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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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