophisticated buyer of healthcare is<br />

drawn to the international healthcare bizarre on<br />

the internet – and a sale is made half way ‘round<br />

the earth, in the dead of night.<br />

Joe Sixpack<br />

Let’s say you’re a self insured employer –<br />

responsible for the first $50,000 or so on each<br />

employee. Would you consider recommending<br />

Old Joe from Sales to contemplate an awake,<br />

beating heart coronary artery bypass grafting at<br />

a superspeciality hospital in India - instead of<br />

at a local provider? Would you ask/beg Joe to go<br />

halfway around the world for a couple months<br />

of cancer treatments for the good of the<br />

company? Would you rewrite your plan<br />

document to take advantage of global pricing?<br />

Britons Taking Up Private <strong>Medical</strong> Plans<br />

Would you consider Singapore as your Preferred<br />

Provider Network?<br />

And what about taxpayers? Should the U.S.<br />

Government send Medicaid patients packing?<br />

What about Medicare? Should taxpayers shell<br />

out $50,000 for grandma’s new hip when she<br />

can get one of those innovative, high tech hip<br />

resurfacing jobs for about $10,000 bucks or so<br />

in India or Thailand?<br />

How about all those new, high deductible health<br />

plans being sold by the carriers - where your<br />

best interest (maybe your only interest) is finding<br />

and buying the most cost-effective care you can<br />

afford?<br />

Would you fly 10,000 miles for a couple new<br />

crowns - plus a week on the beach - if you’d<br />

save $1,000? A TIME <strong>Magazine</strong> poll in May<br />

2006 found that 45% of uninsured people said<br />

they would; 19% of insured people said they<br />

would, too. When asked if they could save<br />

$5000, 61% of the uninsured and 40% of insureds<br />

said they would travel 10,000 miles for an<br />

elective procedure.<br />

Hold the Mayo<br />

Imagine your Executive Physical at a Mayo vs.<br />

Maya? (Come on, guys, wouldn’t you be more<br />

inclined to actually have an annual physical –<br />

even with a colonoscopy – if it included a week<br />

on the beach with a martini and a massage for<br />

less than you’d spend for three days in<br />

Rochester, Minnesota?)<br />

How interested would<br />

you be in traveling to<br />

another country for a<br />

routine procedure (e.g.<br />

your Executive Physical)<br />

if you knew the cost<br />

would be considerably<br />

less - and the care would<br />

be equally good?<br />

<strong>Medical</strong> <strong>Tourism</strong> is Hot. (Some call it:<br />

“<strong>Medical</strong> Value Travel;” others:“Consumer<br />

Driven Healthcare at its most driven level.”)<br />

Whatever YOU call it, it’s economics applied to<br />

healthcare for the first time in 50 years.<br />

<strong>Medical</strong> Value Travel has been going on in the<br />

world for a long time, but most tourism has been<br />

inbound to the Mayos and the Cleveland Clinics<br />

of the world. Since 911, however, inbound<br />

<strong>Medical</strong> Travel has all but dried up; outbound<br />

tourism is growing by leaps and bounds. Instead<br />

of Cleveland, it’s Chennai; instead of Mayo, it’s<br />

Mumbai.<br />

What’s a CEO to do?<br />

Nicolet Bank Business Pulse© is a quarterly<br />

economic and business study of CEOs, O&Os<br />

and GMs in 10 Northeastern Wisconsin<br />

counties. (Businesses from all sectors and all<br />

sizes are represented in the sample.) In January,<br />

Nicolet Bank posed several questions about<br />

<strong>Medical</strong> <strong>Tourism</strong>: 52% of the CEOs, O&Os and<br />

GMs never heard of <strong>Medical</strong> <strong>Tourism</strong>; 23%<br />

heard of it, but didn’t know much about it; 17%<br />

were somewhat familiar; 9% very familiar.<br />

The Nicolet Bank Business Pulse© also asked:<br />

“How interested would you be in traveling to<br />

another country for a routine procedure (e.g.<br />

your Executive Physical) if you knew the cost<br />

would be considerably less - and the care would<br />

be equally good?”<br />

“Nearly a third said they’d be interested,” said<br />

Dr David Wegge, president of Intellectual<br />

Marketing, LLC – the firm that conducts the<br />

studies for Nicolet Bank of Green Bay. “I don’t<br />

know how this compares to national CEO data;<br />

I suspect we’re the first to ask.”<br />

Wegge was surprised that a third of the CEOs<br />

would be interested, “especially among CEOs<br />

who probably have health insurance and fewer<br />

financial worries.” 30% were definitely not<br />

interested; 23% were probably not interested;<br />

19% said, “It depends on the country.” (Of the<br />

countries listed, Canada was the overall preferred<br />

provider; Russia was dead last – definitely an<br />

OUT of network provider!)<br />

Nicolet Bank also asked CEOs 1.) “Would<br />

you be more interested if a medical trip were<br />

combined with a business opportunity and; 2.)<br />

Would you be more interested if it included a<br />

vacation with spouse/partner.” “The levels<br />

changed substantially,” Wegge said.*<br />

It’s a Brave New World; a Small World after all.<br />

*Contact Wegge for detailed analysis:920 217 7738<br />

The Financial Times reported that with the inherent wait lists and hospitals breeding “superbug” bacteria, more and<br />

more Britons are enrolling in private medical insurance policies than ever. 12% to be precise. Insurers are offering<br />

sure-sell policy plans to lure employers into offering them to their employees. The most popular plans are international<br />

plans geared towards people looking to fly abroad to the US, Europe and Canada for treatment. Companies like<br />

Allianz offer full refunds for care and in some cases, the insurer will pay to “repatriate” you back home if you have<br />

suddenly fallen ill or hurt. The costs of coverage is relatively high, with world coverage including the US and<br />

Canada averaging $8,700, to $4,000 excluding North America.<br />

DECEMBER 2007 49


Why pay for performance?<br />

Pay for performance ( P4P ), is a new trend in<br />

reimbursement that is gaining momentum in the<br />

United States. Traditional payments to<br />

hospitals and doctors were based on diagnosis<br />

~ the government or managed care companies<br />

would pay a specific fee to doctors and hospitals<br />

based on these diagnosis, regardless of outcome,<br />

complications, patient satisfaction, or errors.<br />

Today, many large insurance companies and the<br />

federal government (CMS) are incentivizing, or<br />

paying bonuses to doctors and hospitals that<br />

follow specific guidelines set out as “quality”<br />

by these reimbursing entities. These may include<br />

using certain medications, timeliness of care, or<br />

complication rates. These guidelines are most<br />

often clinical, but some also include measures<br />

of cost effectiveness as well.<br />

Today there are only a few system-wide<br />

implementations of the pay for performance<br />

plan and most projects are still pilots. Med-<br />

Vantage and The Leap Frog Group projected<br />

there will be 155 Pay for Performance programs<br />

in place this year compared to a mere 39 in<br />

2003. The metrics are still being hotly debated<br />

by providers, payors and regulatory agencies.<br />

Costs of P4P<br />

Opponents of Pay for Performance argue that<br />

P4P increases administrative costs. Many<br />

private payors are piloting new P4P projects<br />

that involve penalties. Although only few<br />

penalties have been enacted, different structures<br />

MEDICAL TOURISM<br />

Pay for Performance:<br />

Here today…..<br />

here tomorrow?<br />

We all recognize that there is no perfect payment system. The historical “fee for service”<br />

method does not align quality of treatment and treatment results with reimbursement ~ but<br />

rather with volume of treatment. Financial incentives have been demonstrated to change<br />

behavior. The current “Pay for Performance” method established by many insurance<br />

carriers is intended to reward providers for achieving certain performance measures for<br />

clinical quality and efficiency. So the theory is that high quality should be rewarded and<br />

that better care will lead to better outcomes. The question is…is it working?<br />

By DAN BONK<br />

50 DECEMBER 2007<br />

are being discussed, some of which include a<br />

reduction in base reimbursement as incentives<br />

increase. These same payors are also placing<br />

more of the burden of measurement and reporting<br />

on providers in order for them to obtain Pay for<br />

Performance incentives and thereby increasing<br />

provider administrative costs. Lower<br />

performing providers are improving the fastest,<br />

but receiving the smallest allocation of P4P<br />

returns. (JAMA October 12, 2005)<br />

Operational Efficiency<br />

Pay for Performance revenue less operational<br />

efficiency (OE) are the two factors that are<br />

directly correlated to organizational profitability.<br />

Where 80th percentile Pay for Performance with<br />

only a 10th percentile OE may net out at a level<br />

well below the national average industry<br />

profitability, this factor is critical. Pay for<br />

Performance cannot be evaluated without<br />

assessing the impact of OE. To improve<br />

profitability in future P4P environments, we<br />

need to increase quality or operational indicators<br />

while holding the other constant. But to move<br />

the curve in the future P4P environment,<br />

quality improvements will need to increase OE<br />

or vice versa.<br />

Operational Efficiencies<br />

Financial Indicators<br />

� Operating Margin<br />

� Contribution Margin<br />

Quality Indicators<br />

� Patient Satisfaction<br />

� Mortality Rates<br />

� Rehospitalization within 72 hours<br />

Operational Indicators<br />

� Average Length of Stay<br />

� Cost per Discharge<br />

� FTE’s per Occupied Bed<br />

P4P already indirectly rewards Operational<br />

Efficiency by generating increased profitability<br />

due to lower costs as a percentage of charges,<br />

but what if P4P were applied to your<br />

operations? A higher than average percentage of<br />

spending on administration implicitly means that<br />

your organization is spending LESS (as a<br />

percentage of revenue) on patient care.<br />

Philanthropic organizations are already measured<br />

and rated based on their percentage of<br />

administrative cost. (www.charitynavigator.org)<br />

Source: National Center for Health Statistics<br />

Is the US Healthcare System broken?<br />

It is no secret that employers are dropping<br />

insurance plans and cost shifting to employees.<br />

In some cases, it takes 18-30 months for<br />

coverage to take effect. What about the quality<br />

of care received in the US? It is estimated that<br />

only 55% of medical care received is actually


Hotel<br />

Retail<br />

Airlines<br />

Healthcare<br />

the correct care for patients’ conditions. There is an average of 98,000<br />

deaths per year directly related to medical errors. With 46 million<br />

Americans uninsured, and although healthcare is always on the political<br />

agendas at the national and local levels, there does not appear to be<br />

any immediate solution in sight. Needless to say, one of the greatest<br />

American myths is that we have the best healthcare system in the<br />

world.<br />

A crisis in need of P4P<br />

Healthcare’s share of the economy continues to grow and is projected<br />

to reach 19.6% BY 2016. US healthcare spending far exceeds that of<br />

other “developed” countries both in terms of per capita spending and<br />

percent of GDP.<br />

Physician Compensation and the Delivery of Quality Health<br />

Care<br />

We all recognize that there is no perfect payment system. In fact,<br />

financial incentives have been demonstrated to change behavior. The<br />

fee for service/volume system can encourage over utilization while<br />

prepayment or capitation risk models encourage wider utilization<br />

even when prevention is encouraged. Salary systems without<br />

incentives can discourage effort and innovation. Peter Lee, CEO of<br />

The Pacific Business Group on Health said, “We pay even if doctors<br />

make mistakes, run unnecessary tests and have to redo their work.”<br />

Today there is no national set of performance standards against<br />

which physicians are measured. The CMS pilot project may be the<br />

first effort announced in 2003. CMS administrator Tom Scully has<br />

criticized the current system for paying every healthcare provider<br />

“the same rate, whether they are the best or the worst” (New York<br />

Times, July 11, 2003). Under the P4P program, medical groups submit<br />

data toward a common scorecard that grades them on patient<br />

Percentage of Revenue Spent on Administration<br />

2%<br />

3%<br />

5%<br />

Per Capita<br />

$ 2,094<br />

$ 2,467 $ 2,508<br />

15%<br />

Health Care Spending<br />

in Selected Developed Countries, 2004<br />

$ 8,000<br />

$ 7,000<br />

$6,000<br />

$5,000<br />

$4,000<br />

$3,000<br />

$2,000<br />

$1,000<br />

$0<br />

$ 2,825 $ 3,043 $ 3,120 $ 3,159 $ 3,165<br />

$ 4,077<br />

Spain Italy UK Sweden Germany Australia France Canada Switzerland USA<br />

% of GDP<br />

$ 6,102<br />

8.1% 8.7% 8.1% 9.1% 10.6% 9.6% 10.5% 9.9% 11.6% 15.3%<br />

Sources: OECD Health Data 2006, Statistics and Indicators for 30 countries, October 2006.<br />

18%<br />

16%<br />

14%<br />

12%<br />

10%<br />

8%<br />

6%<br />

4%<br />

2%<br />

0%<br />

DECEMBER 2007 51


satisfaction, clinical treatment, and investment in information<br />

technology.<br />

Some substantial payments are being made. In addition, on August<br />

24 Blue Cross of California, a subsidiary of WellPoint, announced<br />

that is was rewarding 126 physician groups a total of $69 million in<br />

bonuses for performance in 2006. About a week earlier, Blue Shield<br />

of California announced that it distributed $31 million in bonus<br />

money.<br />

What do Physician Groups Fear about P4P?<br />

� Getting used in a “shell game” manipulated by the payors<br />

� To date there is no long term commitment to P4P by payors<br />

� Measures are not geographically or socio-economically fair<br />

or reliable<br />

� P4P compliance is too burdensome and expensive<br />

� Public reporting can increase liability<br />

� Cost controls will masquerade as quality and initiatives<br />

Physicians have embraced some P4P models over the last several<br />

years such as the one Beckman developed for physician stages of<br />

change P4P (see illustration below).<br />

REGULATORY & LEGAL ISSUES<br />

The issue of increased liability for P4P participation raises several<br />

legal and regulatory issues – yet to be resolved. These include<br />

Physician Anti-Self-Referral Law (the “Stark” law), Anti-Kickback<br />

Statute, Civil Monetary Penalties Act, Antitrust, Defamation,<br />

Malpractice and Privacy.<br />

52 DECEMBER 2007<br />

MEDICAL TOURISM<br />

Physician Self-Referrals<br />

The Stark Law prohibits a physician from referring Medicare and<br />

Medicaid patients for designated health service to entities with which the<br />

physician (or an immediate family member) has a financial relationship. A<br />

P4P arrangement may be exempted from the Stark prohibitions by meeting<br />

one of the following exceptions: personal services exception, fair market<br />

value compensation exception, electronic items and services exception. In<br />

the hospital/physician model, a hospital may become involved in a P4P or<br />

gainsharing program by contributing funds as part of the program. If this<br />

is the case, a financial relationship with the participating physicians will<br />

be created, and the financial relationship must satisfy each element of a<br />

Stark exception.<br />

Anti-Kickback Statute<br />

The Anti-Kickback statute prohibits the solicitation of, offering of, or<br />

payment of any type of remuneration (directly or indirectly, in cash or in<br />

kind) in exchange for referrals or the arranging for the furnishing of health<br />

care that is paid for by federal health care programs. A P4P arrangement<br />

may be immune from Anti-Kickback liability if it meets one of the following<br />

Safe Harbors: investment interest, personal services and management<br />

contracts, electronic items and services.<br />

Civil Monetary Penalties Act<br />

This Act prohibits a hospital from making a payment directly or indirectly<br />

to a physician as an inducement to reduce or limit services to Medicare or<br />

Medicaid beneficiaries under the physician’s care. This is the major issue<br />

for gainsharing programs.<br />

Antitrust<br />

To avoid a price fixing charge, an arrangement should indicate financial and<br />

clinical integration.


Defamation<br />

If a report questions the quality of care administered by a physician, would the<br />

peer review privilege apply? Are the network decisions regarding credentialing<br />

and termination protected from discovery? Are patient surveys subject to<br />

discovery?<br />

Malpractice<br />

Do reported quality indicators make physicians more susceptible to malpractice<br />

claims? Will quality rankings be admissible in a malpractice lawsuit?<br />

Privacy<br />

P4P arrangement may involve the sharing of patient information, which would<br />

trigger applicable privacy laws. HIPPA concerns will need to be addressed or<br />

provider confidence will be an issue.<br />

Also, in the future, medical staff by laws, and rules and regulations need to be<br />

reviewed and possibly revised. <strong>Medical</strong> staff policies need to be reviewed and<br />

possibly revised to address a provider’s performance. Both the hospital and the<br />

medical staff should consider establishing loss control/loss mitigation strategies<br />

related to outcome data use.<br />

Is P4P Here to stay?<br />

As reported in Health Leaders News on August 1, 2006, “100 healthcare leaders<br />

from hospital, physician, supply chain and policy sectors were asked to rank the<br />

top 10 most important issues that are transforming US healthcare. Pay-forperformance<br />

programs were ranked #1.”<br />

Paul Danello, former counsel DHHS, OIG wrote recently, “This is the beginning<br />

of the third wave of reimbursement, not some fad.”<br />

Mark McClellan, 2005 in “Quality, Safety, and Transparency: A Rising Tide<br />

Floats all Boats” wrote, “During the next 5 to 10 years, P4P could account for<br />

20% to 30% of what federal government pays providers.” While Leslie Norwalk,<br />

CMS wrote : “The Premier Hospital Demonstration is showing that even limited<br />

additional payments, focused on supporting evidence-based quality measures,<br />

can drive across-the-board: improvements in quality, fewer complications and<br />

reduced costs.”<br />

Another CMS leader was overheard comparing the CMS P4P pilot to the study<br />

of a new drug. His analogy compared P4P to a new drug, and our current payment<br />

mechanism to the placebo. His analogy was that P4P was curing patients while<br />

the placebo group was remaining ill. He joked that possibly we should call off<br />

the study, throw away the placebo, and “cure everyone” by implementing P4P!<br />

Overall, it looks like Pay for Performance has the right idea to at least improving<br />

the quality of care for patients. Although the providers find the program to be<br />

costly and unfair, it would appear that at least the patients are reaping the<br />

benefits of a better quality of care.<br />

Dan Bonk is the Executive<br />

Vice-President, Central Region of<br />

Aurora Healthcare, a successful<br />

senior healthcare leader for over<br />

25 years. He is also an Advisory<br />

Board Member of the <strong>Medical</strong><br />

<strong>Tourism</strong> Association.


MEDICAL TOURISM<br />

What is Self-funded Healthcare<br />

&<br />

Amazingly many overseas hospitals don’t<br />

know what self funded health care is (sometimes<br />

referred to as Self Funding). Every hospital<br />

should, because self funded healthcare is one of<br />

the few ways for hospitals to tap into the<br />

patient pool for Americans that already have<br />

health insurance coverage, but may choose to<br />

go overseas for healthcare rather than receive it<br />

domestically in the U.S. Understanding how<br />

Self Funded Health Care fits into <strong>Medical</strong><br />

<strong>Tourism</strong> is a key factor in the growth of this<br />

industry.<br />

U.S. Employers juggling the high costs of<br />

healthcare are always looking for solutions,<br />

flexibility on benefit coverage, and ways to<br />

reduce the cost of their healthcare. Partial Self<br />

Funding/Self Insurance with Stop Loss Coverage<br />

is an attractive alternative to employers utilizing<br />

a fully insured plan such as BCBS, CIGNA,<br />

AETNA, Humana or United HealthCare.<br />

What is a Self-Funded / Self-Insured<br />

Plan?<br />

A partially self-insured, or self-funded plan,<br />

is one in which the employer assumes a portion<br />

of the financial risk in providing health care<br />

benefits to it’s employees. The employer<br />

chooses a plan of benefits, which may be similar<br />

to or identical to the employer’s current fully<br />

insured plan. Rather than obtain medical<br />

coverage from an insurance carrier (such as<br />

BCBS or Aetna), the employer elects to fund<br />

the risk of medical claims up to a certain level<br />

where a Reinsurance or Stop Loss Insurance<br />

carrier is brought in. For larger employers, no<br />

reinsurance or stop loss insurance is brought in<br />

and the employer is fully 100% at risk for all<br />

medical claims.<br />

54 DECEMBER 2007<br />

How does <strong>Medical</strong> <strong>Tourism</strong> fit into it?<br />

Stop Loss or Reinsurance is designed to limit<br />

the employer’s risk of self funding their<br />

healthcare and limits the losses for medical<br />

claims to a specified amount, to ensure that<br />

large, or unanticipated claims, do not upset the<br />

financial integrity of the self-funded plan. The<br />

level of risk an employer takes on with self<br />

funding and the point at which a reinsurance or<br />

stop loss insurance kicks in is in direct relation<br />

to the employer’s size, nature of their business,<br />

past medical claims experience and tolerance<br />

for risk.<br />

Normally, in self funded arrangements, a Third<br />

party administrator (TPA) administers the plan.<br />

A TPA performs the same functions that a fully<br />

insured carrier would. A TPA’s responsibility<br />

includes maintaining eligibility, customer<br />

service, managing a network of contracted<br />

providers, adjudicating and paying claims,<br />

managing and negotiating claims, preparing<br />

claim reports, plus arranging for managed care<br />

services such as network access and case<br />

management.<br />

Self Funding – A Comparison to Fully<br />

Insured Plans<br />

Everything that is provided in a fully insured<br />

health plan is duplicated in the self funded health<br />

plan. (Everything that the fully insured carrier<br />

offers in a fully insured plan, is offered in the<br />

self funded plan – from PPO networks to<br />

benefits, such a co-pays, deductibles and<br />

coinsurance.)<br />

The difference is that with the partially self<br />

funded plan the employer holds the cash needed<br />

to fund benefits (claims from providers), and<br />

instead of sending the fully conventional<br />

premium to the insurance company (such as<br />

By JONATHAN EDELHEIT<br />

BCBS or Aetna), only a small fraction of the<br />

conventional premium is sent in to the<br />

reinsurance carrier and a small amount to the<br />

TPA. The employer purchases reinsurance for<br />

protection, holds the remainder of the<br />

conventional funds (claim funds), invests them,<br />

segregates them if desired, or utilizes them for<br />

general business purposes until they are needed<br />

for the funding of medical claims. The employer<br />

retains and keeps the funds when claims do not<br />

materialize, hence realizing further profit. So,<br />

if an employer was paying BCBS or Aetna<br />

$5,000,000 a year in premiums, and the<br />

employer’s employee claims were only around<br />

$2.5 million, then it is possible for the fully<br />

insured carrier to walk away with close to $2.5<br />

million in profits. If the employer self funds,<br />

the employer is the one who walks away with<br />

the $2.5 million dollars in savings at the end of<br />

the year.<br />

Example A: (Fully Insured Example)<br />

Acme Company is fully insured with a Fully<br />

Insured Carrier and pays a premium of<br />

$1,500,000.00 annually for their health<br />

insurance plan. Claims experience shows that<br />

Acme Company only had $1,000,000 in claims<br />

and administration expenses. The fully Insured<br />

Carrier keeps the $500,000 in profits.<br />

The advantages of self-funding are many.<br />

There is tremendous flexibility in the benefit<br />

plan design. You can decide what you want to<br />

cover and what you don’t, whether it’s certain<br />

vaccinations, chiropractors, injectibles, obesity,<br />

or infertility. Another major advantage, is<br />

portability from one carrier to another. There’s<br />

no disruption in plan when you shift between<br />

reinsurance carriers. You don’t have to start all<br />

over again with new I.D. cards, booklets and


doctors, the way you do with the fully-funded<br />

plans. Also, for employers with more than one<br />

office, it is possible to offer the same plan to<br />

everyone in every location. This makes it so<br />

much more administratively efficient. By Self<br />

Funding an employer can utilize one<br />

national PPO network or multiple local PPO<br />

networks with the same benefit plans. But the<br />

bottom line, is cost savings.<br />

Example B: (Partially Self Funded<br />

Example)<br />

Acme Company’s group health insurance is<br />

self funded with a Third Party Administrator<br />

with reinsurance. Acme Company’s potential<br />

worst case scenario for the year is $1,600,000<br />

annually (what they would have paid to a fully<br />

insured carrier). Acme Company pays $20,000<br />

a month in fixed premium costs and holds in<br />

claims reserves $1,360,000 for potential claims.<br />

The $1,360,000 is retained by Acme Company<br />

and it is theirs to utilize as they see fit until<br />

claims materialize. At the end of the year Acme<br />

Company’s claims are $1,000,000. Their fixed<br />

premiums were $240,000 for a total of $1.24<br />

million. Acme Company retains the $360,000<br />

it reserved in a worst case scenario. Acme<br />

Company realizes a $360,000 savings by going<br />

Self Funded versus Fully insured.<br />

ClaimsExperience—Immediate<br />

Realization of Hard Dollar Savings<br />

Under a fully insured program, if an<br />

employer’s experience is “better than expected,”<br />

the insurance company gains financially and<br />

makes an unexpected profit. The insurance<br />

carrier does not refund the excess profit to the<br />

employer. Even if an employer has good claims<br />

experience, the insurance company will still<br />

pass on a renewal based upon the insurance<br />

companies’ pool of thousands of groups.<br />

Employers are not truly rated based upon the<br />

employer’s claims experience and can be treated<br />

unfairly. With Self Funding your renewals are<br />

based on “YOUR” company’s claims<br />

experience, and it is not based on thousands of<br />

other companies that have no relation to your<br />

company or industry. You, the Employer, not<br />

the insurance company enjoy the advantage of<br />

favorable claims experience. You, the Employer,<br />

keep the savings, not the fully insured carrier.<br />

How Does <strong>Medical</strong> <strong>Tourism</strong> fit into<br />

Self Funding?<br />

Most Self Funded plans have reinsurance,<br />

which is a form of insurance that protects<br />

employers from catastrophic losses. So, the<br />

employer funds the base of the plan, with a<br />

reinsurer taking care of catastrophic losses.<br />

One form of this insurance is Specific Stop<br />

Loss Reinsurance. Specific Stop Loss -<br />

Reinsurance (also known as Individual Stop<br />

Loss or Specific Deductible) protects a selffunded<br />

employer from large claims from any<br />

one individual or dependent. If any one<br />

individual’s claims hits the Specific Deductible/<br />

Individual Stop Loss Level (a specific dollar<br />

amount) the employer’s liability ceases and<br />

the reinsurance carrier takes on the liability<br />

and the claims. The Stop Loss Carrier will<br />

then reimburse the employer for all claims in<br />

excess of the specific deductible for the rest of<br />

the plan year. The Specific Stop Loss<br />

Deductible is determined by the following<br />

demographics of the employer: number of<br />

employees, age, sex, claims experience, etc..<br />

<strong>Medical</strong> <strong>Tourism</strong> is the only<br />

real solution in health care<br />

today where employers are<br />

guaranteed to save money.<br />

Specific Deductibles can range from $20,000,<br />

and upto $250,000 for much larger groups.<br />

Let’s take a $100,000 specific deductible as an<br />

option. The employer must pay the first<br />

$99,999.99 on any person within the health<br />

plan. Once that person’s claims hit $100,000<br />

the reinsurer pays the remaining claims for<br />

that person for the year. So, if a member needs<br />

a heart procedure that costs $100,000, the<br />

employer is guaranteed to pay $100,000<br />

because the reinsurer pays only after claims<br />

hit $100,000. This means the employer is<br />

guaranteed for a heart procedure to pay the<br />

Malaysia<br />

$99,999.99 in a self funded health care plan.<br />

If the employer can implement medical tourism<br />

and convince an employee to go overseas for<br />

healthcare, and the employee goes to Asia for<br />

example, then the cost for the surgery may<br />

only be $9,000. That means the employer just<br />

saved $91,000 “hard” cash. By the U.S.<br />

employer utilizing <strong>Medical</strong> <strong>Tourism</strong> they just<br />

cut their health care expenses for major<br />

surgeries by up to 90%!<br />

A creative method some Third Party<br />

Administrators and employers are doing is<br />

creating incentives for employees. These<br />

incentives could be from paying for the member<br />

and a loved one’s airfare to the foreign country,<br />

plus picking up all expenses, hotel, food, etc.<br />

Some companies are even offering cash<br />

incentives on top of an all expense paid trip/<br />

vacation, allowing employees to take a<br />

vacation they otherwise couldn’t afford and<br />

still have cash in their pocket. For a $100,000<br />

surgery in America that would cost $9,000 in<br />

the U.S., if the employer waived a $2,000<br />

deductible, paid for airfare for the member and<br />

a loved one, plus all expenses and a $5,000<br />

cash incentive, the employer could walk away<br />

spending less than $20,000 for the surgery.<br />

Which is still a $80,000 savings (80%) over<br />

getting the surgery done in the United States.<br />

Don’t forget, with self funding, this is the<br />

employer’s money that’s being saved, not the<br />

insurance carrier..<br />

The most important part for the Third Party<br />

Administrator and Employer is partnering<br />

with a quality hospital and ensuring the<br />

employee or participant has an amazing health<br />

care experience. Next month we will address<br />

how employers should approach medical<br />

tourism with their employees and how it can<br />

change the corporate culture.<br />

Jonathan Edelheit is President<br />

of the <strong>Medical</strong> <strong>Tourism</strong><br />

Association with a long history<br />

in the healthcare industry,<br />

providing third party administration<br />

services for fully insured,<br />

self-funded and mini-medical<br />

plans to large employers groups.<br />

Malaysia attracted 230,000 foreigners for medical tourism in 2005.<br />

Dr Kulaveerasomgam, Chairman of the Association of Private Hospitals<br />

of Malaysia committee stated that “Malaysia is slowly coming up in medical<br />

tourism business – we can see from the statistics that its growing. The<br />

outlook for medical tourism in the country is very bright – it is a recession<br />

proof industry.” Malaysia is working with local universities to develop<br />

specialty areas for example in cancer, neurology, and orthopedics.<br />

DECEMBER 2007 55


MEDICAL TOURISM<br />

PLANNING YOUR<br />

MEDICAL TRIP ABROAD<br />

Recovery Retreat or Hotel:<br />

An Interview with Jim Follett of<br />

International Hotel Group<br />

As the amount of US patients<br />

traveling abroad for elective care<br />

continues to increase, where to stay<br />

when arriving at a destination<br />

country is becoming big business.<br />

By LOURDES GASPARONI<br />

The needs of the “<strong>Medical</strong> Tourist” are much<br />

different than those of someone traveling on business<br />

or vacation. Historically, for a medical tourist, staying<br />

at a traditional hotel comes with much apprehension.<br />

While a hotel may be very appropriate for someone<br />

having dental work done, it may not be very suitable<br />

for someone having a cosmetic or bariatric procedure<br />

for example. Challenges include: the lack of privacy<br />

after the procedure, rooms often times not properly<br />

equipped to handle post-surgical issues, medical needs,<br />

such as nurse care and massage therapy, are not readily<br />

available. This may cause frequent trips to a medical<br />

facility for post-operative care and follow up.<br />

Many hotels are trying to make the adjustments. Jim<br />

Follett of International Hotel Group, based in Dallas,<br />

TX says, “As the hotel company with more guest rooms<br />

than any other company in the world, we are focusing<br />

on the individual traveling internationally for various<br />

medical treatments.”<br />

Jim is the Director of Global Sales in Latin America<br />

and has spent much time in Central and South America.<br />

“Our research found these individuals have special<br />

requirements at the facilities they select for their<br />

recovery period. Our brands InterContinental, Crowne<br />

Plaza, Holiday Inn, Holiday Inn Express, and Staybridge<br />

Suites are committed to satisfying the unique needs of<br />

these guests.”<br />

“The initial markets where we are developing programs<br />

for these guests include San Jose Costa Rica, Monterrey<br />

Mexico and Sao Paulo Brazil. Each city has multiple<br />

IHG brands which will satisfy the different budgets of<br />

the travelers. The Real InterContinental San Jose for<br />

example offers 24 hour room service, health club and<br />

business center which is very important to many of<br />

these guests. The newly renovated Holiday Inn San<br />

56 DECEMBER 2007


Jose-Aurora located in the city center offers walking<br />

access for the guest to the city - a plus for individuals<br />

interested in exploring the city as they recover.”<br />

“The hotels will have specifically designed programs<br />

for the medical tourist. Their recovery needs will vary<br />

based on the various medical procedures. Staying with<br />

internationally recognized brands will reduce some of<br />

the anxiety these patients experience. Additional<br />

services such as daily transfer to the facility, special<br />

dietary offers and free local phone calls to their doctors<br />

will include some of the services these guests will<br />

experience with IHG brands. A web site has been<br />

established for the industry, specifically for the medical<br />

tourism providers in the USA and Canada. We<br />

anticipate working in concert with these professionals<br />

to insure a quality experience for the guests.”<br />

Outside of hotels, many countries in Latin America<br />

catering to medical tourists, have left it to the<br />

physicians and hospitals to come up with solutions<br />

to this need. A plastic surgeon or hospital, for example,<br />

may offer an apartment that is nearby to the medical<br />

facility with 24 hour nurse care.<br />

Some countries such as Costa Rica, however, have<br />

been quick to identify a medical tourist’s needs and<br />

have made adjustments accordingly.<br />

“There are over 15 recovery-type retreats in San<br />

Jose alone,” said Raul Cossio, Owner of the Paradise<br />

Cosmetic Inn. “Hotels are not medically equipped to<br />

handle surgical patients, in fact, many of the local<br />

hotels will tell people to contact us instead.” He<br />

believes the biggest difference is the 24 hour nurse<br />

attention and “the fact that you are among people<br />

that you have a lot in common with and can share<br />

your experience, is a big factor.” “It’s like a big pajama<br />

party, everyone is comfortable, it’s the perfect<br />

atmosphere for relaxing and recharging, which<br />

facilitates the healing process.” “By the time the<br />

people leave, everyone feels like one big happy family<br />

planning a reunion at Paradise.”<br />

Like hotels, there are some challenges to the Recovery<br />

Retreat for a <strong>Medical</strong> Tourist. The issues that they<br />

run up against involve the limitations on what is<br />

available at the facility. This is particularly an issue<br />

for those <strong>Medical</strong> Tourists that bring a spouse or<br />

companion. Meal selection and entertainment can be<br />

limited and the costs for extra services that may be<br />

included in the price at a hotel, needs to be evaluated<br />

by the <strong>Medical</strong> Tourist. Also, after the required period<br />

of recovery in which the <strong>Medical</strong> Tourist needs daily<br />

medical attention for Post-operative care, they may<br />

“outgrow” the facility. Consideration to changing<br />

venues for the remainder of the stay may be a good<br />

option.<br />

Consulting the doctor, who is carrying out the<br />

procedure is very helpful in deciding how and where<br />

to stay. Based on their experience, they will be able to<br />

provide you with what your expected recovery time<br />

should be and how long a recovery retreat would be<br />

beneficial.<br />

Both the recovery retreat and a traditional hotel have<br />

their advantages. Doing your homework and research<br />

to determine what is best for you, the medical tourist,<br />

will help make your experience a very positive one.<br />

Lourdes Gasparoni is a proprietor of<br />

Premier MedEscape in Palm Beach<br />

Gardens, Florida and may be reached at<br />

info@premiermedescapes.com.<br />

DECEMBER 2007 57


What is Your Country’s<br />

Ranking?<br />

The WHO report came out as the first ever analysis of the performance of the health<br />

systems of WHO’s 191 Member States. The performance assessment of health systems is<br />

based on many country variables such as: socio-economic, political and technological.<br />

WHO rankings show that even countries with the same levels of income can have very<br />

different healthy life expectancies while many countries fall short of their potential for<br />

performance.<br />

According to Dr Uton Muchtar Rafei, WHO’s Regional Director for South-East Asia,<br />

“This Report will hopefully provide a framework for the review of health sector reform in<br />

these countries, and will enable them to adopt various policy options in order to obtain<br />

higher levels of health.”<br />

According to Dr Uton, “Choosing the right interventions and providing incentives to the<br />

providers is one way to improve the performance of the health system. WHO calls for a<br />

new ‘universalism’ - which means providing the simplest and most basic quality care for<br />

all, including the poor. Developing countries should rationalize their investment in human,<br />

physical and technological resources. The health ministries need to play a strong stewardship<br />

role, and should invite and regulate investment by other sectors, including the private<br />

sector into health.”<br />

58 DECEMBER 2007<br />

MEDICAL TOURISM<br />

As the healthcare crisis in the US<br />

continues to grow and Americans are<br />

looking to overseas alternatives for<br />

treatment, many people are looking<br />

back to the World Health Report from<br />

the year 2000 that focuses on the<br />

performance of health systems world<br />

wide. It assesses health systems and<br />

the 35 million or more people they<br />

employ. The report notes that the<br />

well-being of billions of people<br />

around the world, the quality, and<br />

length of their lives, depends on the<br />

performance of the health systems.


The following is the list provided in that report. Where does your country rank? Surprised?<br />

1 France<br />

2 Italy<br />

3 San Marino<br />

4 Andorra<br />

5 Malta<br />

6 Singapore<br />

7 Spain<br />

8 Oman<br />

9 Austria<br />

10 Japan<br />

11 Norway<br />

12 Portugal<br />

13 Monaco<br />

14 Greece<br />

15 Iceland<br />

16 Luxembourg<br />

17 Netherlands<br />

18 United Kingdom<br />

19 Ireland<br />

20 Switzerland<br />

21 Belgium<br />

22 Colombia<br />

23 Sweden<br />

24 Cyprus<br />

25 Germany<br />

26 Saudi Arabia<br />

27 United Arab Emirates<br />

28 Israel<br />

29 Morocco<br />

30 Canada<br />

31 Finland<br />

32 Australia<br />

33 Chile<br />

34 Denmark<br />

35 Dominica<br />

36 Costa Rica<br />

37 United States of America<br />

38 Slovenia<br />

39 Cuba<br />

40 Brunei<br />

41 New Zealand<br />

42 Bahrain<br />

43 Croatia<br />

44 Qatar<br />

45 Kuwait<br />

46 Barbados<br />

47 Thailand<br />

48 Czech Republic<br />

49 Malaysia<br />

50 Poland<br />

51 Dominican Republic<br />

52 Tunisia<br />

53 Jamaica<br />

54 Venezuela<br />

55 Albania<br />

56 Seychelles<br />

57 Paraguay<br />

58 South Korea<br />

59 Senegal<br />

60 Philippines<br />

61 Mexico<br />

62 Slovakia<br />

63 Egypt<br />

64 Kazakhstan<br />

65 Uruguay<br />

66 Hungary<br />

67 Trinidad and Tobago<br />

68 Saint Lucia<br />

69 Belize<br />

70 Turkey<br />

71 Nicaragua<br />

72 Belarus<br />

73 Lithuania<br />

74 Saint Vincent and the Grenadines<br />

75 Argentina<br />

76 Sri Lanka<br />

77 Estonia<br />

78 Guatemala<br />

79 Ukraine<br />

80 Solomon Islands<br />

81 Algeria<br />

82 Palau<br />

83 Jordan<br />

84 Mauritius<br />

85 Grenada<br />

86 Antigua and Barbuda<br />

87 Libya<br />

88 Bangladesh<br />

89 Macedonia<br />

90 Bosnia-Herzegovina<br />

91 Lebanon<br />

92 Indonesia<br />

93 Iran<br />

94 Bahamas<br />

95 Panama<br />

96 Fiji<br />

97 Benin<br />

98 Nauru<br />

99 Romania<br />

100 Saint Kitts and Nevis<br />

101 Moldova<br />

102 Bulgaria<br />

103 Iraq<br />

104 Armenia<br />

105 Latvia<br />

106 Yugoslavia<br />

107 Cook Islands<br />

108 Syria<br />

109 Azerbaijan<br />

110 Suriname<br />

111 Ecuador<br />

112 India<br />

113 Cape Verde<br />

114 Georgia<br />

115 El Salvador<br />

116 Tonga<br />

117 Uzbekistan<br />

118 Comoros<br />

119 Samoa<br />

120 Yemen<br />

121 Niue<br />

122 Pakistan<br />

123 Micronesia<br />

124 Bhutan<br />

125 Brazil<br />

126 Bolivia<br />

127 Vanuatu<br />

128 Guyana<br />

129 Peru<br />

130 Russia<br />

131 Honduras<br />

132 Burkina Faso<br />

133 Sao Tome and Principe<br />

134 Sudan<br />

135 Ghana<br />

136 Tuvalu<br />

137 Ivory Coast<br />

138 Haiti<br />

139 Gabon<br />

140 Kenya<br />

141 Marshall Islands<br />

142 Kiribati<br />

143 Burundi<br />

144 China<br />

145 Mongolia<br />

146 Gambia<br />

147 Maldives<br />

148 Papua New Guinea<br />

149 Uganda<br />

150 Nepal<br />

151 Kyrgystan<br />

152 Togo<br />

153 Turkmenistan<br />

154 Tajikistan<br />

155 Zimbabwe<br />

156 Tanzania<br />

157 Djibouti<br />

158 Eritrea<br />

159 Madagascar<br />

160 Vietnam<br />

161 Guinea<br />

162 Mauritania<br />

163 Mali<br />

164 Cameroon<br />

165 Laos<br />

166 Congo<br />

167 North Korea<br />

168 Namibia<br />

169 Botswana<br />

170 Niger<br />

171 Equatorial Guinea<br />

172 Rwanda<br />

173 Afghanistan<br />

174 Cambodia<br />

175 South Africa<br />

176 Guinea-Bissau<br />

177 Swaziland<br />

178 Chad<br />

179 Somalia<br />

180 Ethiopia<br />

181 Angola<br />

182 Zambia<br />

183 Lesotho<br />

184 Mozambique<br />

185 Malawi<br />

186 Liberia<br />

187 Nigeria<br />

188 Democratic Republic of the Congo<br />

189 CentralAfrican Republic<br />

190 Myanmar<br />

DECEMBER 2007 59


MEDICAL TOURISM<br />

The Boomers are Coming!<br />

The Boomers are Coming!<br />

THE ADVENT of baby boomers entering their sixth decade,<br />

with a population that is living longer, but not healthier, represents<br />

the potential for disaster in the healthcare industry in America.<br />

THE BABY BOOMER BULGE,<br />

A PIG GOING THROUGH A PYTHON<br />

It’s the “Baby Boomers!” The emergence of the baby-boomer<br />

generation has been driving many of the changes in American society<br />

and culture. Everything from hairstyles and health clubs to the<br />

Dr Spock method of parenting is affected. Similarly, boomers are<br />

driving the healthcare needs of the future.<br />

The Baby Boomers are the generation of Americans born between<br />

1946 and 1964, after World War II. The leading edge of this generation<br />

turned 60 years old this year and by the year 2030, the entire baby<br />

boom generation will be 65 or over. Currently baby-boomers make<br />

up approximately 27% of the total population, or nearly 77 million<br />

people, representing a peak in the overall population of our nation.<br />

Charting the baby-boomers on a horizontal graph would represent<br />

them as a bulge, referred to by aging expert and author<br />

Dr Ken Dychtwald, as “a pig going through a python.” Every day,<br />

almost 11,000 boomers turn 50 – that is one every eight seconds.<br />

Aging of the Baby Boomers<br />

2000 2010 2020 2030<br />

Age 36-54 Age 46-64 Age 56-74 Age 66-84<br />

78 Million 75 Million 70 Million 58 Million<br />

60 DECEMBER 2007<br />

By BOB MEISTER<br />

This bulge works its way through time and has had significant effects at<br />

each point in time. The baby boomers put stress on the educational system<br />

when they were coming through their K-12 years. They helped bring about<br />

a surge in the housing market when they reached middle age and, in the near<br />

future, they are going to put incredible pressure on American health care<br />

for generations to come.<br />

While the boomers alone will create a notable rise in demand for healthcare<br />

services, the demand will continue to rise, rather than drop, as the boomer<br />

population decreases because everyone including the members of<br />

Generations X and Y are living longer.<br />

ELDER BOOMERS ARE THE NEW AGE WAVE<br />

• The number of Americans aged 65 or over will double by 2050<br />

• The number of people age 85 or over will quadruple by 2050<br />

• By 2030 over half of U.S. adults will be over age 50<br />

• In the 21st century life expectancy may exceed 120 years<br />

What next? Ken Dychtwald answers, “For starters, they are no longer<br />

baby boomers. They have become a continued demographic force – an “age<br />

wave”. As this generation travels along the lifeline, it will profoundly<br />

induce change in American society, now and for the future. The boomers<br />

have broken the rules and exploded the norms at every stage of life they<br />

inhabit. Undoubtedly, they will continue to do so as they turn 60, 70, 80 or<br />

100 years old. Imagine a nation not of baby boomers, but elder boomers.<br />

It’s coming. Our country is about to be transformed by an age wave that<br />

leaves each stage of life changed forever.”<br />

LIFE EXPECTANCY ~ LIVING 120 TO 180 YEARS<br />

It is not just the shear numbers of baby-boomers that will affect future<br />

health care needs and costs; it is also the overall increasing life expectancy<br />

in our society. Life expectancy in 1900 was 49 years and by the end of the


20th Century, it had increased to 77 years. The increase in life<br />

expectancy during that period was due primarily to basic improvement<br />

in living conditions as well as improved medical technology. Futurists<br />

believe that we are again on the verge of making significant improvements<br />

in life expectancy so that in the future we may have life expectancy<br />

levels of 110 to 120. In fact, a program held at the World Future<br />

Societies annual convention in the summer of 2003 was entitled “Living<br />

120 to 180 years.”<br />

Life Expectancy at Birth 1900 to 2000<br />

Men Women<br />

1900 47.9 50.7<br />

1920 55.5 57.4<br />

1940 61.6 65.9<br />

1960 66.8 73.7<br />

1980 70.8 77.6<br />

2000 74.8 79.5<br />

In one sense, increased life expectancy represents a human success<br />

story; America now has the luxury of aging. Or is it really a luxury?<br />

Most would agree that it depends on the quality of life we can maintain<br />

as our lives are extended years beyond expectations. But that isn’t<br />

always a pretty picture.<br />

Take Gertrude from Wisconsin, for example. When she was born in<br />

1911, her life expectancy was 53.2 years, yet she lived to almost 92.<br />

However, the difficulty was that after age 78, her health problems<br />

compounded. It began with diabetes, then a quadruple heart by-pass,<br />

followed in a couple years by a heart-valve transplant, then cancer and<br />

finally a punctured lung, which occurred while getting a pacemaker<br />

installed. Her quality of life diminished and was dependent on thirteen<br />

different medications, family assistance, home care, then assisted living,<br />

followed by a series of hospital and recuperative nursing home stays.<br />

This all too common sequence of events and series of procedures<br />

tapped out Gertrude’s personal resources and used up many times the<br />

Medicare dollars she contributed during her working years. The point<br />

is that life expectancy often comes at a very high price financially and<br />

also in terms of human comfort.<br />

Every day, almost 11,000<br />

boomers turn 50 – that is<br />

one every eight seconds.<br />

SKYROCKETING COST OF CARE<br />

The cost of health care has been rising at a rate much higher than<br />

inflation and family incomes. Health care expenditures in America<br />

have gone from 246 billion in 1980 to just under 1.7 trillion in 2003.<br />

The problem is compounded when employers discontinue employee<br />

insurance, contributing to the rising number of uninsured Americans.<br />

Examples of Health Care costs in the United States<br />

Hartford, CT Fairbanks, AK<br />

Home Health Care – Aide $13,130 year $12,558 year<br />

Home Health Care – LPN $22,180 year $34,112 year<br />

Assisted Living $27,888 year $28,550 year<br />

Nursing Home – private $99,692 year $153,227 year<br />

Procedures*<br />

Heart Bypass Angioplasty Knee Replacement Spinal Fusion<br />

$130,000 $57,000 $40,000 $62,000<br />

AMERICANS HAVE SUFFERED AN OVERALL DECREASED<br />

QUALITY OF LIFE<br />

Results of a study that approximates quality of life, published by<br />

the United States Department of Health and Human Services Centers<br />

for Disease Control and Prevention, demonstrate that overall healthrelated<br />

quality of life worsened dramatically in the 12 years between<br />

1993 and 2005. While this research does not conclude that the increase<br />

is related to extended life or to baby boomers, it does present a trend worthy<br />

of note.<br />

Percentage of people with 14 or more activity limitation days<br />

1993 1998 2000 2005<br />

4.8% 5.6% 5.8% 6.6%<br />

Percentage with 14 or more physically unhealthy days overall<br />

1993 1998 2000 2005<br />

8.6% 9.4% 10.1% 10.7%<br />

BOOMERS WILL RESHAPE THE FUTURE OF HEALTHCARE<br />

In May of this year, First Consulting Group, Long Beach, CA conducted a<br />

study that helps project the effect of the baby boomer generation on future<br />

health care in the United States. Following are some results and conclusions<br />

drawn from “When I am 64.”<br />

“The wave of aging Baby Boomers will reshape the health care system<br />

forever. There will be more people enjoying their later years, but they’ll be<br />

managing more chronic conditions and therefore utilizing more health care<br />

services by 2030.”<br />

• The over 65 population will nearly triple as a result of the aging<br />

Boomers.<br />

• More than six of every 10 Boomers will be managing more than one<br />

chronic condition.<br />

• More than 1 out of every 3 Boomers – over 21 million – will be<br />

considered obese.<br />

• One out of every four Boomers – 14 million – will be living with<br />

diabetes.<br />

• Nearly one out of every two Boomers – more than 26 million – will be<br />

living with arthritis.<br />

• Eight times more knee replacements will be performed than today.<br />

DECEMBER 2007 61


As Boomers age, the<br />

number with multiple<br />

chronic conditions is<br />

expected to grow from<br />

almost 8.6 million today<br />

(about one out of every 10<br />

Boomers) to almost 37<br />

million in 2030.<br />

MEDICAL TOURISM<br />

Sixty-two percent of 50 to 64 year olds reported they had at least<br />

six chronic conditions (hypertension, high cholesterol, arthritis,<br />

diabetes, heart disease and cancer). As Boomers age, the number<br />

with multiple chronic conditions is expected to grow from almost<br />

8.6 million today (about one out of every 10 Boomers) to almost 37<br />

million in 2030. Since the biggest factors influencing medical spending<br />

are chronic illness and a patient’s level of disability, the growing<br />

incidence of multiple chronic conditions will put increasing demands<br />

on our health care system.<br />

“The confluence of the large Boomer population, increase in chronic<br />

conditions and rise of available medical treatments will begin to<br />

impact health care in 2010, when the oldest Boomers turn 65 – when<br />

more health services typically begin to be used.”<br />

• By 2030, there will be nearly twice as many adult physician<br />

visits as there were in 2004, and Boomers will account for<br />

more than four of every 10 of these visits.<br />

• By 2030, if all Boomers with diabetes receive recommended<br />

care, they will need 55 million laboratory tests per year – 44<br />

million more than today.<br />

• Physician office visits will number more than one billion by<br />

2020. Four out of 10 will be Boomers.<br />

• The growing demand of chronic disease will increase the<br />

need for medical sub-specialists.<br />

• The increase in longevity of Boomers – on top of advances<br />

in medications, less invasive treatments and diagnostic testing<br />

– will greatly increase the demand for cardiology.<br />

“The severe workforce shortage will challenge the health care system’s ability<br />

to meet this Boomer demand”.<br />

• In 2005 there was a shortage of about 220,000 registered nurses; by 2020<br />

that gap will be over one million.<br />

• Even if the number of geriatric specialists remains stable, there will be a<br />

shortage of almost 20,000 by 2015.<br />

• Between 2000 and 2020 the supply of orthopedic surgeons will increase<br />

by only 2 percent while the demand will increase 23 percent.<br />

• Between 2000 and 2020, the supply of cardiologists will increase by only<br />

5 percent while demand will increase by 33 percent<br />

• The projected gap for primary care physicians will increase as Boomers<br />

age.<br />

THE DILEMMA<br />

While the combination of the largest demographic cohort in history and the<br />

extended years (provided to us by new drugs, and medical technology and<br />

procedures) may not be a formula for disaster, it does raise a red flag and a few<br />

questions.<br />

• How can we improve quality of life during our extended years?<br />

• How can we pay for the health care that makes them possible?<br />

• Where will we find the medical workforce to care for the elderly boomers?<br />

• Will more baby boomers travel overseas to live or to receive healthcare?<br />

• As more and more baby boomers get older, will Medicare allow<br />

payments to overseas providers to help reduce the cost of providing<br />

health care to baby boomers?<br />

Bob Meister is a faculty member at CareQuest University. CQU provides education and certification for professionals in health care planning,<br />

financial planning and insurance. Most of Bob’s business experience is in designing and implementing market strategies and concepts as a<br />

consultant to manufacturers, service providers and associations. His focus over the past 12 years has been aging, healthcare and retirement.<br />

References: “The Long-Term Care Challenge”, David Wegge, Care Quest University; Care Options OnLine, NavGate Technologies;<br />

www.agewave.com, Ken Dychwald; Aetna; “When I’m 64", FCG; “An Aging World”, US Census Bureau.<br />

*Approximate retail costs, based on HCUP data<br />

62 DECEMBER 2007


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