Medical Tourism by Gustavo Fernandez

Editorial

The MTA Advisory Board includes ROBERT K. CRONE MD, President & CEO of Harvard Medical International; Boston, Mass. JOHN F. P. BRIDGES PhD, Assistant Professor at Johns Hopkins Bloomberg School of Public Health; Baltimore, Maryland PRADEEP THUKRAL Head of International Marketing at Wockhardt Hospitals Group; Mumbai, India THOMAS JOHNSRUD Senior Consultant, N.A., Parkway Hospital; Singapore BRAD COOK International Benefits Director at Hospital Clinica Biblica; Costa Rica KAMALJEET SINGH GILL GM, International Business Development Unit of National University Hospital; Singapore JONATHAN EDELHEIT President, Medical Tourism Association, Inc.; Palm Beach, Florida RENEE-MARIE STEPHANO Esq., General Counsel for Medical Tourism Association and Editor of The Medical Tourism Magazine STEPHEN M. WEINER Esq., Chairman of the Health Law Practice of Mintz, Levin, Cohn, Ferris, Glovsky & Popeo, P.C.; Boston, Mass. SCOTT A. EDLESTEIN Esq., of Counsel at Squire, Sanders & Dempsey, LLP; Washington D.C. DANIEL BONK Executive VP ~ Central Region, Aurora Healthcare; Wisconsin FREDERIC J. ENTIN Esq., Partner at Foley & Lardner, LLP; Chicago, Ill. MARY ANN KEOUGH Professor at Eastern Washington University; Washington State DALE C. VAN DEMARK Esq., Member of Epstein, Becker & Green, PC; Washington, D.C. KEVIN RYAN Esq., Member of Epstein, Becker & Green, PC; Washington D.C. LAURA CARABELLO Principal of CPR Communications, Publisher of Medical Travel Today Newsletter; New York RUBEN TORAL Proprietor of MedNet Asia, Ltd.; Bangkok, Thailand DAVID C. KIBBE MD, MBA, Principal of The Kibbe Group LLC; North Carolina

America is viewed as the land of the great and the land of opportunity. Unfortunately, that is painting a pretty rosy picture that isn’t exactly true. At the end of the day our health care system is broken. It really upsets me that Americans are so disenchanted with our U.S. health care system that some have to travel overseas. The fact that hard working taxpaying Americans, whether white, black, Hispanic, Indian, or Asian or any race have no access to affordable healthcare in the U.S., while in some cases illegal immigrants get free and better care than Americans is very frustrating. The reality is, at the end of the day, almost 50 million Americans have no access to healthcare, 120 million do not have dental insurance, and the number is growing each day. Working in the healthcare industry the trend is simple, more and more employers are canceling their group health insurance because the cost is too high, and more and more individuals can no longer afford medical insurance. It gets really bothersome to see the politicians constantly talking about Health Care being broken in the U.S. Some offer no solutions. The rest offer unrealistic solutions Nationalized healthcare, mandatory health care, etc. The politicians talk, but don’t do anything. Massachusetts passed a law, which soon will go into effect and requires people to have mandatory health coverage or pay penalties. Hillary Clinton has proposed mandatory health care also with the possibility of Tax credits. If our health care system is broken and costs are too high, then why do politicians believe forcing people to buy health care will solve our problem. It will only continue us down a negative path, as each year goes by Americans are forced to pay higher prices for ever increasing cost of health care. Eventually everyone will have mandatory health insurance they can’t afford. Why isn’t anyone attacking the actual problem? Why has not one politician actually stood up and acknowledged the problem. Some of the major costs of our U.S. health care system today are medical malpractice, high costs of labor, and inflated costs of medical supplies and prescription drugs. Why do parts for a surgical procedure in the U.S. cost almost $9,000, while the same parts by the same U.S. manufacturer for a procedure in India cost only about $2,000? Why does a prescription drug that costs $1,600 in the U.S. cost $800 in Costa Rica? How is it that a U.S. trained and board certified doctor in the U.S. can perform a procedure in India and Thailand for almost up to 80% less than the United States? Why is it that for certain heart procedures in Asia, American patients spend almost 5 times longer in the hospital to recover than American patients in American hospitals? Have we given up on providing quality care in America, and instead race to send the patient home? When will Politicians stop putting band aids on our health care problem and really try to fix it? When will everyone in America stand up and say enough is enough and band together? Obviously not yet! Because on October 2nd a U.S. farmer traveled to India for surgery he couldn’t afford in the United States. In October a single mother of two, who hasn’t been able to hold down a job for two years because of a broken back and tremendous pain, is going to India for surgery she can’t afford in the U.S. Apparently, no one cares that we are sending Americans overseas for surgery. Since no one cares, then that leaves us one option. We are in a Global Health Care world, and we all need to come together to focus on the best quality of care and best outcomes for Americans going overseas. We need to pull together, because Medical Tourism is the only real viable solution to America’s health care crisis. Am I ashamed that we are sending hard working Americans overseas and in some cases around the world, because that is the only place they can receive affordable, quality care? Yes, I am. Do I believe that Americans can get care equal to or in some cases better care than here in America? I absolutely do. I hope everyone can come together within this industry and show everyone how amazing Medical Tourism is, and the cutting edge medicine and care available globally.

By JONATHAN EDELHEIT

President Medical Tourism Association

December 2007

Medical Tourism AT A GLANCE

EDITORIALS Time to Rally Around Medical Tourism

FEATURES Costa Rica: The Great Opportunity

Vice-Minister of the Costa Rican Council on Competitiveness, Jorge Woodbridge Gonzalez speaks out about the challenge of competitiveness in medical services and international accreditation. BY JORGE WOODBRIDGE GONZALEZ

Who are Those Masked Men?

The physicians of Costa Rica undergo educational requirements comparable to those in the U.S.

Costa Rica: Big Trip Little Country

Traveling to a foreign country can be intimidating, so in order to assure a good trip, you should do your research ahead of time. BY RENEE-MARIE STEPHANO

Deep Venous Thrombosis: The Traveler’s Disease

Decreasing your time in flight could provide for better medical travel, but if you must fly far, here are some precautions to take. BY Dr ELLIOT GARITA JIMINEZ

5 Elements to Choosing an International Hospital

There are no perfect doctors and no perfect hospitals, but sifting through the available information increases your odds of a perfect experience. BY BERNAL ARAGON BARQUERO

Got a Passport? Gain a Smile.

The dental possibilities in Costa Rica are endless and affordable. BY EUGENIO J. BRENES, DDS

Patient Processing, Clinica Biblica Style

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As the draw to Costa Rica accelerates for medical tourism, Clinica Biblica has created their in-house medical tourism company to provide excellent service to international patients. We live a day in the life of an international patient.

DECEMBER 2007

Costa Rica Ecotourism to World Class Healthcare

The road looks promising as Costa Rica reinvents itself as a global healthcare arena. BY WILLIAM COOK

COLUMNS JCI CORNER The Value of Accreditation

President and CEO of JCI, Karen Timmons, speaks about the characteristics and the value of promoting safety and quality of care in international medical facilities. BY KAREN TIMMONS

LEGAL ISSUES Surrounding Medical Tourism

Understanding the nature of potential liability requires first an underlying basic understanding of the American Legal System. Can Americans even bring a claim against foreign providers in US Courts? BY FREDERIC J. ENTIN, ESQ.

BINA BUZZ Unaffordability Ebola Spreading Throughout Healthcare Driven by the number one concern of adults and businesses in the US, an insatiable, immutable “Unaffordability Ebola” is attacking another compliant US host: the American healthcare system. BY MICHAEL BINA

December 2007

Medical Tourism AT A GLANCE

ECONOMICS What are the True Financial Savings in Medical Travel?

Are the numbers you hear regarding savings on healthcare abroad truly an accurate depiction of what you can keep in the bank? BY MICHAEL D. HOROWITZ, MD

Self-Funding Your Medical Travel

Medical Tourism is a perfect fit for American Employers with self-funded health plans. BY JONATHAN EDELHEIT

The Boomers are Coming! The Boomers are Coming!

Every day, almost 11,000 baby boomers turn 50 – one every eight seconds. How are we going to pay for their healthcare? BY BOB MEISTER

Pay for Performance: Here Today…Here Tomorrow?

Why are physicians so fearful about P4P and how will this be affected by the rise in medical tourism? BY DAN BONK

The Fully Insured Myth

Hospitals should not expect massive amounts of fully insured Americans to travel overseas for healthcare. BY JONATHAN EDELHEIT

NEWS & INSIGHTS Selecting a Medical Travel Destination

Making a list and checking it twice, the 4 D’s in selecting a destination that is more than meets the eye. BY DARREN TAM & DR JEREMY LIM

Psychological Barriers to Medical Tourism

The concerns of returning home after surgery are plentiful. How do you bring your doctor onboard? BY THOMAS C. JOHNSRUD

What is Your Country’s Ranking?

The World Health Organization surveyed the international healthcare systems in 2000 and ranked the quality of care. Where does your destination fall?

The Lure of Medical Tourism in Asia

What makes Americans travel thousands of miles for healthcare? The first world treatment at third world prices is just part of the puzzle. BY GERALDINE CHEW & NORZILAWATI MT

Dr John Bridges of Johns Hopkins takes a look at the three barriers to understanding medical tourism. BY JOHN F. BRIDGES, PH.D.

Planning Your Medical Trip Abroad: Recovery Retreat or Hotel?

Engaging Your Family Physician in Medical Travel

While both have their advantages, the medical tourist needs to do their homework to find their home away from home. An interview with Jim Holt of Intercontinental Hotel Group. BY LOURDES GASPARONI

Editor-in-Chief Renée-Marie Stephano, Esquire 10130 Northlake Boulevard Suites 214-315 West Palm Beach, Florida 33412 866-756-0811 Fax Renee@MedicalTravelAuthority.com

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MEDICAL TOURISM In the UK it is not uncommon to hear patients grumbling from having to wait for as long as six months to get treated by the public health service due to the system being too stretched to cater to everyone. Otherwise they will have to opt for private health services which is very expensive. The Guardian wrote a classic case example on the medical care hiccups in Britain. George Marshall, a violin repairer from Bradford was diagnosed with coronary heart disease. He was told that he could either wait for up to six months for a heart bypass operation on the National Health Service or pay $38,000 to go under the scalpel immediately. He chose to outsource his operation to India instead. He went for an operation at the Wockhardt Hospital and Heart Institute and paid only $9,763.24 for surgery including travel expenses. Research and studies have shown support on the increasing trend in medical tourism. Dr Arnold Milsein, medical director of the United States based medical group Pacific Business Group, told a U.S. Special Committee on Ageing in 2006 that the typical combined hospital and doctorâ&#x20AC;&#x2122;s charges for operations in â&#x20AC;&#x153;technologically advanced hospitals in lower-wage countriesâ&#x20AC;? such as Thailand were 60 to 85 percent lower than charges in the US hospitals. An independent survey on medical tourism prices in 2006 by European Research Specialists commissioned compiled data from 108 clinics, hospitals and healthcare providers in 30 countries. Research revealed that patients from UK can save up to 80 percent by going overseas for surgery and medical treatment Medical Tourism Takes off the Runway Medical tourism is made possible and has gained popularity due to the advancement in medical technology, more affordable travel and the availability of information provided by the mass media.

By GERALDINE CHEW & NORZILAWATI MT

ou ld you travel across the globe for a heart bypass if it will only cost you a tenth of the usual US $122,000? The concept of medical tourism started thousands of years ago. People have been traveling across the continents in search of cures for any imaginable illnesses and making therapeutic trips for health wellness. In ancient Greece, pilgrims and patients came from all over the Mediterranean to the sanctuary of the healing god, Asklepios at Epidaurus, and from the 18th century wealthy Europeans have been traveling to spas from Germany to the Nile. In recent years, medical tourism is becoming more popular with patients seeking treatment for health and well-being purposes abroad. Why Are People Traveling? If you can get your ailing heart cured or get your flat-nose fixed at home, why bother to travel across the globe for medical treatment? Patients seeking treatment abroad are motivated to do so by various reasons. Many are attracted by the low cost factor or they are simply dissatisfied with the existing medical care in their home country. Frustrated by the long waiting times, inadequate medical care and exorbitant medical expenses, many go abroad in search of medical care. The steep medical costs in America have contributed to many Americans flying to other countries in search of cheaper alternatives. According to the Census Bureau, as many as 46.6 million Americans were uninsured in 2005. As these uninsured Americans are not able to afford the costly medical care, many will jump at the opportunity of getting treatment abroad at a fraction of the price at home. 6

DECEMBER 2007

As medical costs accelerate, patients are finding alternatives for low-cost treatment, and going abroad to get healthy seems very appealing. Lured by the promise of high quality, reliable medical care at a lower cost, patients are flying across the globe for medical treatment that they otherwise would not have access to easily due to prohibitive costs, long waiting time or unavailability of treatment in their home country. The promise of medical care and the attraction of exotic places are taking people places for medical care. First World Treatment at Third World Prices International patients are flocking to Asia for elective and cosmetic procedures, an increasing pool of patients are getting their ailing heart fixed or have hip replaced in countries such as Singapore and India. Choices are also not limited to medicine or western treatment; there are growing interests in alternative medicine providing holistic therapy to patients. Alternative medicine such as

Ayurveda, acupuncture, osteopathy, chiropractic and homeopathy etc. are gaining popularity among medical tourists. Countries such as China and India are promoting alternative medicine to international patients searching for holistic cures.

Hundreds of hospitals and clinics catering to foreigners are establishing themselves across the country like mushrooms on a rainy day. They offer everything from dentistry and cosmetic surgery to heart operations and sex change procedures to preventive care and health treatment.

Hospitals in Asia are carving out an outstanding reputation for themselves, drawing overseas patients with top-notch doctors, low cost, high-tech equipments and high quality patient care. Countries such as Thailand, Singapore, India, Philippines, South Korea and Malaysia see a combined 1.3 million tourists each year for medical treatment. This move is expected to contribute at least US $4 billion by 2012 to the Asia medical tourism industry and US $40 billion globally.

Catering to the alternative medicine market, Tria, the new kid on the block introduced into the market by the Piyavate Hospital is a specialist spa promising to bring wellness to a new level. Equipped with the latest in modern science combined with homeopathic and other treatments to provide preventive care and health treatments, the four storey complex boasts 19 consultation rooms, four detoxification rooms and two colonic-hydrotherapy rooms.

Experience Asia’s Best

Incredible India

Amazing Thailand Thailand better known among foreigners as a popular destination for leisure tourism has earned for itself a name in the medical tourism industry. The Thai government is quick in realizing and identifying the great opportunities that medical tourism will bring. They have made significant inroads as an early investor in medical tourism with strong support from the healthcare institutions in the country, making Thailand into one of the leading medical tourist destination in Asia. The medical tourism industry is expected to attract two million medical tourists into Thailand by 2012.

Medical tourism is not new to India – housing some of the world’s best medical care providers that are equipped with technological sophistication and infrastructure, India drew an estimated 150,000 overseas patients last year. Coupled with its vast experience in dealing with overseas patients, medical tourists have no qualms about traveling to India to receive medical treatment. The Escorts Heart Institute and Research Centre ranks as having the best cardiac hospital in India. Equipped with state-of-the-art infrastructure and equipment, the 332-bed

Institute has nine operating rooms and carries out nearly 15,000 procedures every year. The Wockhardt Hospitals Group has an association with Harvard Medical International, the global arm of the Harvard Medical School and is the first super specialty hospital in South Asia to achieve accreditation from Joint Commission International (JCI), USA. This established Group has a chain of super specialty hospitals such as Wockhardt Brain & Spine Hospital, Wockhardt Hip Resurfacing Centre and Wockhardt Liver & Kidney Institute, Kolkatta, catering to specific needs of their patients. Uniquely Singapore SingaporeMedicine, a multi-agency government initiative, aims at developing Singapore into one of Asia’s leading destinations for international patients. Looking at the visibility that Singapore has gained as a top destination for medical travelers, Singapore Medicine is fast on its way to achieving this objective. Through their aggressive campaigns, Singapore is expected to attract over one million foreign patients annually by 2012. Singapore’s efforts in promoting medical tourism have shown success. According to recent reports, Parkway Group Healthcare received 170 Russian patients last year with average bill between $10,000 and $60,000 for each patient, and Raffles Hospital, for example, boasted a 36 percent of its occupancy by foreign patients.

DECEMBER 2 0 0 7

MEDICAL TOURISM WOW Philippines

As this industry is driven by patients or travelers who become patients, it will be interesting to see whether the industry will meet their expectations.

The Philippines has also jumped on the medical tourism bandwagon. It has become so popular and successful in driving its medical tourism effort, officially known as the Philippine Medical Tourism Program (PMPT), that the country’s medical directors and government officials met in California in May this year to discuss the health tourism industry and how to effectively promote it.

Medical Tourism – The Other Side of the Story

Prominent hospitals like St. Luke’s Medical Center, Asian Hospital and Medical Centre and Philippine Heart Centre etc. are active participants and advocates for this program.

The Medical Tourist

Jade del Mundo, Health Undersecretary of the Philippines said that a total of 200,000 foreigners came to the Philippines for medical treatment such as cosmetic surgery and eye or dental treatments. He said that the bustling medical tourism program of the Philippines is expected to contribute between US $300 million and US $400 million next year. The Philippines health department, estimates as much as US $200 million has been generated from medical tourism alone.

Much have been said and claimed about the surging medical tourism industry and how its players are benefiting from it, however, not much is known about the other side of the story – the patients themselves.

There are many testimonies supporting the claim of quality medical care and low cost expenses by those who have been there and done that, however what about the potential medical tourists. Where can they find quality information on the services provided abroad? How do they know who’s good and who’s not. Although there are a few indisputable medical centers who have already carved their name in the industry, there are a great many more that are less well known. Should this have a bearing on whether they are capable of providing quality healthcare? Take for example India; there are thousands of hospitals sprawling across the country. Some have already been identified as the place to go for medical treatment, however, there are still many that are below the radar. The richer hospitals are able to afford to provide patients with the luxury of five star accommodation and service with equally advanced treatments and services, but the hospitals that are less well funded are only able to provide medical care minus the other peripherals. So how do the medical tourists choose? Medical Tourism Riding on the Waves The term and concept of modern medical tourism may have been around for the last decade but it is still in its infancy stage. There are many challenges and obstacles ahead as with any burgeoning industry.

Medical Tourism Whetting Appetites The spurt in the industry has created a vacuum that is quickly being filled with organizations or professionals eager to capture a share of the pie. Everyone from finance, insurance, travel, hospitality as well as health professionals, who have seen the potential of this industry with its growing audience, are looking for opportunities to fill in the gap in the medical tourism puzzle. Though many are eager to be the right pieces in the puzzle, many are still struggling to get the right fit. There are a number of concerns and risk factors for patients getting treatment much less seeking them abroad. Some additional concerns for patients include a consistent quality of care, lack of extensive dialog between the patient and the doctor, lack of post-op follow up, cultural differences and difficulty in obtaining sufficient insurance coverage.

Packages to India At the first meeting of the Private Sector Advisory Group (PSAG) of the US-India Trade Policy Forum held in New York in September, Indian Commerce Minister Kamal Nath said that the US was “keen to ask its insurance companies to work with hospitals in India.” Evidently the US is pushing insurance companies to come up with medical tourism packages with Indian hospitals, some offering up to forty percent discounts on annual premiums for those people who will go to India for treatment. Others are adding tourism to their package offerings and financial incentives for their family and friends to stay at nearby hotels. Have the insurance companies really started taking this leap? We could not confirm that any major medical carrier is doing this, but we got the picture that it is not too far off.

DECEMBER 2007

There are a few players who are already paving the way and leading from the front but there is significantly more who are jumping onto the bandwagon. It is crucial that in this race to be the best and offer the most, the travelers/patients do not get ‘marginalized’ in the industry. Continuous training for healthcare workers to ensure consistent quality of care is essential as is consistency in the service that a patient receives before and after deciding on their doctor or the medical centre where they will be receiving treatment. Medical referrers and those providing concierge services need to have a strict understanding of the quality of medical care provided by those that they are affiliated with and ensure that that information as well as the risks is clearly brought across to the travelers. Each player must play their part in ensuring that the medical tourism industry will continue to grow and benefit those that are in it – both patients and providers. Both Authors work for Avail Corporation, which had put on a conference called International Medical Travel Conference (www.MedicalTravelconference.com), in November 2007 at Manila, Philippines.

MEDICAL TOURISM

SELECTING A MEDICAL TRAVEL DESTINATION

With advertorials from international healthcare providers increasingly commonplace, it can be challenging to distinguish bona fide foreign hospitals from fly-by-night outfits which are out to make a quick buck. Offered here is a consumer decision-making checklist that ensures you board the plane knowing that you will get the care you need at a price you are comfortable with.

ccording to the National Coalition on Health Care, approximately half a million Americans travelled internationally to seek surgical treatment in 2006. This trend looks set to continue increasing with the population aging and the prospect of lower healthcare costs in America nowhere in sight. There are 4 D’s one should consider in selecting a medical travel destination which have been described by Dr Rome Jutabha of UCLA: “Domain, Doctors, Data and Disaster.” Let’s deal with each one in turn, but before that, a few words about the importance of the country of destination.

COUNTRY-SPECIFIC INFORMATION Being left hanging high and dry is the last thing you would want while you are convalescing. Thus, it is important to assess if the country that you would be visiting is generally safe and has an adequate regulatory framework to protect you, the consumer. Good sources of information include the US State Department’s regular travel advisory for US citizens and a recent World Bank 10

DECEMBER 2007

By DARREN TAN & DR JEREMY LIM publication – Governance Matters 2007: Worldwide Governance Indicators 1996-2006. The latter ranks countries in terms of their political stability, government effectiveness, regulatory quality and rule of law, and control of corruption. Another important consideration would be on who the main driver of medical tourism in the country is. If it were driven primarily or regulated strongly by the government, then there would be greater assurance that the international consumer would be adequately protected because the country’s reputation would be at stake. Lastly, as most blood banks are run by national or regional governments, it would be prudent to check the quality of the blood supply and the rigor with which blood is tested for infectious diseases such as HIV and hepatitis. HOSPITAL-SPECIFIC INFORMATION Domain- What is the hospital’s clinical focus? Is the hospital really a specialist in the procedure you are undergoing? There is little point travelling thousands of miles if the attending physician is not an expert.

records that the Singapore National Eye Centre is currently involved in 18 clinical trials (Site accessed on Sept 12, 2007). Data- Nothing beats knowing the doctors’ and hospital’s results are publicly available. However, while many hospitals publish online their own results, it is often unclear how the data is collected and whether the data has been subject to external audit for accuracy. It would be much more reassuring if an independent body such as the government centrally collates and publishes this information and this is already happening. In New York City, the New York City Health and Hospitals Corporation has begun to put online the outcomes of certain diseases such as pneumonia and heart attack including complications such as infections. In Singapore, the Ministry of Health regularly publishes not only the clinical outcomes of procedure, e.g. Lasik and cataract surgery, but also the price patients pay for them. Another measure of reliability of data is the publication of results in peer reviewed publications such as the New England Journal of Medicine and the Lancet. Disaster- Despite the best efforts of everyone, disasters can and do happen in healthcare and you want to know you will receive the best possible care if something unfortunate occurs. As mentioned above, check that the blood supply is safe. If you are seeking treatment at a hospital that adopts a ‘focused factory’ approach, i.e. it only manages heart diseases or orthopedic conditions, then make sure that the hospital has ready access to all the specialists you might need in a medical disaster, e.g. nephrologists in case of post-operative kidney failure requiring dialysis, infectious disease physicians for post-operative wound infection etc. Doctors and Hospitals- The qualifications of the doctors are important but as U.S. board certification requires specialist training to be undertaken in the U.S. and not anywhere else, there would be relatively few doctors in the world having American board certified qualifications compared to the number of overall physicians. Membership and fellowship of the Royal Colleges in the United Kingdom are the main specialist qualifications for much of the Commonwealth countries in the world such as Singapore which is a major medical travel destination. Accreditation with Joint Commission International (the international arm of the Joint Commission) is the usual ‘mark of quality’ for hospitals outside the United States but there are many other accrediting bodies such as Trent Accreditation Scheme in the United Kingdom. Experience is probably more relevant given the diversity of medical qualifications and accrediting bodies globally. The doctors treating you should have a good track record in the procedure and be able to tell you their own personal results as well as that of the hospital. While scientific publications and conference presentations are not essential to clinical expertise, they are a useful measure of peer recognition and the standing of your

attending physician in his or her medical specialty.

Being left hanging high and dry is the last thing you would want while you are convalescing.

The number of clinical trials the doctor or hospital is involved in can also be telling. Pharmaceutical and medical devices companies will only work with doctors and hospitals that meet their stringent standards to be trial sites and you can capitalize on the background checks done by them to double-check the standards of the hospital you are about to enter. For example, www.clinicaltrials.gov (a website hosted by the National Institutes of Health documenting clinical trials worldwide)

Traveling outside the United States is something Americans are seriously considering in ever-increasing numbers. Like any other overseas venture, there will always be uncertainty, but the savvy patient can minimize risk by carrying simple checks and asking the right questions before leaving the U.S

Darren Tan. MHS (Mgt), BSc (Biology) leads the Outcomes Research team at the SingHealth Centre for Health Services Research. He and his team works extensively on evaluating clinical interventions, which forms the bridge linking the endpoints of practices and interventions with their effectiveness. Dr Jeremy Lim. MBBS, MPH, MRCS (Edin), MMed (Surg), a surgeon by training, Jeremy leads the SingHealth Centre for Health Services Research. He has written and lectured widely on health policy and maintains a personal and professional interest in public healthcare quality and accessibility for all, especially the poorest segments of society.

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MEDICAL TOURISM

The Value of Accreditation

Why Americans Needing Health Care Abroad Should Choose JCI-Accredited Facilities By KAREN TIMMONS President and Chief Executive Officer of Joint Commission International

s Americans seek care in other countries, they look for reassurance that health care organizations abroad meet certain quality and safety standards they have come to expect. Therefore, hospitals abroad who hope to attract Americans to their institutions often seek Joint Commission International (JCI) accreditation, which is endorsed by the World Health Organization, because it demonstrates to the international community that the hospital has voluntarily sought an independent review of its commitment to safety and quality, and has met standards that contribute to good patient outcomes. But in addition, overseas hospitals tell us that they seek our consulting services and accreditation because our standards help them learn a common language – like that used by air traffic controllers – which ensures safety and consistency in the delivery of health care. Every hospital earning JCI accreditation must also set up parameters for a safe organization and meet JCI’s International Patient Safety goals. JCI is part of Joint Commission Resources (JCR), an affiliate of the U.S.-based Joint Commission. The Joint Commission accredits over 90% of hospitals in the United States. JCI extends the Joint Commission’s mission, which is to improve the quality and safety of patient care, into the international arena through international consultation, publications, education, and accreditation.

DECEMBER 2007

JCI is Different from JC Accreditation in the US

JCI accreditation standards are comparable to Joint Commission accreditation standards, but they are different. The difference is that the JCI standards and survey process were adapted for the international community and designed to be culturally applicable and in compliance with laws and regulations in countries outside the United States. For example, informed consent by patients is a JCI requirement, but different cultures handle this in different ways. In some cultures, patients fill out a form in front of a witness, while in others a family member may be the only one allowed to give consent. JCI accreditation allows for these differences.

We believe Americans can receive high quality care internationally, but first, patients needing care abroad must carefully research the physicians and health care organizations they are considering using and visit our website to determine if the hospital is accredited by JCI. Using a JCI-accredited hospital is basically a risk-reduction activity because when hospitals improve patient care and safety, patients are more likely to have good outcomes. Americans using JCI-accredited hospitals will also find other advantages. JCI accreditation requires that every patient is spoken to in a language and manner they can understand and that patients are involved in their care decisions. Patient rights must be protected, including confidentiality and privacy. When a patient prepares to leave the hospital and return home to his country, we require that the hospital transfer information to the patient and provide recommendations for follow-up care at home. All of these steps make it less likely the medical traveler will have some type of error or problem with his care. How Accreditation Works

JCI accreditation standards are comparable to Joint Commission accreditation standards, but they are different. JCI standards were developed by an International Standards Subcommittee made up of experts representing five major regions of the world. These standards address important topics such as the qualifications of doctors and nurses, properly assessing patients to match care to their identified medical needs, anesthesia procedures, and safe use of medicines. In addition to accreditation, JCI has extensive international experience working with public and private health care organizations and local governments in more than 60 countries. Part of meeting JCIâ&#x20AC;&#x2122;s mission is helping individual countries develop their own accreditation programs. In many countries, JCI works with the ministries of health to develop their own standards and establish their own accrediting bodies. JCIâ&#x20AC;&#x2122;s standards have also become a model for standards developed by governments around the world.

JCI accreditation is a rigorous process for which most hospitals prepare at least a year, if not longer. JCI accreditation is for a period of three years. After three years, JCI will conduct a full, onsite survey. Before accrediting a hospital, JCI sends in a team, usually including a doctor, nurse, and administrator, for a period of 3 to 5 days. Although at this time, the JCI surveys are announced visits, JCI may move to unannounced visits in the future. Our surveyors use a tracer methodology, which is a systems approach, rather than just examining each department within a hospital. We believe the best way to gauge the quality of care provided by an institution is to trace the journey of patients as they move through the institution and examine how various departments work together to provide the care they need. Typically we trace 8 or more patients during our site visits. JCI has approximately 300 standards which hospitals must meet and 1200 measurable elements which is what surveyors examine and score. Before leaving, surveyors conduct an exit interview with administrators, and hospital leadership is given a copy of the preliminary report, which allows them to know whether or not they will likely receive accreditation. All reports are confidential; all we share with the public is a list of the hospitals currently accredited by our organization. There are approximately 140 JCI-accredited hospitals in 26 countries. For the names of these hospitals or more information on JCI accreditation, you can visit our website at www.jointcommissioninternational.com.

Canadian Firms Pushing Cuban Healthcare Two Canadian-based medical tourism companies are offering overseas medical care to Cuba. Thatâ&#x20AC;&#x2122;s right, even though the US embargo makes it illegal for Americans to spend money there for treatment, these firms believe that the rising costs of healthcare may make some Americans take the plunge. Cuba currently boasts patients from Spain and Italy and many other countries and is known for high standards of care. While the issue of high standards is often disputed, no one can dispute the cost savings, with prices at about one third of the cost in the US for some procedures. Nevertheless, with Latin and Central America rising in the industry of medical tourism, and waiting times for some surgeries in Canada of up to 18 months, there will likely be a great rise in the numbers of Canadian patients heading to socialist Cuba.

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MEDICAL TOURISM

Financial Savings in

MEDICAL TOURISM?

merican patients pursue health care in medical destinations primarily to save money. Employers and insurance companies are exploring offshore healthcare options for the same reason. Although there has been much discussion about low costs in medical tourism, the magnitude of financial savings actually realized by patients and third-party Payors is not always clear.

Insurance Company Savings For insurance companies, determination of potential savings is fairly straightforward. Third party Payors already know exactly how much they pay for their beneficiaries to have care in the domestic marketplace. First, they must establish what the charges would be for their beneficiaries to have equivalent care in medical tourism destinations. In order to make offshore arrangement acceptable to employers and beneficiaries, third party Payors will also have to assume some costs that they would not generally cover when care is obtained within the United States, including travel and certain accommodations in destination countries. Calculating potential savings for any given patient is a simple undertaking for insurance companies with core competency in collecting and analyzing data. However, projecting which segments of their beneficiaries can have – and will agree to – offshore care is a much more challenging issue. Patient Savings For patients who pay for their own care, determining the potential savings available in the medical tourism marketplace is a more complicated undertaking. Interestingly, the difficulty is not determining charges for offshore care but, rather, establishing what a patient’s expenses would be in their own hometown. To say what the financial savings are we must have this latter figure. Although it is easy and attractive to use stated charges, I believe that this practice leads to erroneous overestimation of potential savings. This practice also disregards the fact that a substantial proportion of the posted charge for procedures done here in the US is never paid due to either discounts or defaults. Getting to Best Price and Terms The number we should use for the cost of care in the domestic marketplace is the best price that patients can reasonably get if they are willing to ask for a discount and commit to clear payment terms.

DECEMBER 2007

MICHAEL D. HOROWITZ, MD, MBA In healthcare there is a chaotic relationship between the prices that providers charge and the payment they will actually accept. Most providers are willing to accept payment of less than posted charges from self-pay patients – they already do just this for Medicare, Medicaid and commercial insurance plans. In order to get such a discount, a patient must commit to reasonable terms and a clear payment arrangement before having treatment. (In the context of medical tourism, a patient who can arrange care in a foreign country has the wherewithal to try to do this.) Providers are much more agreeable to any arrangement if a patient makes a meaningful deposit at the time terms are discussed. The increasing number of firms that provide financing for medical and surgical care may allow patients to negotiate even better prices because this frees providers from collection costs and eliminates the risk of default. The price that a patient can likely get will probably fall below the quoted charge but above the payment provided by commercial insurance plans. My analysis compares the total out-of-pocket payments for unilateral hip replacement surgery in the US, India and Costa Rica. The data was obtained from the public web sites of several medical tourism agencies, supplemented by information provided by an experienced agent during a telephone interview. The quoted price for this operation in the United States ranges from about US$ 44,000 to US$ 62,000. For the reasons explained above, I am using the figure US$ 40,000 for this analysis. In order to make useful conclusions, it is necessary to control for uncertainties by making certain assumptions in this analysis. First, I assume that there are no additional

Dr Horowitz has been researching medical tourism and international medical travel since 2005. A graduate of the University of Miami School of Medicine, Dr Horowitz practiced Cardiothoracic Surgery for more than 15 years and obtained his MBA from Goizueta Business School of Emory University. He can be contacted at michael_horowitz@mac.com.

charges for postoperative complications in any of the groups. Second, American patients having care within the United States incur no charges for travel and accommodations. Third, patients travel offshore in economy class with one other party â&#x20AC;&#x201C; a spouse or other companion. This analysis shows that the medical savings for unilateral hip replacement are 86.5% and 83.5% in India and Costa Rica, respectively. The calculated savings are actually quite close to the commonly cited number of 90%. But American patients are not particularly interested in medical savings. They really want to know what their total savings will be since this is what truly affects them. For this analysis of hip replacement, the total cost savings are 75% for both India and Costa Rica, as compared to what a patient would really pay in the United States, presuming reasonable efforts to get a discounted price. Although medical costs are US$ 1200 less in India than in Costa Rica, much of the savings are consumed by the greater cost of travel to Asia than to Central America. Opportunity Cost: the Overlooked Factor Opportunity cost is a very important issue that has not been addressed in any analysis of savings in medical tourism that I have seen. If a patient has surgery in their own hometown, their spouse might miss a day or two of work. But a trip to a foreign country may well result in prolonged unpaid absence from fruitful employment. Furthermore, if a patient and partner are away for several weeks there may be expenses for childcare and/or elder care. On the other hand, in certain situations, offshore health care allows some patients to enhance their savings by combining their medical travel with previously considered or planned tourism activities. Opportunity costs, the expenses created by absence from home and the enhanced savings are extremely variable and not well suited to quantitative analysis. Nevertheless, they clearly have a great impact on the financial decision for patients considering offshore health care. In summary, this analysis indicates that patients who have hip replacement surgery in India or Costa Rica realize total savings of approximately 75%, compared to estimated best prices that patients could reasonably get in the United States. Cost for Hip Replacement at US and Offshore Medical Centers. Destination

United States

Cost Date Cost of Medical Care

India

Costa Rica

$ 40,000

$ 5,400

$ 6,600

n/a

$ 800

$ 1000

n/a

$ 2,700

$ 1,200

n/a

$ 1,100

$ 1,050

$ 40,000

$ 5,400

$ 6,600

100%

13.5%

16.5%

$ 34,600

$ 33,400

Physicians Facilities

Cost to Arrange Care Commission to agent Pre-travel evaluation Pre-operative labs

Cost of Travel (Patient plus 1 companion) Air travel Travel insurance

Cost at Destination Concierge services Hotel ( 5 nights) Meals at destination

Analysis Medical Cost Medical Cost

(% of US Value)

Medical Savings

($)

Medical Savings

(% of US Value)

Total Cost Total Cost

(% of US Value)

Total Savings

($)

Total Savings

(% of US Value)

0.0 %

86.5 %

83.5 %

$ 40,000

$ 10,000

$ 9,850

100%

25.0%

24.6%

$ 30,000

$ 30,150

75.0 %

75.4 %

For clarity of presentation, some data are aggregated and rounded up or down to the nearest $50 increment. Travel costs are based on quotes by a medical tourism agent and confirmed using an online travel web site. Travel costs are for the patient and one confirmed, in economy class from Atlanta to New Delhi, India/ San Jose, Costa Rica.

2007 Michael D. Horowitz

MEDICAL TOURISM

LEGAL ISSUES

The United States Court System and Liability for Treatment of American Patients Overseas ~ Challenging Jurisdiction ~ By FREDERIC J. ENTIN, ESQUIRE

liability insurance, service of process and enforcement of judgments will be adjudicated in American courts of law.

Wow! A market of at least 100 million potential patients, employers looking for relief, political paralysis and you have a product that is of better or equal quality and far less expensive to offer to U.S. citizens. Why not go for it?

To best understand how these issues will be resolved, it is helpful to note which aspects of the United States legal system have and will affect medical malpractice litigation. In the United States, different jurisdictions with different principles of law, aggressive and creative lawyers, and the unpredictability of individual judges will have a profound affect on the success of a medical malpractice claim. As care is delivered outside of the United States, poor outcomes will inevitably occur. Patients will quickly realize that legal recourse outside of the U.S. courts is unattractive and inadequate by our standards. Once retained by the patient, their lawyers can be expected to examine every step in the process from initial patient contact to discharge to follow up care at home, to find a way to get jurisdiction in a U.S. court and to have that court apply U.S. law. The same creativity and aggressive lawyering that has made for large judgments and broad liability here will be applied to these new factual circumstances. A careful examination of our system by those looking to facilitate and provide care for American citizens may influence decisions about who is treated, how the patient is treated and how the services of the provider are marketed.

o you manage a hospital or work with a hospital outside of the United States and you just cannot ignore the fact that the U.S. health care system is not readily available to just about one-third of all Americans. It seems like every day you see the same statistics quoted in the news media, cited by candidates running for political office or in the trade press, that as many as 50 million Americans have no health insurance and that at least another 50 million are inadequately insured. You read the complaints of U.S. businesses that the cost of providing health care benefits is increasing at a rate that threatens global competitiveness, if not corporate viability altogether. You see Michael Mooreâ&#x20AC;&#x2122;s documentary, Sicko, and you know that you just might have an affordable option for care and treatment to many of these Americans. Finally, you think you understand enough of the public policy debate in the United States over health care to conclude that fundamental change to the current system is a long way off.

Appropriately, you hesitate and wonder what risks are associated with this great opportunity. Although health care in the United States is heavily regulated, raising tax, ERISA, privacy, licensing and insurance issues, more likely than not, the first thing you think about is medical liability. If you are a provider, you correctly wonder if engaging in the care of American citizens exposes your organization and the individuals who provide clinical and other services to liability in United States courts. If you help facilitate obtaining care for American citizens in foreign hospitals, you also wonder if you will find yourself in court. And if so, what does that mean and can the risk of liability in US courts be managed sufficiently to justify a business decision to go after the American market?

The American Judicial System No doubt you already know that the United States is the most litigious country in the world and you expect that you might get sued. Inevitably, some US citizen will experience a bad result and you wonder if your healthcare facility has adequate defenses to protect you from liability in our courts. Defenses and postjudgment realities such as personal jurisdiction, waiver, choice of law and forum selection clauses, theories of medical liability,

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51 American Court Systems Unlike other countries, the United States does not have a unified single body of law for the entire country. Although there is a Federal Court System, liability of the type commonly alleged when a patient has a bad outcome is covered by state law. Each state has its own legislature that makes the law and courts that interpret and enforce the laws. Including the District of Columbia, that makes for 51 separate jurisdictions with sometimes subtle and sometimes significant differences in substantive law and procedure. In the early part of this decade, the medical malpractice insurance crisis caused many state legislatures to reexamine state medical malpractice law. What resulted is typically American. Some states did nothing, many states passed reforms and plaintiffâ&#x20AC;&#x2122;s lawyers immediately started challenging the constitutionality of the reforms. The differences from state to state may be substantial enough to influence where the foreign provider markets its care. The incentives to sue are high and the barriers to the courts are low in America. While the law continues to vary from state to state, it is clear that judgments and settlements are much higher in all of the 51 jurisdictions than in other country. This is largely attributable to the ability in almost all states to recover

non-economic damages and the high cost of care that cause actual damages to be so high. No matter which state the patient decides to sue in, access to the courts is easy because each side pays its own legal fees and this type of case is almost always taken on a contingency basis thus, requiring no legal fees to be paid by the injured patient until the case is resolved.

Lawyers and the Search for Deep Pockets The expansion of liability theories in medical malpractice law in the U.S. can be attributed to the constant creativity of plaintiff’s lawyers. Physicians typically carry no more than $1,000,000 of liability insurance for any one claim. As lawyers seek to increase the size of judgments, they look for other defendants to share the burden of paying for judgments that exceed the amount of insurance of any single physician defendant. Medical malpractice attorneys have responded aggressively and resourcefully by advocating new theories of liability which open up the pockets of others in the continuum of care to joint and several liability for the same injury. Starting with the 1967, Illinois Supreme Court decision in Darling, hospitals have been independently liable under an increasing number theories for the care delivered to patients. Injured patient’s lawyers have successfully applied theories of direct and apparent agency to expand the number of defendants against whom liability could be imposed, even when the care is delivered in the doctor’s office. And in the quest for even larger awards and settlements, plaintiffs’ attorneys have convinced courts and juries of the viability of pain and suffering and new basis upon which their clients can be compensated for non-economic damages. Faced with a client allegedly injured as a result of care in a foreign provider, it is not unreasonable to expect the same persistence and ingenuity to be applied to finding a way to bring the claim to a U.S. court under U.S. law. Anyone arguably involved in the care of the patient can be a target.

Judges are People Too Just as the law may be different from state to state, the interpretation and application of the law can be highly influenced by the judge before whom the case is tried. In many states, judges are elected by the citizens of the county or region in which the judge will preside. While judges are bound to follow the law and the precedent from prior cases, the application of the facts of any single case to the law can be somewhat subjective even in the same state. Some judges sit in areas of the same state which are vastly different in culture and perspective. In Illinois for example, Cook County could not be any different than its immediate neighbor to the west, Du Page County. Judges and juries in Cook County are generally known to be more inclined to side with a plaintiff and if so, the size of the judgment is likely to be higher than in Du Page County. Further, as will be discussed later, a judge facing a ruling on whether he has jurisdiction over a defendant may be more inclined to find some basis to take the case if the alternative is that a member of his community is left with no adequate legal recourse if injured in another country. Assuming the business proposition is compelling enough to encourage you to go forward, what are the defenses that can be raised in the event a lawyer wants to get his client’s claim decided in an American court of law and what can be done to put the providers in the best position to defend?

Personal Jurisdiction A court must have personal jurisdiction over a defendant before it can enter a valid judgment imposing a personal obligation on the defendant. Therefore, first line of defense for a foreign hospital or provider will be to challenge the court’s jurisdiction. Will the fact that you are located outside of the United States, that you have no offices or employees in the state where the suit is filed, that you have not consented to jurisdiction, and the alleged injury

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MEDICAL TOURISM

occurred outside of the United States, immunize you from liability? It depends! But it is clear that over the years, starting with a case called International Shoe Co. v Washington, the United States Supreme Court, has allowed state courts to assert personal “long-arm” jurisdiction over a nonresident even though the defendant is not personally served within the state, provided the defendant has certain “minimum contacts” and the action “does not offend traditional notions of fair play and substantial justice.” Long-arm jurisdiction can be general or specific.

Specific Personal Jurisdiction A court can exercise specific personal jurisdiction over a non-resident defendant when the defendant’s activities within the state serve as or are related to the basis of the lawsuit. For example, a patient calls a medical tourism facilitator in another state acting as a representative of a foreign health care provider, and the representative assists the patient in the selection of a hospital and the patient alleges he has been the victim of negligent care. In addition to suing the hospital and physicians for negligence, the patient might also allege that the decision to travel abroad for the procedure and the referral to the specific hospital or physician was the proximate cause of the injury. Before the defendants are forced to defend the claim on the merits, they can first challenge whether there is proof of the requisite connection between the act allegedly occurring in the state in which suit is sought, the recommendation or referral and the injury. An inquiry of this nature would not extend to the actual merits of the negligence claim, but if the court believes there is a connection, it will exercise specific personal jurisdiction and force the defendant hospital and physicians to defend or face a default judgment. Even if the defendants are successful in getting the matter dismissed for lack of personal jurisdiction, it will cost time and money to defend. With extensive use of the Internet to reach out to prospective patients, claims of specific personal jurisdiction are likely to arise. Developing case law tells us that the interactivity of the website consulted by and used by the patient and the hospital, may give a court sufficient grounds to find specific personal jurisdiction. It is important to remember that specific personal jurisdiction is for

that case only and other claims involving the same defendant and the same state are subject to fresh analysis of the underlying facts.

General personal jurisdiction As opposed to specific personal jurisdiction, general personal jurisdiction exposes a defendant to the jurisdiction of the courts for all actions. A court can exercise general jurisdiction over a person if the defendant’s conduct in the state is “continuous and systematic”. Because a plaintiff bears a higher burden of proof to establish general jurisdiction, even the use of a highly interactive web site on the internet would be less likely to constitute the kind of continuous and systematic presence in the state to give a court the basis to assert general personal jurisdiction. However, the more the website becomes a virtual transactional workplace, developing legal precedents might encourage a judge to conclude that the website is no different than a physical office, that the presence of the foreign defendant is “continuous and systematic” and that there is jurisdiction for all purposes.

Conclusion Bad results and poor outcomes occur whenever patients receive health care. This will be true whether the patient receives treatment in the United States or abroad. Methods of compensation for medical injuries in other countries are likely to be viewed as inadequate when compared to the American system. Some patients will understand that limited compensation in the event of a poor outcome is one of the tradeoffs for going abroad for medical care. Other patients may not be as forgiving. Those who choose to help arrange for care and those who engage in the treatment of Americans abroad must prepare to defend against clever, resourceful and aggressive lawyers and sympathetic judges. This article has discussed the first line of defense, challenging jurisdiction. While a future article will go into more detail about jurisdictional pitfalls, other articles will discuss how to manage risk in the event a sympathetic judge takes jurisdiction and requires the foreign health care provider to defend itself.

Fredric J. Entin is a partner with Foley & Lardner LLP. A member of the firm’s Health Care Industry Team, he served as chair of the former Health Legislation/Associations Practice. Mr. Entin has broad experience representing hospitals and other health care providers focusing on compliance with a wide variety of issues including antitrust, Medicare and Medicaid, medical staff and exempt tax law. He has also represented trade associations and their subsidiaries for many years. Prior to joining the firm, Mr. Entin served as senior vice president and general counsel for the American Hospital Association (AHA) for more than eight years. Fred is an Advisory Board Member of the Medical Tourism Association.

DECEMBER 2007

Choosing an

International Hospital

Elements to Consider When Making Your Selection By LIC. BERNAL ARAGON BARQUERO General Director of Hospital Clinica Biblica, Costa Rica.

e live in a generation of information overload. With so many choices available to us, it is sometimes difficult to discern truth from fiction and make sense of the mountain of information that is coming our way. This is especially true when it comes to choosing and trusting the right hospital for our particular needs. You and I have the opportunity and the capability to interact with thousands of people and organizations via the internet. With the development of the worldwide web, experts and non experts alike are filling up web pages of blogs and vlogs, having found an interactive space to share their lives and experiences with the rest of the world. As far as hospitals go, the internet also allows us the advantage of â&#x20AC;&#x153;visiting and experiencingâ&#x20AC;? a hospital before physically traveling there. Additionally, sites such as MySpace, Facebook, Hi5 or LinkedIn, help us to find information that will assist us in making a sound decision 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 could skew reality. In other words, how do we sift through this mountain of information and ultimately make the correct decision about the best hospital for our needs? Below are some tips to make sense of all that information:

LOOK FOR JCI ACCREDITATION The Joint Commission is a non governmental agency that certifies US hospitals. The International branch of the Joint Commission certifies hospitals outside the US health system that have comparable standards to a US hospital. A list of accredited institutions can be found at www.jointcommissioninternational.com/23218/iortiz. LOOK FOR EXPERIENCE Many hospitals outside the United States have been providing services to the local population for a long time. Local reputation is a good indicator of good quality. Look for institutions that have been in the market for over 50 years. This would give you confidence that things would run smoothly since they have experience. Some hospitals care only for locals, some others care for tourism alone. Seek hospitals that provide a healthy combination of locals and tourists. CHOOSE SHORT TRAVEL DISTANCES OF LONG ONES Air travel increases the risk of certain complications like deep venous thrombosis (DVT). DVT is the formation of blood clots in your legs. These clots can migrate up to your lungs and create a Pulmonary Embolism, The risk of DVT increases by 2.93 times 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 undergo surgery, are pregnant, smoke, take birth control or suffer from cancer are at higher risk of suffering this condition than the rest of the population. There are many ways to reduce the risk. There are other complications from long haul air traveling, like jet lag, changes in air pressure, humidity, oxygen concentrations. A healthy conversation with your local doctor and your physician at the destination of your care can help diminish your specific risk. The World Health Organization has published a segment on International Health and Travel that includes a segment on the health considerations of air traveling. This segment is available at their website, www.who.int. SEEK PHYSICIANS THAT SPEAK YOUR LANGUAGE Communication has been the weak point of humanity ever since it came to existence. The risk of communication failure increases if two people do not speak the same language. Make sure you ask what percentage of staff and doctors speak English or your language at the Hospital. Avoid surprises. COMPARE YOUR OPTIONS We have been mentally trained to trust our doctors. No matter who we are, the white coat has a halo effect that blinds our consumer oriented mentality. Comparing hospitals and doctors is a healthy practice since past performance is the best predictor of future outcomes. Google your procedure and educate yourself about the complications and risk of the surgery or treatment. Ask specific questions about these risks and complications including hospital based risk like infection control. If these are being measured and they are willing to compare, it is a good sign of quality management at that institution.

Overall, there are neither perfect hospitals nor perfect doctors, but being able to find one that fits our expectations of healthcare is a task that we can only do for ourselves.

MEDICAL TOURISM

Costa Rica: From Ecotourism Leader to World Class Healthcare Provider By WILLIAM COOK

ention Costa Rica to someone and invariably you’ll hear words such as eco-friendly, misty rainforests and picture-perfect volcanoes to name just a few. Costa Rica is well known around the world as a premier ecotourism destination. Its proximity, stunning scenery and friendly locals have been luring North American travelers for at least three decades, long before the term “ecotourism” became popular. With all the focus on Costa Rica’s natural attractions, many people are not aware that the country is also a popular destination for top quality health care at very affordable prices.

That is now changing. According to Costa Rica’s Tourism Bureau, the number of visitors to the country coming in search of medical treatment has doubled since 2003 1. Although exact numbers are hard to come by, (a 1991 study by the University of Costa Rica suggested that nearly 14% of visitors came for medical purposes; other surveys put this number much lower), there is no doubt that more and more North Americans are finding Costa Rica a very attractive destination for their healthcare needs. 20

DECEMBER 2007

Why Costa Rica? PRICE If you have done any research, you will quickly discover that the price of medical procedures in Costa Rica tends to be at least 40-70% less than what you would pay in North America. This is due in part to lower wages, a favorable exchange rate and lower malpractice insurance. Price is no doubt the principal reason why patients choose Costa Rica and other foreign destinations. LOCATION, LOCATION, LOCATION Located just two and a half hours from Miami, Florida, Costa Rica is one of the closest off-shore medical care destinations for people living in North America. If you choose, you can literally fly to Costa Rica’s

capital city of San José on one day, have your surgery that same day, and be on your way home the following day. This, by the way, is not recommended, but it is an attractive option for less invasive procedures. For many, however, the advantage of a relatively short flight home is what puts Costa Rica at the top of their list of medical tourism destinations. Coupled with the fact that Costa Rica is a favored vacation destination for American travelers, the country is a convenient option for people who are looking to combine a regular vacation with a health check-up or surgery procedure. I mean, who wouldn’t want to slide into bubbling thermal springs or explore an emerald-green rainforest and then take care of an ailing health problem all on the same trip? Add to this picture the luxury of a wide variety of recovery retreats, a feature unique to Costa Rica, and it is easy to see why this country is such an attractive destination for plastic surgery as well as other medical procedures. A LITTLE HISTORY Even back in the early 1980’s there was already a healthy flow of North American patients coming to Costa Rica for cosmetic surgery procedures. The low cost of cosmetic and dental procedures is still one of the main attractions for patients abroad. Increasingly however, travel to Costa Rica and other countries for medical care is being driven by North Americans who don’t have health insurance or have only minimal coverage. According to the New England Journal of Medicine, “These patients are not ‘medical tourists’ seeking low-cost aesthetic enhancement but middle-income Americans who need life saving surgeries and want to evade impoverishment by succumbing to expensive healthcare options in America.” 2 This trend of traveling abroad for life-saving medical treatments is expected to increase dramatically over the coming years due to rising health care costs, higher deductibles and insurance premiums that are well beyond the reach of many middle income Americans. In a typical scenario, Tom, a self-employed roofing contractor, is told by his U.S. doctor that he requires knee replacement surgery. The price he’s quoted is close to $40,000, and, as one of America’s 47 million uninsured, Tom has no way of footing the bill. Through a friend, Tom hears that there may be more inexpensive options abroad. A Google search brings up a hospital in Costa Rica where Tom learns that the exact same procedure costs only $9,500. After carefully researching the site and talking to doctors and former patients, Tom decides to use the hospital to arrange his surgery and logistics. During this time Tom speaks several times with his Costa Rica physician and is impressed by his warmth and knowledge, as well as by his credentials and fluency in the English language.

Tom arrives in Costa Rica a few days before his surgery and takes advantage of the hospital’s concierge services to visit an active volcano and relaxing hot springs. A few days later, Tom is picked-up at his hotel by a hospital representative and taken to the hospital for surgery. The hospital’s caring staff and ultra-modern facilities quickly put Tom at ease. After surgery, Tom spends three days in the hospital and an extra week in a recovery retreat before heading back home. Total expenses including round-trip air-fare? $10,700. ARE WE FORGETTING ABOUT QUALITY? Sure, soaking it up at a tropical paradise may sound all fine and dandy. But who’s to say the masked man hovering over me is a qualified medical professional and not some quack that just stayed at a Holiday Inn Express? Is there any kind of government regulation? How does one weed out the good doctors and hospitals from the bad ones? First off, just as in life, things usually aren’t so black and white. Whether in the United States, Canada or Costa Rica, some doctors and hospitals simply have more experience in certain procedures and are therefore more likely to have better outcomes. Here or abroad you’ve got many good

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MEDICAL TOURISM

doctors and then a small few that are not so good. It pretty much comes down to doing the research and using common sense. In Costa Rica, all practicing medical professionals must be registered with the “Colegio de Médicos” (the College of Physicians) www.medicos.sa.cr, a good place to start your research. To its credit, Costa Rica also has a long tradition of offering high quality medical care to all it citizens through a national public healthcare system. Besides the public health system, the country has a strong private health system with hospitals and clinics of great prestige and reputation. FACTS TO CONSIDER: • The World Health Organization’s most recent survey of healthcare systems published in the World Health Report 2000, ranks Costa Rica’s health system among the top three in Latin America ahead of 154 other countries including the United States, New Zealand and Thailand • In 2004, Costa Rica’s infant mortality rate was nearly as low as the United States (9.25 deaths for every 1000 born live in Costa Rica, against 6.5 deaths for every 1000 born live in the United States). This is especially relevant considering that the United States has more neonatologists and neonatal intensive care beds per person than Australia, Canada and the United Kingdom (not to mention Costa Rica) and a per capita income nine times more than that of Costa Rica. • According to the World Bank, Costa Rica has the highest life expectancy in all of Latin America. With 78.7 years of life expectancy at birth, Costa Rica equals Canada, and beats the United States life expectancy by one year. Additionally, many of the country’s doctors have trained in the United States or Europe and a significant percentage speak English or another second language.

THE FUTURE Traditionally in Central and South America (as well as many other parts of the world), most medical services have been marketed abroad through individual doctors and small clinics. Recently, however, larger hospitals have begun to actively solicit foreign patients. A case in point is Thailand, which boasts several hospitals that have successfully marketed their services to an international clientele. In Costa Rica, the Hospital Clinica Biblica has taken a leading role in positioning itself as the region’s premier medical institution for international patients. This privately owned, non-profit institution boasts one of Costa Rica’s most technologically advanced medical facilities and will soon be the region’s first JCI accredited hospital. The JCI accreditation is a world-renown seal of approval that indicates a hospital meets high performance standards comparable to hospitals in the United States and Europe. Founded in 1927 by North American protestant missionaries, Hospital

Clinica Biblica has a long tradition of catering to resident aliens and more recently to medical tourists. It recently opened an international department and is considering dedicating an entire hospital wing solely for the use of international patients. Presently over fifteen percent of its patients are foreigners and this is only expected to increase. It is initiatives such as these and others like it that bode well for Costa Rica’s incursion into this exploding market. With no end in sight to the U.S. healthcare crises, aging baby boomers and the number of uninsured continuing to grow, the road ahead looks promising as this country reinvents itself from solely a top ecotourism destination to a leading player in the global healthcare arena.

As Patient Coordinator for Hospital Clinica Biblica International Department in Costa Rica, Bill Cook oversees operations and customer relationship management initiatives aimed at increasing customer loyalty and satisfaction. Bill also overseas web content development and marketing strategy for Medical Tours Costa Rica, a locally based medical tourism operator. Bill can be reached at www.hospitalbiblicamedicaltourism.com.

DECEMBER 2007

References 1

Milstein and M. Smith, “America’s New Refugees-Seeking Affordable Surgery Offshore,” New England Journal of Medicine 2006; 355(16): 1637–1640 2 ICT: Llegadas de turistas internacionales por LA VIA AEREA 2001-2006

MEDICAL TOURISM

CostaTheRica Great Opportunity By JORGE WOODBRIDGE GONZÁLEZ, Vice-minister Costa Rican National Council on Competitiveness

osta Rica is the country of sunny beaches on the Pacific Ocean and Caribbean rhythm on its Atlantic Coast. It is the country with the best coffee in the world, of tasty bananas, pineapple and melon consumed on the tables in five continents. It is also a country that manufactures microchips, develops software and where corporate services of important multinationals like Intel, Panasonic, Hewlett Packard and others are outsourced. Finally, it is the oldest democracy in Latin America, a country whose President, Dr Oscar Arias Sánchez, was awarded the Nobel Peace Prize. The closeness of Costa Rica to the United States at just two hours and thirty minutes from Miami lures thousands of Americans to its beaches and volcanoes for ecotourism. However, the quality of its medical professionals, the guaranteed international level of service in its clinics, the hospitability of its people and its natural beauty and excellent hotel infrastructure lure thousands of patients to its shores, making Costa Rica the new convenient destination for medical tourism where patients can recover in full and relaxing comfort. Competitiveness in Medical Services The strengthening of a cluster of medical services is one of the priorities of the competitiveness program being developed by the Government of Costa Rica. It is estimated that in 2006 about 4,500 medical procedures were performed on non-Costa Rican patients. The immediate goal for the country is to provide an opportunity for at least 0.5% of Americans without medical insurance to travel to Costa Rica to get treatment, which would mean at least 230,000 patients. To achieve this challenge, we are betting on the

DECEMBER 2007

competitiveness of the whole system. The most effective way to accomplish this goal is first and foremost to safeguard the quality of physicians and hospitals. In terms of marketing, Costa Rica is developing the potential of receptive offers, particularly from specialized recovery centers, promoting agreements with large international insurers, and promoting medical and nursing careers in both public and private universities.

The immediate goal for the country is to provide an opportunity for at least 0.5% of Americans without medical insurance to travel to Costa Rica to get treatment, which would mean at least 230,000 patients.

Jorge Woodbridge González may be reached at jorgewg@racsa.co.cr

The Challenge of International Accreditation Undoubtedly, the main challenge the country faces is to promote the international accreditation of its hospitals. Some Costa Rican structures have already started certification processed before the Joint Commission International (JCI), the international arm of the Joint Commission (JC), an organization endorsed by the U.S. Department of Health and Human Services. In the short term, we want all hospitals in Costa Rica to be duly accredited, since we are aware that only in this way we can guarantee the positioning and sustainability of an industry with a lot of added value. In past months, all agents related with the medical services cluster were called by the National Competitiveness Council to work on a strategic development plan for the sector. Hospitals, physicians, hoteliers, and different Government entities (among them the Ministry of Health, Ministry of Tourism, Ministry of Foreign Affairs, Ministry of Economy, Industry and Commerce) have committed to make our country a world-class medical center within the next 10 years. We trust Costa Rica will be able to succeed in this challenge, becoming a regional leader in health care tourism, so we can again be referred to as the “Switzerland of Central America.”

MEDICAL TOURISM

Costa Rica

More than Cosmetic & Dental Surgery

Who are those Masked Men? Costa Rica not only has universal health care, but Costa Rica is considered to have one of the best health care systems in all of Latin America The government runs more than 30 hospitals and 250 clinics. The Costa Rican health care system has been in existence for almost 60 years. Most Americans are shocked to find out that Costa Rica has been rated higher by the World Health Organization than the US, and in the last 2000 WHO report the United States rated 37, below Singapore and Costa Rica.

Requirements to become a doctor What exactly does one have to do to become a physician in Costa Rica? Like doctors in the US, medical doctors in Costa Rica receive formal university training followed by a postgraduate residency program. The latter ensures that they have extensive practice knowledge in their specialty. In addition, all medical physicians must meet general requirements to be a member of the Costa Rican Doctors’ and Surgeons’

Association (Colegio de Médicosy Cirujanos ~ medicos@racsa.co.cr). Dentists, on the other hand, are certified by the Costa Rican Surgeons and Dentists Association (dentista@racsa.co.cr). Obtaining a medical degree in Costa Rica requires some undergraduate studies in the medical field and a graduate degree in medicine. It takes six years at the National University of Costa Rica to obtain a graduate medical degree, but even then a doctor is not ready for practice. A prospective doctor must complete a Doctorate Title in Medicine and one year of social service at one of the Social State Hospitals. For postgraduate residency, the amount of time spent in the various programs depends on the specialty field. For instance, plastic surgeons are required to complete an extra eight years of post-graduate residency study. Four of those years are spent in general surgery and the following four years in plastic surgery. That means a plastic surgeon has totally fourteen years of study, comprising of graduate study and post graduate residency study, before they can practice. Endocrinologists must perform an additional two to four years post graduate residency study to become a specialist, and a doctor must spend five to seven years in post graduate residency study just to qualify in general medicine.

Requirements to become a nurse The University of Costa Rica requires students who are applying for a nursing degree to perform aptitude exams with a score of 700 or more to qualify. The private universities, however, do 26

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not require this exam. It takes from three to four years for a nurse to graduate from the University and four to five years in total to graduate as a licensed nurse. To qualify with a masters in nursing, a nurse will spend another one and a half years on top of the license nurse requirements. In order to work, nurses need a Costa Rican Accreditation Title and must be affiliated with the School of Nurses of Costa Rica. All other nurse titles require accreditation from the Nurses School of Costa Rica. While Costa Rica has a public healthcare system, it has a growing private health care system which is starting to focus on attracting Americans to Costa Rica for medical care above and beyond the prior reputation for inexpensive cosmetic and dental surgery. Costa Rica is now becoming known for surgeries such as Hip replacements, back or spinal surgeries and knee replacements. In fact, laboratory materials are all FDA approved and shipped in from the United States. For Americans traveling to Costa Rica for medical care the healthcare is quite affordable. Many of their doctors not only speak English but also have received training in the United States, Canada or Europe. The Two main hospitals in Costa Rica are Clinica Biblica and CIMA. Unfortunately, at the time of writing this article, CIMA hospital had not finished completing its hospital floor specifically for medical tourists. CIMA also did not provide written information to the Medical Tourism Association regarding its hospital and other items such as infection rates. We hope to

Carole Velosa indicated that last year she saw a shift from plastic surgery as the primary sought after medical treatment from foreigners to now about only fifty percent of foreigners coming for plastic surgery. The other fifty percent are looking for general medical care and surgery found in American hospitals. Of this fifty percent, patients are seeking heart bypasses, lap bands, knee replacements, hip replacements and hysterectomies.

include more information about CIMA once their new wing has been opened. In the interim, we have provided some information provided by New York raised, Costa Rican CEO, Carole Velosa. CIMA is an impressive complex of buildings, two of which are high rises, home to 400 physicians on a campus and 1500 on staff. Most of the physicians at CIMA are trained outside of Costa Rica. CIMA has erected two new medical towers, laid stylish like in New York. Nearby, a developer plans on building condominiums, a shopping center and even an Imax theater to cater to its hospital staff. CIMA can handle 120 inpatients per day and has all the modern technology of MRIs, ultrasounds, a 9 bed emergency room and trauma center. The hospital has its own helipad for the “five people per week who fall and need to be airlifted,” according to Carole Velosa.

The third floor of the hospital is intended to be the “Tourist Unit,” Velosa described, “with six beds and four suites, all English speaking with a separate staff, computer room and common area. The unit will have an all American menu and WiFi access. CIMA just began their process for JCI Accreditation.” Hospital Clinica Biblica, on the other hand, has a dedicated Medical Tourism Department of 5 full time employees, who speak both English and Spanish, and also a newly dedicated floor for medical tourists. The two brothers, Brad and Bill Cook, who run the international department, spent some time growing up in the United States and so there clearly is no culture barrier here in dealing with them. Hospital Clinica Biblica is a private hospital established by American missionaries and built in 1929. The hospital is affiliated with Tulane University in Louisiana with a capacity of 5000

Costs of Surgeries In Costa Rica vs United States Medical Procedures

USA

Costa Rica

Heart Bypass

$130,000

$24,000

Heart Valve Replacement

$160,000

$15,000

Angioplasty

$57,000

$9,000

Hip Replacement

$43,000

$12,000

Hysterectomy

$20,000

$4,000

Knee Replacement

$40,000

$11,000

Spinal Fusion

$62,000

$25,000

Facelift

$7,000 - $13,000+

$4,600-$5,000

Rhinoplasty

$3,000 - $12,000+

$3,500 - $3,900

Breast Lift

$4,000 - $9,000+

$3,000-$3,400

Breast Augmentation

$5,000 - $9,000+

$2,700-$2,900

Blepharoplasty (Eyelid Surgery)

$1,500 - $7,000+

$2,000 -$2,200

Tummy Tuck

$5,000 - $9,000+

$3,900 - $4,200

Bridges

$1,000 - $3,000+

$250-400 per tooth

Crowns

$500 -$900+ per tooth

$250 - $400 per tooth

Implants

$1,000 - $5,000+

$700 - $900

Porcelain Veneers

$1,000 + per tooth

$300 - $500 per tooth

Root Canal

$360 - $900+

$125 - $250

outpatients and 120 inpatients per day. Most of the non-Costa Rican patients come from the US, Canada and Europe, making up a generous percentage of the 14,400 procedures performed at the hospital each year. At least ten percent of the physicians at Clinica Biblica are US board certified in specialties such as general surgery, orthopedics, cardiac and urology. With its 800 employees, this hospital boasts that all of its nurses are registered nurses and the nurse to patient ratio is approximately four to one, and all rooms are private and some are suites. Clinica Biblica has almost completed the lengthy and arduous process of JCI accreditation. It has spent thousands of dollars in training all its employees in resuscitation techniques approved by the American Heart Association. Even the janitors are certified. There are state of the art voice activated video surgery rooms, and high tech infection prevention architecture reducing the infection rate at Hospital Clinic Biblica to less than three percent . What was interesting about Hospital Clinica Biblica was the atmosphere of the facility and its employees. The whole hospital is painted in blue and green because research suggests that those colors are indicative of emoting calmness, and suitable for patient healing. There are also TVs located in ICU rooms which has been shown to create good patient outcomes. The attitude of the physicians is not one of superiority and it is common that patients have access to their doctor’s cell phone numbers. As one doctor stated, “We are just people helping people.” That being said, your overall experience at a hospital in Costa Rica may be more than you expected, especially at the lower costs for services. If the surgeon is the right one for your particular medical condition and the hospital meets your approval, we suggest you go for it!

Cosmetic Surgery

Dental Surgery

Medical Tourism Association August 2007 Survey. Prices in US vary by many factors, including but not limited to, zip code, location, and provider experience.

DECEMBER 2 0 0 7

MEDICAL TOURISM

All these are procedures we do in the branch of orthopedic surgery. Instead, I asked some of my former overseas patients for advice as to what they would like to read about in regards to Medical Tourism in Costa Rica. Almost all agreed their attention was called primarily to the type of care they had received in our Clinic, including my care, the care provided by the medical team, as well as the entire staff in charge of their care. We are a group of professionals devoted to solving your medical problems without forgetting to care for the person behind the ailments. We want to see that you recover well from your surgery, but also feeling emotionally well throughout the entire process. Unlike in America, patients are not just numbers in a production line. Fortunately, thus far, we have achieved this commitment. All our patients not only leave satisfied with the medical result obtained, they leave thankful for having found a different way of medical care. From the medical point of view, it behooves just to mention that in Costa Rica we have the highest longevity index of Latin America, comparable with USA and Canada. This compels us to have extensive practice in procedures frequently performed on patients beyond age sixty as are joint replacements. With a Social Security institution giving coverage to 100% of the population and offering highly efficient services, we have experience in handling implants from the best manufacturers, both American and European (Biomet, Zimmer, Depuy, Johnson & Johnson, Synthes, etc.)

ORTHOPEDIC SURGERY IN

COSTA RICA Although Costa Rica is known for its excellence in cosmetic and dental surgery, the specialties found in most American hospitals can be found in Costa Rica. Many of the surgeons are board certified and trained in the U.S. and their medical practices overseas are second to none. They care for the whole patient, not just the medical problem.

By OSCAR OEDING B, MD

he n I was asked to write an article for publication in a Medical Tourism related journal, I thought of giving a medical report including statistics of results obtained in Total Knee Replacement, Total Hip Replacement, Reconstruction of the Anterior Cruciform Ligament, Rotator Cuff Plasty, etc.

New York Health Crisis Reuters reported that one out of 6 New Yorkers lacks health insurance, even though almost two thirds of these individuals are employed. Forty one percent of those without insurance did not seek medical care due to not having health insurance. New Yorkers without health insurance were four times more likely to not seek medical care as those with health insurance. Dr Frieden, New York City’s health commissioner stated “All of this adds up to people landing in emergency rooms with costly, devastating health problems that could have been prevented or treated.”

DECEMBER 2007

In sports, our national soccer football team ranks around the 35th place worldwide. This is the most practiced sport in our country, bringing us frequent injuries such as Meniscus Tear, Anterior Cruciform Ligament Rupture, Damaged Cartilage, etc. Needless to say, we have quite a bit of experience resolving orthopedic problems. For years, Costa Rica has been a strong medical tourism destination with Plastic, Dental and Medical Surgery. Accordingly, we have plentiful experience with private hospital infrastructure and patient recovery and we have excellent rehabilitation centers that our orthopedic patients now are using. I look forward to some day showing you the Costa Rican way we care for patients.

OSCAR OEDING B, MD is an orthopedic surgeon at the Hospital Clinica Biblica in Costa Rica

MEDICAL TOURISM

Deep Venous Thrombosis The Traveler’s Disease

s the world becomes more globalized and traveling becomes easily accessible to most people, we face diseases that may result from travel. Deep Venous Thrombosis (DVT), also referred to as Venous Thromboembolism (VTE), is undoubtedly a disease that can be deadly for an individual. It is therefore important for patients intending to travel abroad and medical tourism companies assisting patients abroad to understand the risks and take measures to prevent them. DVT results from many factors that can easily occur in travelers during flights lasting longer than 3 hours. Although the risk of DVT is not very high, occurring generally in about one in every six thousand people, risk factors such as age, obesity, pregnancy, smokers or people who have had certain surgical procedures like hip or knee replacements, or abdominal surgeries may increase the risks of DVT. Some cancers such as lung, ovarian and breast cancers have been shown to increase the risks as well as anyone having undergone chemotherapy. Certain heart conditions, high blood pressure or cardiovascular disease, bowel diseases and other gastrointestinal conditions can increase the risk as well. 32

DECEMBER 2007

By DR ELLIOTT GARITA JIMENEZ Cardio-Vascular Surgeon, Hospital Clínica Bíblica A prime candidate for DVT might be also be a person with varicose veins who takes a flight longer than 3 hours in an air-conditioned environment that causes dehydration, who failed to ingest liquids, thereby avoiding frequent bathroom visits. DVT results from a blood clot in the deep veins of the lower extremities, producing intense pain in the calves and extreme swelling in the limbs. This swelling may progress from the feet up to the thighs. This phenomenon may not appear for up to 48 hours after a trip. Although there is an immediate concern of pain and swelling, blood clots are not the real causes of concern per se. However, if a clot in a vein breaks off and travels to the arteries of the lung in the form of a pulmonary embolism, this may quickly lead to death or may result in many serious complications that require immediate hospitalization in the Intensive Care Unit. Preventing this and many other diseases is much more effective and economical than treatment. The following recommendations are specifically designed to prevent DVT:

The day before traveling:

Make sure you walk throughout the day. This should not be difficult since you likely have many errands to run before your trip.

Do not forget to take the medications you usually take.

If you regularly use a diuretic, ask your doctor if you can skip it just for this day before travel in order to avoid dehydration.

Take a lot of fluids 24 hours before the trip.

The use of anti-clotting agents (anticoagulants) or anti-platelet agents must only be used as indicated by the treating physician.

The day of travel:

Make sure you use comfortable, loose-fitting clothing that is not tight around the waist.

Avoid using high-heeled shoes to prevent swollen feet.

Make sure you take liquids throughout the day so your bloodstream can become thinner, forcing you to get up and walk to the bathroom during the flight.

Avoid postures that obstruct blood flow back from your legs such as sitting with your legs bent or crossed.

Make sure that you walk frequently along the aisle at least every 3-4 hours.

If your legs are prone to swelling, elastic socks are recommended (avoid bandages, since it is difficult to measure the pressure being applied). Socks pulled up to your knees should have a tension between 15 to 20 mm and may be purchased at any pharmacy.

Stretching exercises are recommended, such as standing on your heels or toes.

If you have suffered previously from leg thrombosis, ask your doctor if you should take any additional precautions.

And remember, if you want to enjoy your stay after a long trip, make sure you follow these simple tips and avoid unnecessary pain. Taking shorter flights or connecting flights might well be worth your while.

Illegal Practices in Australia The Sydney Morning Herald reported that the New South Wales Medical Board is trying to crack down on medical tourism companies that are performing illegal practices of paying Malaysian and Thai doctors to come to Australia to provide consultations in hotels. Thus far, the only report of such events comes against Gorgeous Getaways which advertised on its website for free consultations in Australia with overseas doctors before surgery. The Medical Practice Act, Section 105, states that “It is an offense for a person who is not a registered medical practitioner to advertise or hold themselves out to be qualified…or to give surgical advice and service.” Therefore the surgeons flying to Australia and giving consultations to patients in New South Wales are in violation of the Medical Practice Act. The NSW Medical Board threatened action against Gorgeous Getaways, but they are still promoting the service. What is the experience of some of these medical tourism companies? In some cases, none. One company is run by a former carpet cleaner, and many have no medical background or experience. It is very important to research the medical tourism operator and assure that you are not being misled by false promises.

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Got a Passport? Get a smile! By EUGENIO J. BRENES, DDS & JAVIER QUIROS, DDS

here is currently a trend in the United States, where more and more Americans travel abroad for various medical and dental procedures offered by specialists around the globe. It is not a secret that a great number of Americans are not covered by dental insurance. For those who have dental insurance, their insurance generally does not cover cosmetic or aesthetic procedures, such as veneers, crowns, bleaching or dental implants. Even though these procedures offer superior treatment results, and provide patients with an improvement in their quality of life, insurance companies do not consider them basic dental treatments, and usually reject any claims filed by the patients. The only solution for some patients is to pay out of pocket for dental treatments at typically very high prices. The underlying factors creating the high cost of dental procedures in the U.S. include the high cost of materials that are used, unusually high cost of malpractice insurance, overpriced labor and the unaffordable cost of living in the U.S. Additionally, the number of years of training 34

DECEMBER 2007

that are required by the dental doctors providing these types of procedures is very high in order to provide their patients with predictable and successful treatments. People often may ask themselves why travel abroad? Which procedures can be done in foreign countries? How does one choose the right Doctor? How does one contact these professionals? In order to answer these questions, it is important to understand that a very important factor that drives people to travel outside the U.S. for dental treatment is finances. As emphasized, dental treatments in the U.S. can be extremely expensive, leaving most procedures out of reach for a great percentage of the population. As a result, Americans are traveling abroad seeking more affordable dental care. One of the countries that is fast becoming a Mecca for dental treatments is Costa Rica. Costa Rica has a large number of dental specialists, many of whom are trained in the U.S. at the highest levels and standards, and they provide dental treatment at a fraction of the cost in the U.S.

In my case, I had five years of dental training in Costa Rica, followed by four years of post graduate training and residency in aesthetics, restorative, and prosthodontics procedures at Loma Linda University, in California. Dr Quiros on the other hand, studied in Costa Rica for six years and continued his post graduate education in Dallas, Texas with a Fellowship of two years in Esthetic Dentistry, and a three year Residency in Advanced Prosthodontics. We both speak perfect English and perform the same treatments that are performed in the U.S. We both decided to return to our country and open our practice using all the knowledge and experience we gained, training at some of the top ranked dental schools in the U.S., to help the people in our country. One may wonder how U.S. trained specialists in Costa Rica can charge a third of what a U.S. based specialist will charge. There are a number of reasons for this. First, Costa Rica has a lower cost of labor and fees charged by dental labs (labs that custom make crowns, veneers, dentures, etc.). Costa Rican dental labs provide excellent quality of work

and some of the biggest American commercial dental labs outsource a great percentage of their U.S. business to Costa Rica. That means that a lot of crowns, veneers, and partial dentures, and all sort of dental work used by U.S. doctors in the United States, are manufactured in Costa Rica. Another factor is that the cost of living in Costa Rica is almost one third of what it is in the U.S. When one considers states such as California and Florida, Costa Rica is about one fourth less expensive, and this shows in the final price of the dental treatments.

goals, and expectations regarding your smile. Dental treatments that are done and supervised by a Prosthodontist can go from aesthetic concerns, crooked teeth, missing teeth due to different factors such as accidents, congenital oral defects, or other reasons, to helping you improve your quality of life by having a healthy, functional and beautiful smile.

Why choose Costa Rica and not another country? Besides having world class professionals and state of the art hospitals and clinics, Costa Rica has become one of the most sought after places for travel. Costa Rica It is important to do your research has luscious jungles, breathtaking beaches, amazing volcanoes and because the Prosthodontist is trained as everything in between. Visitors to “a quarterback of dental treatments.” He is Costa Rica have increased form 784,610, in 1995 to 1,452,926 in the best person to coordinate a treatment 2004. Along with the increase in plan, he knows about the results and the number of tourists, is the development of tourist outcomes of the different dental infrastructure. Another factor is the specialties and their procedures... social and economic stability of the country. Since abolishing its army over fifty years ago, Costa Rica has become one of the most developed countries in Latin America, having redirected previously budgeted military funds to furthering education. It is Another question commonly asked is which dental treatments can be known for its high rates of literacy and the warmth of its people and their done in foreign countries. Well, this is a question that is closely related with love for their country. As an independent country, Costa Rica has excellent the question of how to choose the right dentist. In the U.S., the association economic and diplomatic relationships with the U.S. Costa Rica is very that regulates dentistry is the American Dental Association (www.ADA.org). American friendly, and is a preferred country for American expatriates, It recognizes Prosthodontics as the only specialty in dentistry that deals with over 8,000 Americans permanently living in Costa Rica, making it the with aesthetics, function, and oral rehabilitations. In other words, the name country with the most U.S. citizens per capita in Latin America. of the specialty that deals in full detail with the appearance of your smile is called Prosthodontics. And finally, you might wonder how to get in contact with the right professionals. A good way of getting appointments set and procedures How do I know if my dentist is a Prosthodontist? The easiest way is done are by solid institutions, and always look for the right accreditations asking them directly, or by doing a little research on your own. The of such establishments. Look to the top hospitals first for their specialized American Association that certifies dentists with the proper training to dental departments to find the right professional for you. become a Prosthodontist is called the American College of Prosthodontics (www.Prosthodontics.org). On their webpage, you can find Prosthodontists in specific areas, both in the U.S. and other countries. Eugenio J. Brenes, DDS, Advanced Prosthodontics, certified at Loma Linda University, School of Dentistry, Loma Linda, CA., It is important to do your research because the Prosthodontist is trained and Javier Quiros, D.D.S, Advanced Prosthodontics, certified at as “a quarterback of dental treatments.” He is the best person to coordinate Baylor College of Dentistry, Dallas, TX are both Prosthodontists a treatment plan, he knows about the results and outcomes of the different at Hospital Clinica Biblica, San Jose, Costa Rica. dental specialties and their procedures such as periodontics, endodontics, orthodontics, oral surgery, and he can guide you in order to achieve your Some people wonder about the quality of the materials used in dental clinics in Costa Rica. Most of the materials used in Costa Rica are manufactured by multinational corporations that sell the same products in the U.S. These manufacturers distribute their products worldwide, but they have variable pricing in order to be competitive in different markets. Our clinics in Costa Rica use state of the art equipment and the highest quality in all of our clinical and laboratory materials. This gives us the certainty that the final results and treatments are at the same level as those performed in the best clinics anywhere in the world.

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Processing the Patient

CLINICA BIBLICA STYLE G We interviewed Brad Cook, Managing Director of the International Department of Clinica Biblica Hospital in Costa Rica to find out just what it is like to be a patient looking for medical treatment at their hospital and what a patient might expect from beginning to end.

By RENÉE-MARIE STEPHANO

DECEMBER 2007

enerally most patients looking for healthcare overseas start their search on the Internet. Milling through the web pages, some in English, some not, performing your own due diligence can be very wearing. In an effort to make this process easier, Clinica Biblica Hospital established an international patient department specifically dedicated to making life a little easier for the foreign patient. We interviewed Brad Cook, Managing Director of this Department to learn a little more about what their role is in the lives of their patients.

“We receive a call or Web form from the prospective patient and based on the information received, we then put together a price estimate for the requested procedure together with a brief description of the procedure, details concerning recommended arrival date, length of the procedure, inpatient or outpatient, and how many days are

recommended for recovery,” says Cook. “We also request additional information such as photos, medical records and require the patient to complete a detailed medical questionnaire.” Cook went on to explain, “The scheduling process includes a pre-operative consultation with the physician and the procedure itself, with follow-up care, if required.” Generally, scheduling of these appointments may be made on the day the patient first contacts the international department, depending on the availability of medical records and the particular health conditions of the patient. Wait times are almost non-existent at Clinica Biblica as they run a tight ship. “It is not unheard of for a patient to contact us on Monday and schedule his or her surgery for Thursday,” says Cook. However, most patients have a long list of questions and are usually not so quick to commit to the surgery on such short notice. They

typically have questions they would like answered by the physicians usually relating to the doctor’s qualifications, questions about the hospital, the type of pre-op tests involved, accommodation issues, and what the price estimate involves. “We are seeing patients taking a much more proactive approach to their medical care and performing their due diligence since they are traveling out of their comfort zone,” says Cook. “Patients traveling abroad for healthcare are in some cases asking more questions and doing more research on their physicians than they would actually do at hospitals in the U.S. and this is a very good thing, as they are taking control of their healthcare,” he added Over the course of several days many emails and calls are exchanged between the international department staff of Clinica Biblica in order to make the patient feel completely at ease about the decision. The staff generally will make arrangements for the doctor to speak with the patient by phone or by web cam from their office.

medical procedure and the health condition of the patient,” states Cook. “We recommend the following general guidelines which may be adjusted according to each patient health situation. Cosmetic surgery may take 7-14 days, Bariatric surgery 5-7 days, Orthopedics 7-10 days, dental procedures require usually no more than 24 hours,” he added. Does this mean you can get a new smile in less than two days? “Definitely,” says Cook.

Once the decision to travel to Costa Rica for the surgery has been made, the staff sends the patient a formal itinerary confirming all medical services. If the patient desires, staff will meet the patient and any companions at the airport and assist them through Customs. From there, air-conditioned vans driven by bilingual guides deliver the patient to their prearranged hotel accommodations. “On the day of the pre-operative consultation we arrange for patient pick-up and transfer to the hospital and personally assist the patient every step of the way,” affirms Cook. A staff member escorts the patient through pre-operative tests and doctor’s appointments, assisting with translation if required. The international staff generally matches a prospective patient with an English speaking physician, unless, of course, the patient requests a specific surgeon based upon referral, specific experience of qualifications for a certain procedure, or if the patient is bilingual. Costa Rica receives a large number of Spanish speaking patients from the United States. On the day of the surgery the patient is picked up and transported to the hospital where our staff meets the patient for admission. After the surgery, staff periodically visit the patient to assure all needs are being met and will then transport the patient to a hotel with a bilingual registered nurse escort. This registered nurse will then continue to visit the patient periodically over the next few days to assist with bandages or injections if required, administer medications, and to monitor the patient’s recovery process. A day or so before the intended departure, the patient is escorted to the hospital for final evaluation before returning home. A complete medical examination is performed to assure the patient is ready to travel. Then, on the day of departure, the patient is transported to the airport where the staff assists with procuring a wheel chair, if needed.

Brad Cook, is founder and director of Medical Tours Costa Rica and Segrupex S.A. Brad has more than 13 years experience coordinating medical services for international patients at Clinica Biblica Hospital in Costa Rica where his company runs the International Department for the hospital. Under his direction, the International Department has been instrumental in forging relationships with insurance companies throughout the world positioning Clinica Biblica Hospital as a premier destination for international travelers. Mr. Cook is frequently contacted by local hospitals and international billing

Cook says that even after the patient returns home, their staff continues with a close follow-up to make sure the patient is recovering according to plan.

agencies for assistance and services in regards to international

The international staff can also schedule tourism events for friends and family traveling with the patient if requested. “Arrangements and transportation can be provided to visit some of Costa Rica’s exotic attractions,” says Cook, “but generally this is done before the surgery.”

Mr. Cook launched the Medical Tourism initiative for Clinica

Cook informs patients that their surgery procedure can be scheduled very quickly. Once the decision is made, and unless there are extenuating circumstances such as the need for extensive medical records or X-rays, the surgery can usually be scheduled in a matter of days.

of the premiere destinations in the region for medical services.

All surgery procedures require a medical consultation where the patient is present with the surgeon before the actual procedure is done. For very delicate procedures such as open heart surgery, a long distance consultation with the surgeon may be requested. What are the recovery times suggested by the international staff? “It all depends on the

insurance billing.

Biblica Hospital orchestrating an aggressive service oriented model that has helped position Clinica Biblica Hospital as one

His marketing efforts have been successful in attracting local and international media outlets for segments and stories regarding Medical Tourism. He has also been proactive contracting with and hosting medical tourism companies from around the world.

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Costa Rica B i g Tr i p ,

Little Country By RENĂ&#x2030;E-MARIE STEPHANO

n the heart of Central America, bridging the gap between the Pacific and Caribbean Seas, Costa Rica provides an ecotourism for anyone, just a two and a half hour flight from Miami. From die hard backpackers to patients coming for facelifts and lap band procedures, Ticos (as the locals are called) have their thumb on the pulse of attracting Americans. People can get a taste of their days of adventure without going too far or spending too much money. The only problem you might have in Costa Rica is that you might strain yourself trying to do it all before tucking yourself into a hospital bed for a medical procedure. To get the best bang for your buck, you should consider for your trip a series of a few shorter diversions from the jungle covered volcanoes to the cactus hills of Guanacaste. The important thing to remember is that you can take the perfect trip to Costa Rica in about a week and then allow yourself ample time to recover from whatever procedure you might be having. Whatâ&#x20AC;&#x2122;s more, with the relatively small size of Costa Rica, the rest of your family can continue to explore while you are recovering. The President of the Medical Tourism Association, Jonathan Edelheit and I planned a trip to visit some of the hospitals in Costa Rica for our research and for this issue of the magazine. We wanted something different, something exciting during our trip to Costa Rica. We wanted an adventure trip since this was my first time to the ecotourism paradise, and that is just what we did. We stayed at two eco-friendly lodges with toucans, monkeys and hummingbirds. Downtown Reality We arranged for a several day tour of Hospital Clinica Biblica through their special international patient department. Managers Brad Cook and Bill Cook, and their staff took care of all the

DECEMBER 2007

Decades ago, Costa Rica was a pioneer in ecotourism. Now it is also a pioneer in medical tourism. Oh how far it has come.

Okay, so they did tell us to travel light for the one night stay and I thought that was just to prevent you from bringing your valuables and extra your necessities. What I failed to realize was that our luggage was going to be dry bagged and then rafted down by another brave soul with two paddles in an oversized raft. Fitted up in life preservers, helmets and a paddle, we were instructed to get in the Pacuare River and learn how to swim towards the raft in the event we were tossed out. This was the adventure we were looking for! The raft ride into the Pacuare Lodge was not that intense, only Class 3 and 4 Rapids I was told. Not bad at all. With six people and a guide, the raft was comfortable and the company was terrific with Tito also as our river guide, pointing out natural flora and fauna, wildlife and waterfalls, when spotted. The ice cold water quickly dissipated with the heat of the sun and I found myself curiously comfortable in my Florida-thin skin. We stopped for lunch on the river bank, which was prepared by the rafting guides as well. They raft and they prepare food? You cannot ask for more than that! We were warned about the frequent rains in the rainforest, where the river was guiding us, and fortunately we just barely missed the downpour that came through just after we arrived at the Pacuare Lodge (www.pacuarelodge.com).

arrangements. Getting off the plane and going through customs, we were lured into excitement by the large flat screens depicting exotic photographs of volcanoes, toucans and poison dart frogs. Soon thereafter, we were greeted by a nice woman with our names on a sign showing us where to get our baggage and where we should go to meet Luis, of Tropical Expeditions (www.tropicalexpeditions.com). Luis took us on a driving tour of downtown San Jose, the capital city of Costa Rica, pointing out some of the notable monuments, art centers, museums and of course, the international icons of McDonalds and Taco Bell. The majority of the population speaks Spanish, but then again, living only one and a half hours from Miami, I felt right at home. We finally ended at our destination, the Holiday Inn â&#x20AC;&#x201C; Aurora, owned by the Intercontinental Group. This had to be one of the nicest Holiday Inns I had ever stayed in. We met Bill and Brad Cook for dinner in the restaurant of the hotel to discuss our upcoming tour of their hospital and also our prearranged ecotour. The upscale dining and piano accompaniment was a relaxing way to end our first day in this exotic country. The next few days were spent touring the city and the hospital facilities.

The Lodge itself is environmentally responsible inasmuch as there is no electricity, no lights and you do not flush toilet paper. We were greeted by the staff and led to our bungalows by our river tour guides. Tito carried our luggage to our new home away from home and told us dinner was to be served in about an hour. This was like no other bungalow I had stayed in. The place was huge, private and definitely romantic. Minimalist but large accommodations featured a large main bedroom with a small step down hallway and inspired bathroom with rainforest water showers. Our friends were staying in the honeymoon suite, which was worth the long hike to view its privacy, its own swimming pool, magnificent view and outside porch with hammocks. Dinner consisted of five star dining, tables located in the main lodge area where you can sit with anyone staying at the lodge. We ended up sharing our meals with the same people on our raft. After all, we were devoted to saving each others lives out there on the rapids. Interestingly, Tito was also our server and the raft guides were the chefs of our meal. We were able to relax and kickback with backgammon and cocktails under the candle chandeliers until dark. I even indulged myself in an in-bungalow massage.

Rafting the Pacuare River Following our desire to be adventurous, the Cooks arranged an overnight rafting tour through Tropical expeditions and the Pacuare Lodge. Class four to five rapids we were toldâ&#x20AC;Śthe adventure was on. We were picked up by shuttle that made several stops at other hotels to pick up some Americans and some British folk, one couple on their honeymoon, a father and son seeking bonding time and another couple on a one month vacation through Central America. Clearly, we had very little concern that our Spanish was not up to par. Our tour guide was a lively fellow named Tito, employed by the Pacuare Lodge, our ultimate destination. During the one and a half hour shuttle tour through some of the most exhilarating and picturesque countryside, Tito gave us a detailed history of Costa Rica, its people, towns, folk lure, architecture and personal stories about his experience working in the coffee fields. Surely, he must have been handpicked for our tour. His charisma and sense of humor made the long journey at such an early hour very invigorating. We made a stop for breakfast, where we were served local foods at a restaurant located at the top of a hill overlooking the valley. It was a nice break and great photo taking opportunity, not to mention the last toilet break for the whole rafting trip, we were told.

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MEDICAL TOURISM The next day, we all took a wonderful, yet intimidating hike up the mountain terrain to get to the start of the zip-line tour. Capped in hardhats and lining harnesses, we zipped from one tree to another, overlooking the rainforest and all of the beauty Costa Rica has to offer. When you take a zip-line tour, you’re basically as high as the clouds. You go along the top part of the rain forest, also known as a canopy. It is terrifying, yet incredible. There’s only a wire hanging between two trees and you are really high. The natural American in me leads me to think, “Who inspected these things?” Our guide Alex, also a rafting guide assured me that I was not the first person to stop myself just a little bit short of the end so I had to sort of monkey-crawl to finish. Once landed back at the lodge, we prepared ourselves for the big day. Today we would raft on Class 4 and Class 5 rapids. Would we flow through this one like we did the day before? Tito retaught the method of “getting down” in the raft during certain rapid areas, presumably so we would not go flying out of the raft. No problem there, as I was more than willing to be the first down in the raft. Surprisingly, the words of my mentor Tito rang in my ear before each rapid, “okay good position now…get down get down!” This was a piece of cake. After each pass through conceivably deadly rapids, Tito encouraged us with the tapping of our paddles in the air yelling “Pura Vida!” I had developed a strange and deep confidence in this person who had taught me to raft, housed me, fed me and directed me each step of the way. Overall, we only had one person fall out of the raft during the whole trip. He fell over twice, but….we did not hold that against him. After spending the whole day on the water fighting the rapids, we were ready to hit land. The trip overall was unforgettable. After two days of intense physical workout, we decided to spend a couple of days at a place called Peace Lodge. Who could have a bad time at a place called the “Peace Lodge?” The drive to get there was picturesque with views of the coffee fields and volcano rainforest. When we arrived it was raining, but it did not taint the exotic flair of the Peace Lodge with its rooms named after butterflies. The Peace Lodge has established a fantastic series of walkways, hiking paths and stairs that weave you in and around the volcano area to expose three of the most powerful waterfalls I have ever seen this close up. It would seem that the Peace Lodge must have its sufficient share of guests since they did not respond to our request for photos for the Magazine, however, we have included some of our own. Some of the unique charm of the peace lodge is the privacy and the unique care taken to create the rooms, which are very large. Each room has a fireplace, as the rainforest and the elevation makes for chilly evenings. The large bathrooms include a tub with a waterfall backdrop and even a natural rainfall shower that seems to emanate from the wall and ceiling. The stained glass separating from the bathroom and the main bedroom emanates romanticism and who does not appreciate a balcony with a hot tub and its own hummingbird feeder? Although I must say, watch your eyes, those hummingbirds mean business. Costa Rica is truly an amazing and beautiful country. It’s people are friendly, it’s medical facilities state of the art, and it gives medical tourists a wide range of activities to choose from. Even if you don’t choose an eco-adventure, it is still a beautiful country to go to.

TAIWAN TRIAD Under a new program, the Grand Hotel, the Taiwan Hospital Association and the Asia-Pacific Society of Travel Medicine (ASTM) out of Taipei has gotten together for the first time to promote medical tourism in Taiwan. Patients will spend four days and three nights at Taipei’s Grand Hotel visiting local tourist spots and get a three hour health checkup, anti-oxidation treatment, skin care and a magnetic wave face lift. At a news conference, ASTM Director Shieh Ying-hua stated that Taiwan has an excellent chance of developing medical tourism due to its superior medical care even despite its late start in this industry.

DECEMBER 2007

MEDICAL TOURISM

Understanding the

American Healthcare System Understanding the American Health Care System is a four part series with a focus on which aspects of the American Health Care System will readily access overseas medical care.

Part I: The Fully Insured American Patient ~ Dispelling the Myth By JONATHAN EDELHEIT

he most common question asked when you explain the concept of medical tourism is, “What kinds of Americans are going to get onto a plane to travel to a foreign country for healthcare?” Surprisingly, most overseas hospitals have very little idea about what segment of the population their future health care clients come from. Therefore, hospitals seeking to attract medical tourists to their country have no idea who their audience or core market is, providing for futile marketing efforts. If international hospitals are to succeed in attracting Americans they first need to succeed in narrowing their marketing efforts to those where they will generate the greatest returns. Just as many hospitals have been misled into believing Medicare will soon be approving overseas medical treatment, still more hospitals are misled about the types of American patients that will be traveling overseas for health care. Many international hospitals and medical tourism companies are thrilled about the possibility of fully insured health carriers such as Blue Cross Blue Shield, Aetna, CIGNA, Humana, United HealthCare and other insurance carriers affording their fully insured members the opportunity to go overseas for health care rather than receiving care domestically in the United States. In fact, many hospitals have been told that the fully insured American health insurance carriers are about to approve medical tourism, opening the flood gates to swarms of Americans going overseas. Here is a reality check. It’s not going to happen, but if it does, it is not going to happen anytime soon. If an American can go to their local U.S. hospital for the same cost that they can go to an overseas hospital, why would the American go overseas for surgery? Especially if by going overseas the American would incur travel costs, such as airfare, hotel, meals, etc., and having

DECEMBER 2007

to spend a good amount of time far away from home. Many people in the industry are keeping the myth alive that these Americans will magically appear abroad. This is simply not true. And then you hear another rumor. Okay, maybe regular fully insured members won’t go, but what about Americans on high deductible plans? Even if someone has a $10,000 deductible on their U.S. health insurance policy, for most procedures worth going overseas, the cost for the American patient could be the same or comparable to the total costs for having the procedure performed here in the US. For example, if a heart procedure is almost 80% less overseas at a cost of about $9,000, if you

factor in medical expenses, plus the cost of travel for you and a companion or family, hotel and/or recovery center, meals and entertainment, lost wages, possibly child care or missed opportunity in some cases, there may be no savings for the American patient to going overseas, and instead higher costs. So, why would an American with a fully insured health policy decide to go overseas for treatment versus getting it done domestically here in the U.S.? Certainly the average patient has very little interest in saving the insurance carrier any money after the patient has paid the ridiculously high and everincreasing insurance premiums. Moreover, the innate concerns about safety, quality of care and inconvenience are not going to be easily dispelled when the fully insured patient could just as easily be treated domestically for similar out of pocket costs to that patient. Then why would a fully insured patient go overseas for care? Here are two possible reasons. First, the fully insured carrier is going to give incentives to an insured, such as waiving a deductible or coinsurance, and in some cases, picking up travel expenses. Some may go so far as to give cash incentives. If an insured had a $5,000 deductible or a Health Savings Account in the United States, but no deductible overseas, all travel expenses paid, plus a cash incentive of several thousands of dollars, American patients would blink, and clearly would look into the option of getting treatment overseas. Currently, no U.S. health insurance carrier is offering cash incentives for an insured to go overseas. Many health insurers are still focusing on the evaluation of liability and determination of risk involved in sending patients overseas, and especially the risk involved in providing incentives to do so. The second reason a fully insured patient would go overseas would be quality of care. At this time, it is very difficult to determine and compare the quality of care overseas. Several of the largest health insurance carriers in the U.S. have said they are not comfortable with being able to evaluate and determinate the level of quality of care. Many of the fully insured carriers feel there needs to be an extremely high standard for overseas hospitals.

Some have off the record even stated that they feel JCI, the most well-known and sought after accreditation system for the larger overseas hospitals isnâ&#x20AC;&#x2122;t good enough for them and they wish to see a higher standard, however they just donâ&#x20AC;&#x2122;t know what that is right now. And until they know what they want and what they are comfortable with, these U.S. insurers are not going to move forward with sending Americans overseas. A real problem with determining the quality of medical care overseas, especially for fully insured health carriers, but more particularly for patients, is obtaining full disclosure of accurate and detailed information on quality of care and outcomes. As long as hospitals hold this information tight to their chest, American companies will be hesitant to look overseas for health care. Those hospitals willing to progressively move towards transparency, allowing full disclosure of quality of care and outcome data will be more readily embraced by the U.S. health care system. In conclusion, it is extremely important for international hospitals seeking to expand their facilities in the area of medical tourism to realize who their target audience is. Before spending thousands of marketing dollars to attract the insurance carriers and fully insured patients, international hospitals should focus on globalizing their data to allow for full disclosure of quality of care and outcome data. Hospitals need to understand that fully insured carriers will not be sending many patients overseas until quality of care can be confirmed in a way they are comfortable with.

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MEDICAL TOURISM

Engaging Your Family Physician in

Medical Travel By THOMAS C. JOHNSRUD, Medical Travel Consultant, Parkway Hospital

hange is the only constant. And because it is often accompanied by stressful and sometimes difficult adjustments and decisions, we often go to greater lengths to resist rather than embrace change. So how does one make change a little easier? Oftentimes having choices and options makes the transition bearable, and even rewarding. The challenges we face in health care today are certainly no exception. As leaders and employers address the need to manage the rising costs of care in the U.S., consumers have more options than ever. From multiple offerings of plan options, Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) to seeking medical treatment abroad, both insured and uninsured health care consumers now need to research how to spend their own resources. One such option is medical tourism, or as the qualityconscious refer to it, medical travel – traveling abroad expressly for high quality medical care at a lower cost. Traveling to another country for medical care, however, is not without some significant challenges of its own. One of particular importance is exactly how to involve your local physician and ensure that they will have access to the necessary resources when you return home. Medical travel will be more successful with the support of physicians and ancillary providers once back in the United States. A critical component in the success of one’s treatment is the availability and coordination of followup care with the patient’s domestic physician. The consensus among many U.S. physicians is that this is fast becoming a reality of today’s health care market and more and more patients will have choices when it comes to deciding where to seek care – especially for more complex, high-cost treatments and procedures. There are several recommendations you can follow to help smooth out the transition from treatment abroad to after-care at home. First, and most important, locate a provider and physician that support and encourage collaboration with the primary physician in the U.S. and vice versa. This should be viewed as a partnership between your doctor at home and the clinician abroad. It’s not enough to simply discuss the plan of treatment with your attending physician at home, but encourage them and the destination specialist to communicate. Effective communication between all individuals, services, programs and organizations will likely improve the quality of care and level of functioning. According to the March 31, 2007 sentinel event statistics published by The Joint 44

DECEMBER 2007

Locate a provider and physician that support and encourage collaboration with the primary physician in the U.S., and vice versa

Commission, communication was cited as the root cause of the event in nearly 70% of the reported cases. Also, share ALL of your medical history, medications, allergies and any other relevant indications that you and your physician deem important to share. If you are working through a medical travel agent, they should be able to facilitate the transfer of appropriate medical records including current x-rays, diagnostics, etc. In fact, some agents have access to webbased repositories that enable medical records and documentation to be easily shared between authorized providers. Contrary to the more familiar referral process, this is a more complex partnership that requires all involved physicians to work together for the patient to receive the best and safest care. The total plan of care also should include ensuring that the potential resources needed after the initial treatments are available upon your return. Although the acute portion of the recovery may occur at the treatment destination, medical travelers may require the need for several weeks of rehabilitation at home post-treatment. Make sure you and both physicians are aware of what these requirements are before completing your travel plans. The collaborative link between the physicians facilitates a much more comprehensive treatment plan to follow you through your recovery and helps to ensure a better outcome. Medical treatment overseas serves as a complement to, not a replacement for, health care in the U.S.

JOIN THE MEDICAL TOURISM ASSOCIATION Info@MedicalTravelAuthority.com

MEDICAL TOURISM

Psychological barriers to understanding the market for

Medical Tourism By JOHN F.P. BRIDGES, Ph.D.

n recent years medical tourism has become somewhat of a buzzword in the USA – it might even be worth calling it a bubble, given both its links and likeness to the dot-com investment bubble. Although one could view this evolving industry as a manifestation of globalization and more liberal trade common in all sectors of the economy, some have attempted to classify this as a unique phenomenon – often considering it a “disruptive” technology that could revolutionize health care, both here and abroad. Others paint a more sinister picture, claiming that healthcare tourists are “refugees” escaping the high prices of the U.S., displaced from the comfort and quality of American health care systems in order to afford care (with the natural extension that they are sacrificing both comfort and quality by doing so). In reality, the U.S. plays a minor role in the international market for healthcare tourism. The American market is dominated by the Asian market, and both Asia and the Americas are minuscule compared to the size of the European market. This disparity is in part 46

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This disparity is in part due to the misconceived definition of “health tourist,” which focuses on national borders rather than state borders.

due to the misconceived definition of “health tourist,” which focuses on national borders rather than state borders. If we focused on the E.U. and just looked at its collective exterior border, much of the internal trade amongst its member countries would be omitted. Similarly, if the focus in the U.S. were to shift to patients crossing state borders for healthcare, the numbers would be much higher. In fact, Americans cross state borders for healthcare every day in search of better quality of care, better physicians, greater convenience of scheduling and even better pricing. What is surprising about the American market is that most of the current discussions focus on exporting patients to other nations, rather than the traditional market of attracting wealthy foreigners to our elite hospitals systems. It is clear, however, that the debate on health tourism is being manipulated for political means (e.g. healthcare reform in the USA is hard to sell if you focus on the positive elements) and such manipulation is being made possible by a lack of data on health care

tourism (both coming and going). For example, health care statistics in the USA, such as the percentage of GDP devoted to healthcare, are distorted by foreigners who seek health care – quite often at any cost – but who are just added to the statistics for the domestic market.

they physically are ready. By travelling abroad, patients are spending a dedicated amount of time for recovery – often by combining holiday time with their health care - in order to achieve a better state of wellness. The ability to combine holiday with health care is obviously a lure for patients to go overseas.

If we are going to truly understand healthcare tourism in America, then there are at least three barriers that we have to overcome. Unlike most trade barriers, these barriers are in many respects psychological ones or relate to historical biases or have been generated by misinformed media coverage of the issue. Like many trade issues, there are vested interests looking at the market for medical tourism either as an opportunity, (particularly those that want a quick buck out of exploiting this market), or a threat to the status quo. To date, there has not been a rigorous discussion concerning the potential gains from trade associated with the internationalization of health care services. The first barrier to understanding health tourism is realizing that it is not dominated by flows of patients from the developed to the developing world per se. Many health care tourists come from developing countries that lack specialist care or infrastructure. For example, many health care tourists in Singapore come from Indonesia. In fact, when one assesses international trends, two assertions can be made. Generally, patients travel to countries with relative similar levels of development and patients normally seek care in their own region. Of course, many exceptions can be found to these rules, but it is important to note them as exceptions. The second barrier to understanding the market relates to the push and pull of patients. In the U.S. we need to stop focusing on the push factors that are leading people to consider healthcare tourism and focus on mechanisms to pull patients towards our facilities. This will be difficult as the notion of push is so engrained into the American health care system. (When has your surgeon ever said, “Let’s schedule the surgery when it is best for you?”) Managed care engrained the notion of push, and pay-for-performance will do little to make care more patient-centered. In reality, many Americans choose foreign providers because they are attracted by the quality of facilities, customer service and a holistic approach to care. Finally, to understand healthcare tourism one has to realize that it is more than just travel for medical procedures, rather, it incorporates a broad range of lifestyle and wellness factors. While many hospitals in the U.S. are venturing into the realm of complementary and alternative medicine, the environment of the typical aging hospital infrastructure of the U.S. might negate some of the benefits of these therapies. An example of how medical tourism enhances wellness relates to dedicated recovery time. In the U.S., it is common for a patient to return to work or return to their day to day grind before

John FP Bridges Ph. D. ~ John is an Assistant Professor in the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health (www.jhsph.edu/dept/hpm) and a Senior Fellow at the Center for Medicine in the Public Interest (www.cmpi.org). He is an advocate for the scientific study of patient preference in the area of Pharmacoeconomics, Outcomes Research and Technology assessment and is the founding editor of a new journal titled “The Patient – Patient Centered Outcomes Research.” He is also a co-author (with Percivil Carrera) of a study titled “Globalization and Health care: Understanding health and medical tourism,” published in the Expert Revue

Pharmacoeconomics

Outcomes

Research

(2006;6(4):447-453). He can be contacted via email on jbridges@jhsph.edu.

Patient with chronic back pain given life back Canadian 48-year old Jill Misangyi left Canadian waitlists to the wind, traveling thousands of miles to eliminate sixteen years of chronic back pain. Jill returned to her work of a registered nurse just five weeks after her spinal decompression surgery abroad. She only spent $12,000 for the surgery, airfare for her and a companion, hospital stay, hotel stay and other expenses where just the procedure alone in Canada would have cost $40,000. Jill described waiting lists for back specialists of up to six months and wait times for surgery up to two years after that. “It was a wonderful experience. I got my life back. The medical team, the doctors, the nurses and everybody right down to the housekeeping staff, is just wonderful. They make you feel very warm,” says Jill regarding her Indian medical team. Jill used Healthbase, a medical tourism firm out of Boston, Massachusetts.

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MEDICAL TOURISM PART - 1

Unaffordability Ebola

It killed Manufacturing, put Software on life support and is now infecting U.S. Healthcare By MICHAEL BINA

Driven by “The Number One Concern of Adults and Businesses in the U.S.,” an insatiable and immutable ‘Unaffordability Ebola’ is attacking another compliant U.S. host: The U.S. Healthcare System.

DECEMBER 2007

ccording to experts at Harvard, Johns Hopkins and Mercer, the US System is sick; its prognosis, poor.” We’re reaching the outer limits of affordability,” said Arnold Milstein, MD, Medical Director of Pacific Business Group on Health (PBGH) and Chief Physician at Mercer Human Resource Consulting (MHRC). Milstein was addressing an international conference of providers, educators, brokers and facilitators on Global Health when he said, “We’re seeing an upward spread of the ‘Unaffordability Ebola’.” What Happens in Vegas... At the first International Medical Tourism Conference in Las Vegas this year, Milstein was one of the prominent canaries singing an early warning of a virus attacking the seemingly immune U.S. Healthcare System – (formerly known as “The Best System in the World”). The Canaries were singing at all venues in ‘Vegas, but it WON’T stay in

Vegas. The Ebola is spreading across a Flat World faster than people will admit... 500,000 U.S. Patients Abroad The National Coalition of Healthcare estimates 500,000 people left the US for treatments last year; 500,000 international patients will visit India this year infusing $2.2 Billion into its economy; 200,000 patients visited Singapore in 2005; 100,000 visited Malaysia that same year. It’s a $60 Billion Global Business that’s growing 20% a year. At a presentation titled: “Leveling the Global Healthcare Playing Field,” Harvard Medical International President and CEO, Dr Robert Crone argued: 1.) Regional Health Systems have achieved quality services at lower cost than U.S. systems; 2.) Global Standards and Benchmarks of quality are emerging; 3.) Medical Tourism is growing, and global insurers will participate. Privately, he said, “They’re going to eat our lunch.”

Bark and Bite! Dr Crone knows what’s going on. He has the credentials one would expect of a guy who’s at the top of the food chain at Harvard Medical. He’s lectured and implemented health education and delivery system programs in more countries than the average American could name, spell or find on a map! A Top Dog in global healthcare, Crone has the bedside manner of a Junk Yard Dog: both the bark and the bite hurt! ”In the Flat Medicine World, US facilities may be seriously disadvantaged; adversely impacted in the global marketplace. “Oh well,” he said smugly, “we had our Century.” Crone rattled off the maladies running rampant throughout the system today, then piled on several scary scenarios ahead. It was a foreboding message for anyone planning to access US Healthcare today, or tomorrow.. (Meaning everyone; every single American; rich, poor, healthy, sick!) Like other industries, healthcare has globalized and the new, uber competitive marketplace is introducing unimagined (some say impossible) features and benefits to consumers of healthcare: Cheap; Comparable Outcomes; Outstanding Customer Service…What’s not to like? Let’s say you’re uninsured and need a new knee? What if you needed something less invasive like your annual physical? What if you wanted a face lift; breast reduction; tummy tuck or, sex change? Since you’re responsible for the full price on these latter procedures, you’re probably going to shop around, (after you’ve self-diagnosed your problem, of course.) As you’re shopping, you’re probably trying to find other important things to look at and measure. Unfortunately, there is little accessible, comparable consumer information on cost, quality and care in the U.S.! As a result, even the most unsophisticated buyer of healthcare is drawn to the international healthcare bizarre on the internet – and a sale is made half way ‘round the earth, in the dead of night. Joe Sixpack Let’s say you’re a self insured employer – responsible for the first $50,000 or so on each employee. Would you consider recommending Old Joe from Sales to contemplate an awake, beating heart coronary artery bypass grafting at a superspeciality hospital in India - instead of at a local provider? Would you ask/beg Joe to go halfway around the world for a couple months of cancer treatments for the good of the company? Would you rewrite your plan document to take advantage of global pricing?

Would you consider Singapore as your Preferred Provider Network? And what about taxpayers? Should the U.S. Government send Medicaid patients packing? What about Medicare? Should taxpayers shell out $50,000 for grandma’s new hip when she can get one of those innovative, high tech hip resurfacing jobs for about $10,000 bucks or so in India or Thailand? How about all those new, high deductible health plans being sold by the carriers - where your best interest (maybe your only interest) is finding and buying the most cost-effective care you can afford? Would you fly 10,000 miles for a couple new crowns - plus a week on the beach - if you’d save $1,000? A TIME Magazine poll in May 2006 found that 45% of uninsured people said they would; 19% of insured people said they would, too. When asked if they could save $5000, 61% of the uninsured and 40% of insureds said they would travel 10,000 miles for an elective procedure. Hold the Mayo Imagine your Executive Physical at a Mayo vs. Maya? (Come on, guys, wouldn’t you be more inclined to actually have an annual physical – even with a colonoscopy – if it included a week on the beach with a martini and a massage for less than you’d spend for three days in Rochester, Minnesota?)

How interested would you be in traveling to another country for a routine procedure (e.g. your Executive Physical)

Medical Tourism is Hot. (Some call it: “Medical Value Travel;” others:“Consumer Driven Healthcare at its most driven level.”) Whatever YOU call it, it’s economics applied to healthcare for the first time in 50 years. Medical Value Travel has been going on in the world for a long time, but most tourism has been inbound to the Mayos and the Cleveland Clinics of the world. Since 911, however, inbound Medical Travel has all but dried up; outbound tourism is growing by leaps and bounds. Instead of Cleveland, it’s Chennai; instead of Mayo, it’s Mumbai. What’s a CEO to do? Nicolet Bank Business Pulse© is a quarterly economic and business study of CEOs, O&Os and GMs in 10 Northeastern Wisconsin counties. (Businesses from all sectors and all sizes are represented in the sample.) In January, Nicolet Bank posed several questions about Medical Tourism: 52% of the CEOs, O&Os and GMs never heard of Medical Tourism; 23% heard of it, but didn’t know much about it; 17% were somewhat familiar; 9% very familiar. The Nicolet Bank Business Pulse© also asked: “How interested would you be in traveling to another country for a routine procedure (e.g. your Executive Physical) if you knew the cost would be considerably less - and the care would be equally good?” “Nearly a third said they’d be interested,” said Dr David Wegge, president of Intellectual Marketing, LLC – the firm that conducts the studies for Nicolet Bank of Green Bay. “I don’t know how this compares to national CEO data; I suspect we’re the first to ask.” Wegge was surprised that a third of the CEOs would be interested, “especially among CEOs who probably have health insurance and fewer financial worries.” 30% were definitely not interested; 23% were probably not interested; 19% said, “It depends on the country.” (Of the countries listed, Canada was the overall preferred provider; Russia was dead last – definitely an OUT of network provider!)

less - and the care would

Nicolet Bank also asked CEOs 1.) “Would you be more interested if a medical trip were combined with a business opportunity and; 2.) Would you be more interested if it included a vacation with spouse/partner.” “The levels changed substantially,” Wegge said.*

be equally good?

It’s a Brave New World; a Small World after all.

if you knew the cost would be considerably

*Contact Wegge for detailed analysis:920 217 7738

Britons Taking Up Private Medical Plans The Financial Times reported that with the inherent wait lists and hospitals breeding “superbug” bacteria, more and more Britons are enrolling in private medical insurance policies than ever. 12% to be precise. Insurers are offering sure-sell policy plans to lure employers into offering them to their employees. The most popular plans are international plans geared towards people looking to fly abroad to the US, Europe and Canada for treatment. Companies like Allianz offer full refunds for care and in some cases, the insurer will pay to “repatriate” you back home if you have suddenly fallen ill or hurt. The costs of coverage is relatively high, with world coverage including the US and Canada averaging $8,700, to $4,000 excluding North America.

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MEDICAL TOURISM

Pay for Performance: Here today….. here tomorrow? We all recognize that there is no perfect payment system. The historical “fee for service” method does not align quality of treatment and treatment results with reimbursement ~ but rather with volume of treatment. Financial incentives have been demonstrated to change behavior. The current “Pay for Performance” method established by many insurance carriers is intended to reward providers for achieving certain performance measures for clinical quality and efficiency. So the theory is that high quality should be rewarded and that better care will lead to better outcomes. The question is…is it working? By DAN BONK Why pay for performance? Pay for performance ( P4P ), is a new trend in reimbursement that is gaining momentum in the United States. Traditional payments to hospitals and doctors were based on diagnosis ~ the government or managed care companies would pay a specific fee to doctors and hospitals based on these diagnosis, regardless of outcome, complications, patient satisfaction, or errors. Today, many large insurance companies and the federal government (CMS) are incentivizing, or paying bonuses to doctors and hospitals that follow specific guidelines set out as “quality” by these reimbursing entities. These may include using certain medications, timeliness of care, or complication rates. These guidelines are most often clinical, but some also include measures of cost effectiveness as well.

are being discussed, some of which include a reduction in base reimbursement as incentives increase. These same payors are also placing more of the burden of measurement and reporting on providers in order for them to obtain Pay for Performance incentives and thereby increasing provider administrative costs. Lower performing providers are improving the fastest, but receiving the smallest allocation of P4P returns. (JAMA October 12, 2005) Operational Efficiency

Today there are only a few system-wide implementations of the pay for performance plan and most projects are still pilots. MedVantage and The Leap Frog Group projected there will be 155 Pay for Performance programs in place this year compared to a mere 39 in 2003. The metrics are still being hotly debated by providers, payors and regulatory agencies.

Pay for Performance revenue less operational efficiency (OE) are the two factors that are directly correlated to organizational profitability. Where 80th percentile Pay for Performance with only a 10th percentile OE may net out at a level well below the national average industry profitability, this factor is critical. Pay for Performance cannot be evaluated without assessing the impact of OE. To improve profitability in future P4P environments, we need to increase quality or operational indicators while holding the other constant. But to move the curve in the future P4P environment, quality improvements will need to increase OE or vice versa.

Costs of P4P

Operational Efficiencies

Opponents of Pay for Performance argue that P4P increases administrative costs. Many private payors are piloting new P4P projects that involve penalties. Although only few penalties have been enacted, different structures

Financial Indicators

DECEMBER 2007

Operating Margin Contribution Margin

Quality Indicators Patient Satisfaction Mortality Rates Rehospitalization within 72 hours Operational Indicators Average Length of Stay Cost per Discharge FTE’s per Occupied Bed P4P already indirectly rewards Operational Efficiency by generating increased profitability due to lower costs as a percentage of charges, but what if P4P were applied to your operations? A higher than average percentage of spending on administration implicitly means that your organization is spending LESS (as a percentage of revenue) on patient care. Philanthropic organizations are already measured and rated based on their percentage of administrative cost. (www.charitynavigator.org) Source: National Center for Health Statistics

Is the US Healthcare System broken? It is no secret that employers are dropping insurance plans and cost shifting to employees. In some cases, it takes 18-30 months for coverage to take effect. What about the quality of care received in the US? It is estimated that only 55% of medical care received is actually

Percentage of Revenue Spent on Administration

Hotel

3% Retail

5% Airlines

15% Healthcare

the correct care for patients’ conditions. There is an average of 98,000 deaths per year directly related to medical errors. With 46 million Americans uninsured, and although healthcare is always on the political agendas at the national and local levels, there does not appear to be any immediate solution in sight. Needless to say, one of the greatest American myths is that we have the best healthcare system in the world. A crisis in need of P4P Healthcare’s share of the economy continues to grow and is projected to reach 19.6% BY 2016. US healthcare spending far exceeds that of other “developed” countries both in terms of per capita spending and percent of GDP. Physician Compensation and the Delivery of Quality Health Care We all recognize that there is no perfect payment system. In fact, financial incentives have been demonstrated to change behavior. The fee for service/volume system can encourage over utilization while prepayment or capitation risk models encourage wider utilization even when prevention is encouraged. Salary systems without incentives can discourage effort and innovation. Peter Lee, CEO of The Pacific Business Group on Health said, “We pay even if doctors make mistakes, run unnecessary tests and have to redo their work.” Today there is no national set of performance standards against which physicians are measured. The CMS pilot project may be the first effort announced in 2003. CMS administrator Tom Scully has criticized the current system for paying every healthcare provider “the same rate, whether they are the best or the worst” (New York Times, July 11, 2003). Under the P4P program, medical groups submit data toward a common scorecard that grades them on patient

Health Care Spending in Selected Developed Countries, 2004 Per Capita

% of GDP

$ 8,000

18%

$ 7,000

16% 14%

$6,000

$ 6,102 12%

$5,000 10% $4,000

$ 4,077 8%

$3,000 $ 2,825 $2,000

$ 2,467

$ 3,043

$ 3,120 $ 3,159

$ 3,165

$ 2,508

$ 2,094

$1,000

2% 0%

$0 Spain

8.1%

Italy

8.7%

8.1%

Sweden Germany Australia

9.1%

10.6%

9.6%

France

10.5%

Canada Switzerland USA

9.9%

11.6%

15.3%

Sources: OECD Health Data 2006, Statistics and Indicators for 30 countries, October 2006.

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MEDICAL TOURISM

satisfaction, clinical treatment, and investment in information technology. Some substantial payments are being made. In addition, on August 24 Blue Cross of California, a subsidiary of WellPoint, announced that is was rewarding 126 physician groups a total of $69 million in bonuses for performance in 2006. About a week earlier, Blue Shield of California announced that it distributed $31 million in bonus money. What do Physician Groups Fear about P4P? Getting used in a “shell game” manipulated by the payors To date there is no long term commitment to P4P by payors Measures are not geographically or socio-economically fair or reliable P4P compliance is too burdensome and expensive Public reporting can increase liability Cost controls will masquerade as quality and initiatives Physicians have embraced some P4P models over the last several years such as the one Beckman developed for physician stages of change P4P (see illustration below). REGULATORY & LEGAL ISSUES The issue of increased liability for P4P participation raises several legal and regulatory issues – yet to be resolved. These include Physician Anti-Self-Referral Law (the “Stark” law), Anti-Kickback Statute, Civil Monetary Penalties Act, Antitrust, Defamation, Malpractice and Privacy.

DECEMBER 2007

Physician Self-Referrals The Stark Law prohibits a physician from referring Medicare and Medicaid patients for designated health service to entities with which the physician (or an immediate family member) has a financial relationship. A P4P arrangement may be exempted from the Stark prohibitions by meeting one of the following exceptions: personal services exception, fair market value compensation exception, electronic items and services exception. In the hospital/physician model, a hospital may become involved in a P4P or gainsharing program by contributing funds as part of the program. If this is the case, a financial relationship with the participating physicians will be created, and the financial relationship must satisfy each element of a Stark exception. Anti-Kickback Statute The Anti-Kickback statute prohibits the solicitation of, offering of, or payment of any type of remuneration (directly or indirectly, in cash or in kind) in exchange for referrals or the arranging for the furnishing of health care that is paid for by federal health care programs. A P4P arrangement may be immune from Anti-Kickback liability if it meets one of the following Safe Harbors: investment interest, personal services and management contracts, electronic items and services. Civil Monetary Penalties Act This Act prohibits a hospital from making a payment directly or indirectly to a physician as an inducement to reduce or limit services to Medicare or Medicaid beneficiaries under the physician’s care. This is the major issue for gainsharing programs. Antitrust To avoid a price fixing charge, an arrangement should indicate financial and clinical integration.

Defamation If a report questions the quality of care administered by a physician, would the peer review privilege apply? Are the network decisions regarding credentialing and termination protected from discovery? Are patient surveys subject to discovery? Malpractice Do reported quality indicators make physicians more susceptible to malpractice claims? Will quality rankings be admissible in a malpractice lawsuit? Privacy P4P arrangement may involve the sharing of patient information, which would trigger applicable privacy laws. HIPPA concerns will need to be addressed or provider confidence will be an issue. Also, in the future, medical staff by laws, and rules and regulations need to be reviewed and possibly revised. Medical staff policies need to be reviewed and possibly revised to address a provider’s performance. Both the hospital and the medical staff should consider establishing loss control/loss mitigation strategies related to outcome data use. Is P4P Here to stay? As reported in Health Leaders News on August 1, 2006, “100 healthcare leaders from hospital, physician, supply chain and policy sectors were asked to rank the top 10 most important issues that are transforming US healthcare. Pay-forperformance programs were ranked #1.” Paul Danello, former counsel DHHS, OIG wrote recently, “This is the beginning of the third wave of reimbursement, not some fad.” Mark McClellan, 2005 in “Quality, Safety, and Transparency: A Rising Tide Floats all Boats” wrote, “During the next 5 to 10 years, P4P could account for 20% to 30% of what federal government pays providers.” While Leslie Norwalk, CMS wrote : “The Premier Hospital Demonstration is showing that even limited additional payments, focused on supporting evidence-based quality measures, can drive across-the-board: improvements in quality, fewer complications and reduced costs.” Another CMS leader was overheard comparing the CMS P4P pilot to the study of a new drug. His analogy compared P4P to a new drug, and our current payment mechanism to the placebo. His analogy was that P4P was curing patients while the placebo group was remaining ill. He joked that possibly we should call off the study, throw away the placebo, and “cure everyone” by implementing P4P! Overall, it looks like Pay for Performance has the right idea to at least improving the quality of care for patients. Although the providers find the program to be costly and unfair, it would appear that at least the patients are reaping the benefits of a better quality of care.

Dan Bonk is the Executive Vice-President, Central Region of Aurora Healthcare, a successful senior healthcare leader for over 25 years. He is also an Advisory Board Member of the Medical Tourism Association.

MEDICAL TOURISM

What is Self-funded Healthcare

& How does Medical Tourism fit into it? By JONATHAN EDELHEIT

mazingly many overseas hospitals don’t know what self funded health care is (sometimes referred to as Self Funding). Every hospital should, because self funded healthcare is one of the few ways for hospitals to tap into the patient pool for Americans that already have health insurance coverage, but may choose to go overseas for healthcare rather than receive it domestically in the U.S. Understanding how Self Funded Health Care fits into Medical Tourism is a key factor in the growth of this industry.

Stop Loss or Reinsurance is designed to limit the employer’s risk of self funding their healthcare and limits the losses for medical claims to a specified amount, to ensure that large, or unanticipated claims, do not upset the financial integrity of the self-funded plan. The level of risk an employer takes on with self funding and the point at which a reinsurance or stop loss insurance kicks in is in direct relation to the employer’s size, nature of their business, past medical claims experience and tolerance for risk.

U.S. Employers juggling the high costs of healthcare are always looking for solutions, flexibility on benefit coverage, and ways to reduce the cost of their healthcare. Partial Self Funding/Self Insurance with Stop Loss Coverage is an attractive alternative to employers utilizing a fully insured plan such as BCBS, CIGNA, AETNA, Humana or United HealthCare.

Normally, in self funded arrangements, a Third party administrator (TPA) administers the plan. A TPA performs the same functions that a fully insured carrier would. A TPA’s responsibility includes maintaining eligibility, customer service, managing a network of contracted providers, adjudicating and paying claims, managing and negotiating claims, preparing claim reports, plus arranging for managed care services such as network access and case management.

What is a Self-Funded / Self-Insured Plan? A partially self-insured, or self-funded plan, is one in which the employer assumes a portion of the financial risk in providing health care benefits to it’s employees. The employer chooses a plan of benefits, which may be similar to or identical to the employer’s current fully insured plan. Rather than obtain medical coverage from an insurance carrier (such as BCBS or Aetna), the employer elects to fund the risk of medical claims up to a certain level where a Reinsurance or Stop Loss Insurance carrier is brought in. For larger employers, no reinsurance or stop loss insurance is brought in and the employer is fully 100% at risk for all medical claims. 54

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Self Funding – A Comparison to Fully Insured Plans Everything that is provided in a fully insured health plan is duplicated in the self funded health plan. (Everything that the fully insured carrier offers in a fully insured plan, is offered in the self funded plan – from PPO networks to benefits, such a co-pays, deductibles and coinsurance.) The difference is that with the partially self funded plan the employer holds the cash needed to fund benefits (claims from providers), and instead of sending the fully conventional premium to the insurance company (such as

BCBS or Aetna), only a small fraction of the conventional premium is sent in to the reinsurance carrier and a small amount to the TPA. The employer purchases reinsurance for protection, holds the remainder of the conventional funds (claim funds), invests them, segregates them if desired, or utilizes them for general business purposes until they are needed for the funding of medical claims. The employer retains and keeps the funds when claims do not materialize, hence realizing further profit. So, if an employer was paying BCBS or Aetna $5,000,000 a year in premiums, and the employer’s employee claims were only around $2.5 million, then it is possible for the fully insured carrier to walk away with close to $2.5 million in profits. If the employer self funds, the employer is the one who walks away with the $2.5 million dollars in savings at the end of the year. Example A: (Fully Insured Example) Acme Company is fully insured with a Fully Insured Carrier and pays a premium of $1,500,000.00 annually for their health insurance plan. Claims experience shows that Acme Company only had $1,000,000 in claims and administration expenses. The fully Insured Carrier keeps the $500,000 in profits. The advantages of self-funding are many. There is tremendous flexibility in the benefit plan design. You can decide what you want to cover and what you don’t, whether it’s certain vaccinations, chiropractors, injectibles, obesity, or infertility. Another major advantage, is portability from one carrier to another. There’s no disruption in plan when you shift between reinsurance carriers. You don’t have to start all over again with new I.D. cards, booklets and

doctors, the way you do with the fully-funded plans. Also, for employers with more than one office, it is possible to offer the same plan to everyone in every location. This makes it so much more administratively efficient. By Self Funding an employer can utilize one national PPO network or multiple local PPO networks with the same benefit plans. But the bottom line, is cost savings. Example B: (Partially Self Funded Example) Acme Company’s group health insurance is self funded with a Third Party Administrator with reinsurance. Acme Company’s potential worst case scenario for the year is $1,600,000 annually (what they would have paid to a fully insured carrier). Acme Company pays $20,000 a month in fixed premium costs and holds in claims reserves $1,360,000 for potential claims. The $1,360,000 is retained by Acme Company and it is theirs to utilize as they see fit until claims materialize. At the end of the year Acme Company’s claims are $1,000,000. Their fixed premiums were $240,000 for a total of $1.24 million. Acme Company retains the $360,000 it reserved in a worst case scenario. Acme Company realizes a $360,000 savings by going Self Funded versus Fully insured. ClaimsExperience—Immediate Realization of Hard Dollar Savings Under a fully insured program, if an employer’s experience is “better than expected,” the insurance company gains financially and makes an unexpected profit. The insurance carrier does not refund the excess profit to the employer. Even if an employer has good claims experience, the insurance company will still pass on a renewal based upon the insurance companies’ pool of thousands of groups. Employers are not truly rated based upon the employer’s claims experience and can be treated unfairly. With Self Funding your renewals are based on “YOUR” company’s claims experience, and it is not based on thousands of other companies that have no relation to your company or industry. You, the Employer, not the insurance company enjoy the advantage of favorable claims experience. You, the Employer, keep the savings, not the fully insured carrier.

How Does Medical Tourism fit into Self Funding? Most Self Funded plans have reinsurance, which is a form of insurance that protects employers from catastrophic losses. So, the employer funds the base of the plan, with a reinsurer taking care of catastrophic losses. One form of this insurance is Specific Stop Loss Reinsurance. Specific Stop Loss Reinsurance (also known as Individual Stop Loss or Specific Deductible) protects a selffunded employer from large claims from any one individual or dependent. If any one individual’s claims hits the Specific Deductible/ Individual Stop Loss Level (a specific dollar amount) the employer’s liability ceases and the reinsurance carrier takes on the liability and the claims. The Stop Loss Carrier will then reimburse the employer for all claims in excess of the specific deductible for the rest of the plan year. The Specific Stop Loss Deductible is determined by the following demographics of the employer: number of employees, age, sex, claims experience, etc..

Medical Tourism is the only real solution in health care today where employers are guaranteed to save money.

Specific Deductibles can range from $20,000, and upto $250,000 for much larger groups. Let’s take a $100,000 specific deductible as an option. The employer must pay the first $99,999.99 on any person within the health plan. Once that person’s claims hit $100,000 the reinsurer pays the remaining claims for that person for the year. So, if a member needs a heart procedure that costs $100,000, the employer is guaranteed to pay $100,000 because the reinsurer pays only after claims hit $100,000. This means the employer is guaranteed for a heart procedure to pay the

$99,999.99 in a self funded health care plan. If the employer can implement medical tourism and convince an employee to go overseas for healthcare, and the employee goes to Asia for example, then the cost for the surgery may only be $9,000. That means the employer just saved $91,000 “hard” cash. By the U.S. employer utilizing Medical Tourism they just cut their health care expenses for major surgeries by up to 90%! A creative method some Third Party Administrators and employers are doing is creating incentives for employees. These incentives could be from paying for the member and a loved one’s airfare to the foreign country, plus picking up all expenses, hotel, food, etc. Some companies are even offering cash incentives on top of an all expense paid trip/ vacation, allowing employees to take a vacation they otherwise couldn’t afford and still have cash in their pocket. For a $100,000 surgery in America that would cost $9,000 in the U.S., if the employer waived a $2,000 deductible, paid for airfare for the member and a loved one, plus all expenses and a $5,000 cash incentive, the employer could walk away spending less than $20,000 for the surgery. Which is still a $80,000 savings (80%) over getting the surgery done in the United States. Don’t forget, with self funding, this is the employer’s money that’s being saved, not the insurance carrier.. The most important part for the Third Party Administrator and Employer is partnering with a quality hospital and ensuring the employee or participant has an amazing health care experience. Next month we will address how employers should approach medical tourism with their employees and how it can change the corporate culture.

Jonathan Edelheit is President of the Medical Tourism Association with a long history in the healthcare industry, providing third party administration services for fully insured, self-funded and mini-medical plans to large employers groups.

Malaysia Malaysia attracted 230,000 foreigners for medical tourism in 2005. Dr Kulaveerasomgam, Chairman of the Association of Private Hospitals of Malaysia committee stated that “Malaysia is slowly coming up in medical tourism business – we can see from the statistics that its growing. The outlook for medical tourism in the country is very bright – it is a recession proof industry.” Malaysia is working with local universities to develop specialty areas for example in cancer, neurology, and orthopedics.

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MEDICAL TOURISM

PLANNING YOUR

MEDICAL TRIP ABROAD Recovery Retreat or Hotel: An Interview with Jim Follett of International Hotel Group As the amount of US patients traveling abroad for elective care continues to increase, where to stay when arriving at a destination country is becoming big business. By LOURDES GASPARONI

he needs of the “Medical Tourist” are much different than those of someone traveling on business or vacation. Historically, for a medical tourist, staying at a traditional hotel comes with much apprehension. While a hotel may be very appropriate for someone having dental work done, it may not be very suitable for someone having a cosmetic or bariatric procedure for example. Challenges include: the lack of privacy after the procedure, rooms often times not properly equipped to handle post-surgical issues, medical needs, such as nurse care and massage therapy, are not readily available. This may cause frequent trips to a medical facility for post-operative care and follow up. Many hotels are trying to make the adjustments. Jim Follett of International Hotel Group, based in Dallas, TX says, “As the hotel company with more guest rooms than any other company in the world, we are focusing on the individual traveling internationally for various medical treatments.” Jim is the Director of Global Sales in Latin America and has spent much time in Central and South America. “Our research found these individuals have special requirements at the facilities they select for their recovery period. Our brands InterContinental, Crowne Plaza, Holiday Inn, Holiday Inn Express, and Staybridge Suites are committed to satisfying the unique needs of these guests.” “The initial markets where we are developing programs for these guests include San Jose Costa Rica, Monterrey Mexico and Sao Paulo Brazil. Each city has multiple IHG brands which will satisfy the different budgets of the travelers. The Real InterContinental San Jose for example offers 24 hour room service, health club and business center which is very important to many of these guests. The newly renovated Holiday Inn San

DECEMBER 2007

Jose-Aurora located in the city center offers walking access for the guest to the city - a plus for individuals interested in exploring the city as they recover.” “The hotels will have specifically designed programs for the medical tourist. Their recovery needs will vary based on the various medical procedures. Staying with internationally recognized brands will reduce some of the anxiety these patients experience. Additional services such as daily transfer to the facility, special dietary offers and free local phone calls to their doctors will include some of the services these guests will experience with IHG brands. A web site has been established for the industry, specifically for the medical tourism providers in the USA and Canada. We anticipate working in concert with these professionals to insure a quality experience for the guests.” Outside of hotels, many countries in Latin America catering to medical tourists, have left it to the physicians and hospitals to come up with solutions to this need. A plastic surgeon or hospital, for example, may offer an apartment that is nearby to the medical facility with 24 hour nurse care. Some countries such as Costa Rica, however, have been quick to identify a medical tourist’s needs and have made adjustments accordingly. “There are over 15 recovery-type retreats in San Jose alone,” said Raul Cossio, Owner of the Paradise Cosmetic Inn. “Hotels are not medically equipped to handle surgical patients, in fact, many of the local hotels will tell people to contact us instead.” He believes the biggest difference is the 24 hour nurse attention and “the fact that you are among people that you have a lot in common with and can share your experience, is a big factor.” “It’s like a big pajama party, everyone is comfortable, it’s the perfect atmosphere for relaxing and recharging, which facilitates the healing process.” “By the time the people leave, everyone feels like one big happy family planning a reunion at Paradise.” Like hotels, there are some challenges to the Recovery Retreat for a Medical Tourist. The issues that they run up against involve the limitations on what is available at the facility. This is particularly an issue for those Medical Tourists that bring a spouse or companion. Meal selection and entertainment can be limited and the costs for extra services that may be included in the price at a hotel, needs to be evaluated by the Medical Tourist. Also, after the required period of recovery in which the Medical Tourist needs daily medical attention for Post-operative care, they may “outgrow” the facility. Consideration to changing venues for the remainder of the stay may be a good option. Consulting the doctor, who is carrying out the procedure is very helpful in deciding how and where to stay. Based on their experience, they will be able to provide you with what your expected recovery time should be and how long a recovery retreat would be beneficial. Both the recovery retreat and a traditional hotel have their advantages. Doing your homework and research to determine what is best for you, the medical tourist, will help make your experience a very positive one.

Lourdes Gasparoni is a proprietor of Premier MedEscape in Palm Beach Gardens, Florida and may be reached at info@premiermedescapes.com.

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MEDICAL TOURISM

What is Your Country’s

Ranking? T

he WHO report came out as the first ever analysis of the performance of the health systems of WHO’s 191 Member States. The performance assessment of health systems is based on many country variables such as: socio-economic, political and technological. WHO rankings show that even countries with the same levels of income can have very different healthy life expectancies while many countries fall short of their potential for performance. According to Dr Uton Muchtar Rafei, WHO’s Regional Director for South-East Asia, “This Report will hopefully provide a framework for the review of health sector reform in these countries, and will enable them to adopt various policy options in order to obtain higher levels of health.” According to Dr Uton, “Choosing the right interventions and providing incentives to the providers is one way to improve the performance of the health system. WHO calls for a new ‘universalism’ - which means providing the simplest and most basic quality care for all, including the poor. Developing countries should rationalize their investment in human, physical and technological resources. The health ministries need to play a strong stewardship role, and should invite and regulate investment by other sectors, including the private sector into health.”

DECEMBER 2007

As the healthcare crisis in the US continues to grow and Americans are looking to overseas alternatives for treatment, many people are looking back to the World Health Report from the year 2000 that focuses on the performance of health systems world wide. It assesses health systems and the 35 million or more people they employ. The report notes that the well-being of billions of people around the world, the quality, and length of their lives, depends on the performance of the health systems.

The following is the list provided in that report. Where does your country rank? Surprised? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64

France Italy San Marino Andorra Malta Singapore Spain Oman Austria Japan Norway Portugal Monaco Greece Iceland Luxembourg Netherlands United Kingdom Ireland Switzerland Belgium Colombia Sweden Cyprus Germany Saudi Arabia United Arab Emirates Israel Morocco Canada Finland Australia Chile Denmark Dominica Costa Rica United States of America Slovenia Cuba Brunei New Zealand Bahrain Croatia Qatar Kuwait Barbados Thailand Czech Republic Malaysia Poland Dominican Republic Tunisia Jamaica Venezuela Albania Seychelles Paraguay South Korea Senegal Philippines Mexico Slovakia Egypt Kazakhstan

65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128

Uruguay Hungary Trinidad and Tobago Saint Lucia Belize Turkey Nicaragua Belarus Lithuania Saint Vincent and the Grenadines Argentina Sri Lanka Estonia Guatemala Ukraine Solomon Islands Algeria Palau Jordan Mauritius Grenada Antigua and Barbuda Libya Bangladesh Macedonia Bosnia-Herzegovina Lebanon Indonesia Iran Bahamas Panama Fiji Benin Nauru Romania Saint Kitts and Nevis Moldova Bulgaria Iraq Armenia Latvia Yugoslavia Cook Islands Syria Azerbaijan Suriname Ecuador India Cape Verde Georgia El Salvador Tonga Uzbekistan Comoros Samoa Yemen Niue Pakistan Micronesia Bhutan Brazil Bolivia Vanuatu Guyana

129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190

Peru Russia Honduras Burkina Faso Sao Tome and Principe Sudan Ghana Tuvalu Ivory Coast Haiti Gabon Kenya Marshall Islands Kiribati Burundi China Mongolia Gambia Maldives Papua New Guinea Uganda Nepal Kyrgystan Togo Turkmenistan Tajikistan Zimbabwe Tanzania Djibouti Eritrea Madagascar Vietnam Guinea Mauritania Mali Cameroon Laos Congo North Korea Namibia Botswana Niger Equatorial Guinea Rwanda Afghanistan Cambodia South Africa Guinea-Bissau Swaziland Chad Somalia Ethiopia Angola Zambia Lesotho Mozambique Malawi Liberia Nigeria Democratic Republic of the Congo CentralAfrican Republic Myanmar

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MEDICAL TOURISM

The Boomers are Coming! The Boomers are Coming! By BOB MEISTER

This bulge works its way through time and has had significant effects at each point in time. The baby boomers put stress on the educational system when they were coming through their K-12 years. They helped bring about a surge in the housing market when they reached middle age and, in the near future, they are going to put incredible pressure on American health care for generations to come.

THE BABY BOOMER BULGE, A PIG GOING THROUGH A PYTHON

While the boomers alone will create a notable rise in demand for healthcare services, the demand will continue to rise, rather than drop, as the boomer population decreases because everyone including the members of Generations X and Y are living longer.

HE ADVENT of baby boomers entering their sixth decade, with a population that is living longer, but not healthier, represents the potential for disaster in the healthcare industry in America.

It’s the “Baby Boomers!” The emergence of the baby-boomer generation has been driving many of the changes in American society and culture. Everything from hairstyles and health clubs to the Dr Spock method of parenting is affected. Similarly, boomers are driving the healthcare needs of the future.

ELDER BOOMERS ARE THE NEW AGE WAVE • • • •

The number of Americans aged 65 or over will double by 2050 The number of people age 85 or over will quadruple by 2050 By 2030 over half of U.S. adults will be over age 50 In the 21st century life expectancy may exceed 120 years

The Baby Boomers are the generation of Americans born between 1946 and 1964, after World War II. The leading edge of this generation turned 60 years old this year and by the year 2030, the entire baby boom generation will be 65 or over. Currently baby-boomers make up approximately 27% of the total population, or nearly 77 million people, representing a peak in the overall population of our nation. Charting the baby-boomers on a horizontal graph would represent them as a bulge, referred to by aging expert and author Dr Ken Dychtwald, as “a pig going through a python.” Every day, almost 11,000 boomers turn 50 – that is one every eight seconds.

What next? Ken Dychtwald answers, “For starters, they are no longer baby boomers. They have become a continued demographic force – an “age wave”. As this generation travels along the lifeline, it will profoundly induce change in American society, now and for the future. The boomers have broken the rules and exploded the norms at every stage of life they inhabit. Undoubtedly, they will continue to do so as they turn 60, 70, 80 or 100 years old. Imagine a nation not of baby boomers, but elder boomers. It’s coming. Our country is about to be transformed by an age wave that leaves each stage of life changed forever.”

Aging of the Baby Boomers

LIFE EXPECTANCY ~ LIVING 120 TO 180 YEARS

2000 Age 36-54 78 Million

2010 Age 46-64 75 Million

DECEMBER 2007

2020 Age 56-74 70 Million

2030 Age 66-84 58 Million

It is not just the shear numbers of baby-boomers that will affect future health care needs and costs; it is also the overall increasing life expectancy 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 expectancy during that period was due primarily to basic improvement in living conditions as well as improved medical technology. Futurists believe that we are again on the verge of making significant improvements in life expectancy so that in the future we may have life expectancy levels of 110 to 120. In fact, a program held at the World Future Societies annual convention in the summer of 2003 was entitled “Living 120 to 180 years.” Life Expectancy at Birth 1900 to 2000 Men 47.9 55.5 61.6 66.8 70.8 74.8

1900 1920 1940 1960 1980 2000

is related to extended life or to baby boomers, it does present a trend worthy of note. Percentage of people with 14 or more activity limitation days 1993 1998 2000 2005 4.8% 5.6% 5.8% 6.6% Percentage with 14 or more physically unhealthy days overall 1993 1998 2000 2005 8.6% 9.4% 10.1% 10.7% BOOMERS WILL RESHAPE THE FUTURE OF HEALTHCARE

Women 50.7 57.4 65.9 73.7 77.6 79.5

In one sense, increased life expectancy represents a human success story; America now has the luxury of aging. Or is it really a luxury? Most would agree that it depends on the quality of life we can maintain as our lives are extended years beyond expectations. But that isn’t always a pretty picture. Take Gertrude from Wisconsin, for example. When she was born in 1911, her life expectancy was 53.2 years, yet she lived to almost 92. However, the difficulty was that after age 78, her health problems compounded. It began with diabetes, then a quadruple heart by-pass, followed in a couple years by a heart-valve transplant, then cancer and finally a punctured lung, which occurred while getting a pacemaker installed. Her quality of life diminished and was dependent on thirteen different medications, family assistance, home care, then assisted living, followed by a series of hospital and recuperative nursing home stays. This all too common sequence of events and series of procedures tapped out Gertrude’s personal resources and used up many times the Medicare dollars she contributed during her working years. The point is that life expectancy often comes at a very high price financially and also in terms of human comfort.

In May of this year, First Consulting Group, Long Beach, CA conducted a study that helps project the effect of the baby boomer generation on future health care in the United States. Following are some results and conclusions drawn from “When I am 64.” “The wave of aging Baby Boomers will reshape the health care system forever. There will be more people enjoying their later years, but they’ll be managing more chronic conditions and therefore utilizing more health care services by 2030.” • The over 65 population will nearly triple as a result of the aging Boomers. • More than six of every 10 Boomers will be managing more than one chronic condition. • More than 1 out of every 3 Boomers – over 21 million – will be considered obese. • One out of every four Boomers – 14 million – will be living with diabetes. • Nearly one out of every two Boomers – more than 26 million – will be living with arthritis. • Eight times more knee replacements will be performed than today.

Every day, almost 11,000 boomers turn 50 – that is one every eight seconds. SKYROCKETING COST OF CARE The cost of health care has been rising at a rate much higher than inflation and family incomes. Health care expenditures in America have gone from 246 billion in 1980 to just under 1.7 trillion in 2003. The problem is compounded when employers discontinue employee insurance, contributing to the rising number of uninsured Americans. Examples of Health Care costs in the United States Home Health Care – Aide Home Health Care – LPN Assisted Living Nursing Home – private

Hartford, CT $13,130 year $22,180 year $27,888 year $99,692 year

Fairbanks, AK $12,558 year $34,112 year $28,550 year $153,227 year

Procedures* Heart Bypass

$130,000

Angioplasty

$57,000

Knee Replacement

Spinal Fusion

$40,000

$62,000

AMERICANS HAVE SUFFERED AN OVERALL DECREASED QUALITY OF LIFE Results of a study that approximates quality of life, published by the United States Department of Health and Human Services Centers for Disease Control and Prevention, demonstrate that overall healthrelated quality of life worsened dramatically in the 12 years between 1993 and 2005. While this research does not conclude that the increase DECEMBER 2 0 0 7

MEDICAL TOURISM

As Boomers age, the number with multiple chronic conditions is expected to grow from almost 8.6 million today (about one out of every 10 Boomers) to almost 37 million in 2030.

Sixty-two percent of 50 to 64 year olds reported they had at least six chronic conditions (hypertension, high cholesterol, arthritis, diabetes, heart disease and cancer). As Boomers age, the number with multiple chronic conditions is expected to grow from almost 8.6 million today (about one out of every 10 Boomers) to almost 37 million in 2030. Since the biggest factors influencing medical spending are chronic illness and a patient’s level of disability, the growing incidence of multiple chronic conditions will put increasing demands on our health care system. “The confluence of the large Boomer population, increase in chronic conditions and rise of available medical treatments will begin to impact health care in 2010, when the oldest Boomers turn 65 – when more health services typically begin to be used.” • • • • •

By 2030, there will be nearly twice as many adult physician visits as there were in 2004, and Boomers will account for more than four of every 10 of these visits. By 2030, if all Boomers with diabetes receive recommended care, they will need 55 million laboratory tests per year – 44 million more than today. Physician office visits will number more than one billion by 2020. Four out of 10 will be Boomers. The growing demand of chronic disease will increase the need for medical sub-specialists. The increase in longevity of Boomers – on top of advances in medications, less invasive treatments and diagnostic testing – will greatly increase the demand for cardiology.

“The severe workforce shortage will challenge the health care system’s ability to meet this Boomer demand”. • In 2005 there was a shortage of about 220,000 registered nurses; by 2020 that gap will be over one million. • Even if the number of geriatric specialists remains stable, there will be a shortage of almost 20,000 by 2015. • Between 2000 and 2020 the supply of orthopedic surgeons will increase by only 2 percent while the demand will increase 23 percent. • Between 2000 and 2020, the supply of cardiologists will increase by only 5 percent while demand will increase by 33 percent • The projected gap for primary care physicians will increase as Boomers age. THE DILEMMA While the combination of the largest demographic cohort in history and the extended years (provided to us by new drugs, and medical technology and procedures) may not be a formula for disaster, it does raise a red flag and a few questions. • • • • •

How can we improve quality of life during our extended years? How can we pay for the health care that makes them possible? Where will we find the medical workforce to care for the elderly boomers? Will more baby boomers travel overseas to live or to receive healthcare? As more and more baby boomers get older, will Medicare allow payments to overseas providers to help reduce the cost of providing health care to baby boomers?

Bob Meister is a faculty member at CareQuest University. CQU provides education and certification for professionals in health care planning, financial planning and insurance. Most of Bob’s business experience is in designing and implementing market strategies and concepts as a consultant to manufacturers, service providers and associations. His focus over the past 12 years has been aging, healthcare and retirement. References: “The Long-Term Care Challenge”, David Wegge, Care Quest University; Care Options OnLine, NavGate Technologies; www.agewave.com, Ken Dychwald; Aetna; “When I’m 64", FCG; “An Aging World”, US Census Bureau. *Approximate retail costs, based on HCUP data

DECEMBER 2007

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