IHHR 1 - November 2017 by International Hospitals & Healthcare Review

A whole new world How virtual reality is revolutionising healthcare

Destination spotlight Why Thailand is an attractive destination for international patients

Profile, Julie Munro, MTQUA The importance of best practices to ensure quality of care

All about international patient care Issue 1 Âˇ November 2017

Battling drug-resistant bacteria

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5-11. News

18. Race against time

30. Credit where it’s due

Battling drug-resistant bacteria

Accreditation is more than just a marketing tool for international hospitals

10. Profile

Julie Munro, MTQUA

22. Fighting to deliver ‘free’ healthcare: a blood sport

34. Destination spotlight

Healthcare provision in the UK and Canada

Thailand

26. New horizon

36. Industry voice

12. A 3D-printed future The importance of 3D printing in healthcare

The Turkish Republic of Northern Cyprus and its hospitals sector

14. A whole new world How virtual reality is helping hospitals

28. Interview

Dr Richard Heinzl, global medical director of WorldCare International, Inc

Did I produce a catastrophic claim or am I a victim of fraud?

38. Tech corner

Prime Medical’s chlorine-shielded product line

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NEWS

“If it’s not good enough for my good enough for my clients.”

Hello lovely readers, and welcome to the very first issue of the International Hospitals & Healthcare Review (IHHR). This brand spanking new independent publication is all you need to stay in the know about the world of international patient care (in my humble opinion), and I’m very excited to introduce you: readers, meet IHHR, IHHR meet the readers. The magazine will be printed on a quarterly basis, and will include in-depth features and analyses from worldwide correspondents and industry experts. But that’s enough excitement for now, mother, it’s not let’s get down to business and…think about the nemesis you would least like to come face to face with. A few possible contenders…Darth Vader, everyone’s favourite intergalactic tyrant. The Wicked Witch of the West (perhaps outdated, but truly terrifying to a child). What about Cruella Deville? You mess with dogs, you mess with me. Well, something infinitely more terrifying than these fictional characters are the socalled ‘superbugs’; the real-life phenomenon of antibiotic resistance. We explore this growing threat and ask whether the counter measures being implemented are sufficient to overcome this real-life enemy see p.18. Other features helping this first edition kick

off with a bang cover the seemingly futuristic yet real-world topics of virtual reality and 3D printing see p.12, and thoroughly explore hospital accreditation and the ﬁght to deliver free healthcare see p.30…boom! Julie Munro, president of MTQUA, shares her expertise on best practices in international patient care: “If it’s not good enough for my mother, it’s not good enough for my clients.” And Dr Richard Heinzl, global medical director of WorldCare International, Inc. expands on a similar goal: to positively impact on healthcare outcomes across the globe. We also explore why Thailand is such an appealing destination for international patients (can’t argue with price, quality, speed of service and hospitality) and present to you Prime Medical’s innovative chlorine shielded product line, which is ‘changing the fabric of healthcare’. Enough preamble now. Enjoy the issue and please do get in touch if you have any suggestions for future issues and/or would like to contribute. I’d love to hear from you. Until next time, happy reading and stay well!

Lauren Haigh Editor lauren@voyageur.co.uk

Editor-in-chief: Ian Cameron

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Editor: Lauren Haigh

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NEWS

A commitment to excellence Medical Tourism Training, which provides training, consulting, and assessment tools for healthcare providers, facilitators, governments, associations, hotels, resorts and spas, and other organisations involved in medical, dental and wellness travel, has teamed up with worldwide independent certification body Temos International to improve access to higher quality services for patients accessing global healthcare treatments. Medical Tourism Training will act as Temos

International’s representative for the US, Latin and South America (excluding Colombia) and the Caribbean to promote and facilitate certification, hopefully leading to improved patient safety and

superior patient experience for Temos-certified organisations and individuals. The two companies say they have a shared focus on high standards of clinical care, as well as an excellent end-to-end patient experience, and are committed to working with hospitals, clinics and facilitators to provide certification programmes built on evidencebased standards and international best business practices to deliver measurable results. Medical Tourism Training’s president, Elizabeth Ziemba, said that the partnership is an excellent fit for both companies: “We share a commitment to excellence in medical travel from initial contact to after-treatment follow up. Our training and consulting services can help providers and facilitators prepare for Temos certification and our team can introduce Temos’ services to a much wider audience. Temos, with its demonstrated track record of excellence, is an exciting option for providers and facilitators in the US, Latin and South America and the Caribbean who have been looking for a good alternative to high priced accreditation programmes that do not meet their needs or their budgets.”

Welcoming a visionary scholar The founding director of the Institute for Global Health at the University of Maryland’s School

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of Medicine in the US, Dr Christopher Plowe, a leading expert on malaria elimination, has been named director of the Duke Global Health institute (DGHI). Plowe succeeds Dr Michael Merson, who stepped down earlier this year after leading the institute since it was launched in 2006, and will begin his role in January 2018. Plowe leads a clinical translational malaria research programme, with molecular parasitology and clinical vaccinology facilities in Baltimore and field sites in Mali, Malawi and Myanmar. His work includes genomic epidemiology, immunology, international research ethics, HIV-malaria interactions, and clinical trials of drugs and vaccines. He has also had a long-time commitment to training scientists and building research capacity in tropical countries. “Chris Plowe is a star in the global health field,” said Sally Kornbluth, Duke’s provost and Jo Rae Wright University Professor. “He is a visionary scholar and researcher who has already created a world-class institute from the ground up. Chris’s experience in building and growing collaborations across campus, and with partners around the world, will help Duke and DGHI realise our ambitions for the future.”

It’s a Ping thing

Health technology company PatientPing has launched an integrated healthcare delivery system based in Green Bay, Wisconsin, US, in collaboration with integrated healthcare delivery system Bellin Health. The partnership will enable providers within Bellin Health to collaborate on shared patients with other providers outside of their network and across the care continuum, which will enable a team-based, co-ordinated approach to patient care. “At Bellin, quality of care and patient safety are our top priorities. In order to effectively manage the care of our patients, we need to better understand where they access services,” said Dr Brad Wozney, Bellin health medical director, ambulatory quality and information. “PatientPing will allow us to do just that so we can better co-ordinate care.” Providers that join PatientPing receive realtime notifications (‘Pings’) whenever their patients receive care, and access to patient stories that provide critical context such as attributed providers, visit histories and care programme affiliation. This real-time information enables healthcare team providers to engage and co-ordinate during the patient’s healthcare event, which helps prevent duplication of services, reduces avoidable readmissions and ensures safer care transitions. “The PatientPing community is dramatically expanding in the Midwest. It’s a privilege to connect providers in Wisconsin, Michigan, Illinois and beyond so they can more easily and efficiently serve their patients,” commented Jay Desai, cofounder and CEO, PatientPing.

NEWS

Investing in healthcare

Dr Martha Sajatovic, professor of psychiatry and of neurology at Case Western Reserve University School of Medicine, Willard Brown Chair in Neurological Outcomes Research and director of the Neurological and Behavioral Outcomes Research Center at University Hospitals Cleveland Medical Center, has received two major

research grants. The first is a National Institutes of Health (NIH) Fogarty International Center for Health grant in Tanzania. As principal investigator (PI), Dr Sajatovic will work with colleagues at Muhimbili University of Health and Allied Services to reduce the burden of chronic psychotic disorders using a customised adherence enhancement programme combined with injectable, long-acting antipsychotic medication. The second grant is from the Patient-Centered Outcomes Research Institute (PCORI) and will see Dr Sajatovic working with two PIs from the University of Colorado Denver, Dr Bethany Kwan and Dr Jeanette Waxmonsky. This is for a diabetes intervention project comparing two evidencebased treatments: patient-driven diabetes shared medical appointments (SMAs) versus standardised diabetes SMAs.

New company seeks to make an impact

Clinical-stage company Enesi Pharma, which is developing injectable solid dose drug-device combination products, has announced its launch as a new company at the recent World Vaccine Congress. The firm is developing vaccines and therapeutics using its proprietary ImplaVax technology, which it believes has the potential to make a ‘material impact’ on global healthcare. The technology is the combination of a solid dose formation and device technology for subcutaneous vaccination that Enesi Pharma says offers significant potential benefits for patients, care givers, healthcare professionals and payers. The company’s management team is led by

New camera sees through bodies Researchers at the University of Edinburgh and Heriot-Watt University in the UK have developed a camera that can see through the human body, enabling doctors to track endoscopes. The device is able to detect sources of light inside the body, e.g. the endoscope’s illuminated tip. The camera’s advanced technology means it can detect photons, with experts having integrated thousands of single photon detectors onto a silicon chip. In addition to detecting the tiny traces of light that pass through the body’s tissue from the light of the endoscope, the camera can also record the time taken for light to pass through the body, allowing it to also detect the scattered light. In this way, the camera can work out exactly where the endoscope is located in the body. “The ability to see a device’s location is crucial for many applications in healthcare, as we move forwards with minimally invasive approaches to treating disease,” commented Professor Kev Dhaliwal of the University of Edinburgh. “My favourite element of this work was the ability to work with clinicians to understand a practical healthcare challenge, then tailor advanced technologies and principles that would not normally make it out of a physics lab to solve real problems,” said Dr Michael Tanner of HeriotWatt University. “I hope we can continue this interdisciplinary approach to make a real difference in healthcare technology.”

CEO David Hipkiss, who highlighted the company’s potential. “We are delighted to announce the company’s launch today at the World Vaccine Congress. Our novel ImplaVax technology offers a potential step change in innovation offering enhanced immune response, safety and convenience as we strive towards fulfilling our vision of ‘Immunity for Life’,” he stated. “As we apply our platform to a range of high value antigen and vector targets to address serious diseases, the benefits are evident, manifest and clear. I am excited about the Enesi team’s ability to bring new products to patients and make a material impact on global healthcare.”

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NEWS

Collaborating for health A new collaboration between global patientfocused NGO The Max Foundation and Novartis is supporting continued access to treatment at no cost for nearly 34,000 patients with chronic myeloid leukaemia (CML), gastrointestinal tumours (GIST) and other rare cancers. The collaboration, called CMLPath to Care, is an evolution from GIPAP, a partnership that provided the medication Glivec (imatinib) at no cost to diagnosed patients in lower-income countries where there may not be access to reimbursement or funding mechanisms, and to those unable to pay. The Max Foundation will deliver the treatment to these patients, including supply chain management, while Novartis will provide funding

and drug donation support. Novartis expects to donate more than US$29 million to the collaboration, along with approximately 315,000,000 doses of medicine. “Fifteen years ago, Novartis recognized the critical importance of ensuring patients in lowerincome countries had access to breakthrough cancer therapy, and we partnered with The Max Foundation to develop a revolutionary global programme to address this need,” commented Bruno Strigini, CEO of Novartis Oncology. “CMLPath to Care renews and extends our unique collaboration with The Max Foundation and builds on the strengths of both organisations to better serve these patients.”

New drug for chronic women’s health conditions An EXCITE-ing commented Iain Dukes, chairman of KaNDy healthcare partnership A new UK-based clinical-stage company called The Centre for Aging + Brain Health Innovation (CABHI) and breakthrough medical technology evaluation platform MaRS Excellence in Clinical Innovation and Technology Evaluation (EXCITE) have announced that they will be partnering to accelerate the adoption of new health technologies in the seniors’ care sector in Ontario. Improving coordination between CABHI and MaRS EXCITE when working with applicant companies, the partnership is designed to help innovators drive the commercialisation, procurement and adoption of their ageing and brain health solutions. “Ontario has a tremendous opportunity to improve seniors’ health by accelerating the adoption of innovative technologies and processes across the health system,” said William Charnetski, Ontario’s chief health innovation strategist. “The strategic collaboration between CABHI and EXCITE will provide innovators with a single point of access to expertise, funding and pathways to build out their solutions, scale companies and ultimately create jobs in Ontario.” Through MaRS EXCITE, successful applicants can connect with relevant health system stakeholders in Ontario to access opportunities that promote the wide-scale uptake of their innovation in the healthcare system.

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KaNDy Therapeutics has been launched, with a view to maximising the value of a potential breakthrough medicine for the treatment of chronic debilitating women’s health conditions. The medicine, NT-814, is being developed as a non-hormonal alternative to hormone replacement therapy for the treatment of postmenopausal vasomotor symptoms (PMVMS). It is believed to be able to beneficially modulate dysfunctional temperature control and reproductive hormone pathways. KaNDy Therapeutics is expected to advance the development of NT-814 into Phase 2b for the treatment of PMVMS, while also exploring its potential in other women’s health conditions. The medication has already successfully completed a Phase 2a proof-of-concept study, which demonstrated its potential to reduce the frequency and severity of PMVMS. “The formation of KaNDy Therapeutics enables us to maximise the potential of NT-814 in a range of debilitating women’s health conditions,”

Therapeutics. “We believe NT-814 is one of the few true innovations in women’s health in more than two decades and potentially represents a major breakthrough in areas of significant unmet medical need such as PMVMS.” Professor Richard Anderson, a clinical adviser at the University of Edinburgh, said that NT-184 could bring considerable relief to women as a potential once-daily alternative to HRT, without the issues associated with hormone replacement.

Awarding success in healthcare Healthcare staffing company Global Healthcare Group (GHG) is among 50 central Pennsylvania, US-based companies that have been recognised for achieving significant growth. The companies were ranked according to revenue growth over the past three years, with dollar and percentage increases taken into consideration, and learned where they were ranked in the recent Central Penn Business Journal’s 21st annual Top 50 Fastest Growing Companies awards programme. GHG has announced that it ranks at number two on the list. “Loyalty and dedication are the foundation of the GHG business philosophy. This award represents the hard work and commitment demonstrated by the entire GHG team. In carrying out this philosophy, we have exceeded our goals and continue to achieve astounding levels of

success,” said Habib Noor, president and owner of GHG. “The key to our aggressive growth is to identify the individual strengths of our employees and assign them accordingly; a proven strategy resulting in achievement and success.”

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PROFILE

Julie Munro, founder and president of MTQUA, shares some of the personal and professional experiences the Alliance was born from, and stresses the importance of best practices in medical travel to ensure quality of care I started one of the first medical tourism facilitator companies in 2003, Cosmetic Surgery Travel. Two years later, the American CBS television network broadcast a special feature on medical tourism. Overnight, we were swamped with 300 to 500 enquiries a day for more than a week. We didn’t sleep for three days, processing emails. The focus, from day one, has always been on quality of care and outcomes for our patients. My standard was straightforward: If it’s not good enough for my mother, it’s not good enough for my clients. In other words, am I confident that the doctor and the institution will deliver on their promises to me? If so, my clients, my patients, can trust me to deliver on my promises to them. Eventually, this became: If you can’t get the best possible outcome that’s within your budget, what’s the point of travelling for treatment? I’ve been an expat since the 1980s. Every time we moved to a new country, it was up to me to find doctors, hospitals and treatments that our family needed. No internet, no local gossip or support networks, and few medical facilities of the sort I’d had back home. In almost 40 years, my family and I had more than 20 separate episodes of medical

care in half a dozen developing countries that included several surgeries, lithotripsy, fertility treatments and physical therapy. I remember feeling so very relieved when I needed a biopsy in Hong Kong to learn that my doctor was a visiting specialist from MD Anderson in the US, which I knew to be a top cancer hospital. He knew the limitations of the Hong Kong hospital he was working in. He explained to me he didn’t do surgery on a Thursday or Friday because the nursing care on the weekend was not up to par. I can’t count the number of times, as recently as a few months ago in top hospitals in Canada and in Thailand, I’ve asked nurses to sanitise their hands before touching one of my family members. As a facilitator, I drew on these direct experiences to establish protocols, processes, and documentation for creating a common set of standards for international patient care management. We trained local teams who never left the patient’s side, even in the doctor’s consultation, and who kept detailed daily logs. We refused to accept commissions, insisting on proper contracts with providers, and transparently charged patients a fee for services. In this way, we acknowledged that we were accountable, that we were taking responsibility to make sure our clients received the best care management available. We explained our methods and our reasons for them to the doctors we worked with. Some didn’t get it. Many let us know our patients were well-

prepared, had realistic expectations, and were a joy to treat. My work as a facilitator was a natural springboard to developing and formalising best practices and standards in medical tourism, and I created a home for these, the Medical Travel Quality Alliance (MTQUA). There is generally still a great deal of confusion as to what this industry is. I’m not confused. Medical travellers require different and more care management than local patients do. Medical tourism stands on three legs. One leg is care management. The other legs are trust and communications. If any one of these is off kilter

The focus, from day one, has always been on quality of care and outcomes for our patients with the others, the provider’s medical tourism program is not sustainable. I’ve seen this in Thailand, Mexico, Turkey and many other places. Which brings us to MTQUA certification, which is to help hospitals, clinics, specialty treatment centres and facilitators build medical tourism programmes for the long term. We assess their operations and processes in 12 areas, focused on one purpose: to make sure the patient reaches home safe and sound, having been treated with dignity and respect, medically and emotionally. Our reference is the MTQUA Medical Travelers Bill of Rights. We review the marketing that a hospital, clinic or agent does, the websites they put up, how they

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PROFILE communicate and correspond with the potential patient during the planning and preparation stage, through to how they follow a patient’s progress long after they have returned home. We evaluate a provider’s external network, especially their relationship with outside agents. We study the internal support system of co-ordinators, interpreters, and customer service reps.

Clemenceau. Today, of course, these hospitals are among the leading stars of medical tourism. We travel to these facilities to review quality, risk, infection, medication, care management, governance, marketing and training issues, and much more. Hospitals benefit from the exposure, of course, and I’ve been told that the doctors themselves feel proud to be recognised

A few hospitals make the mistake of applying for certification because they see it as a marketing tool. They’re the ones that fall out of the certification process and don’t complete it I also created the annual list of the Top 10 World’s Best Hospitals for Medical Tourists, facilities that reflect the MTQUA approach to international patient care management. Let’s have good clinical outcomes, but let’s also have honest marketing and transparency of costs. Let’s recognise the pressures that medical travellers have that they don’t have at home – time and money restrictions, loneliness, no family support, cultural and language difficulties, different medical attitudes and approaches, and just a whole lot of strange. In 2010, we published our first Top 10 list, to a great deal of skepticism I must admit. Most people had not heard of the hospitals on this list, hospitals like Fortis (Wockhart at the time), Gleneagles, or

internationally for the good work they do for medical tourists and international patients. The World’s Best Hospitals list was created before MTQUA certification. They are both rooted in the same philosophy, but the difference is that hospitals applying for certification must be prepared to make changes and meet our standards. MTQUA certification applies to clinics, specialty treatment centres and facilitators or agencies. It’s an institutional certification, not one that you can pass in an online or weekend test. For certification, required changes may take many months to implement, especially if this involves a change of culture in the institution. A few hospitals make the mistake of applying for certification

because they see it as a marketing tool. They’re the ones that fall out of the certification process and don’t complete it. Medical travel is making a difference to many people around the world, rich or poor, living in rich or poor countries. I probably know too much about the abuses in this industry and this motivates me to find ways to make a difference in how medical travellers are treated, individually in individual hospitals, and universally. This is why MTQUA published its Medical Travel Advisory, to warn people against travelling to places like the Dominican Republic for medical treatment. MTQUA is not a policeman or regulator for the industry, but we do listen to the US Centers for Disease Control, government regulators in the UK, Australia, Switzerland and other countries, and major healthcare systems that report on serious and life-threatening events that medical travellers experience after returning home. I have many stories of patients for whom I’ve made a difference. I don’t work one-on-one with patients any longer, but former clients will occasionally call and insist that I personally help them find treatment and take care of them, that they trust no one else to do this right. That makes me proud. I’m excited when I see hospitals use the MTQUA quality symbols – the certification seal and the World’s Best Hospitals logo – inside their hospitals, at exhibitions, and in their publications. This is a global industry, so I still get a thrill when I see original articles written about MTQUA in major French, Chinese, and Spanish newspapers and magazines, not just translations from Englishlanguage press releases. Looking ahead, I’m actively looking for partners who can help us continue to build the MTQUA certification programme and to expand the World’s Best Hospitals lists to cover specialty hospitals and clinics. l Munro’s top tips for medical travellers • Find an experienced facilitator or independent healthcare professional who you can trust to guide you through your international hospital experience. Be willing to pay this person a fee – don’t accept someone who offers you a service for ‘free’. No one works for free – who’s paying them, and how much? • Don’t cut corners. If your preferred dentist in Budapest is too expensive, find one just as good in Riga where your money goes further. If you need 12 days for surgery and recovery, take all 12 days. This is medical travel. It’s not tourism, it’s healthcare. • If you are treated at a clinic instead of a hospital, check to see how close the nearest hospital emergency department is, what transportation is available to take you there, and how long the trip is during rush hour. Clinics are rarely regulated to the same infection control or medical standards as hospitals.

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FEATURE

Tatum Anderson investigates the importance of 3D printing in healthcare and how it has been driven by customisation Bionic ears may be more at home in a 1970s TV drama, but have actually been created by bioengineers at Princeton University in the US. They managed to build an ear that can hear radio frequencies far beyond the range of normal human capability. Importantly, they created it in a laboratory, using a 3D printer they’d bought off the internet. Making body parts is just one of a multitude of applications of 3D printing being trialled in healthcare today. So far, many kinds of tissues have been printed, and so-called bio printing is of huge interest to healthcare professionals says Dr Ali Khademhosseini, director of the Biomaterials Innovation Research Center at Brigham and Women’s Hospital in Boston. “Basically, the application of bioprinting is for regenerative medicine – to make transplantable tissues – but also making tissues outside the body that you can use for drug testing or other kinds of applications,” he said. 3D printers have produced bone, lung tissue and cartilage used to build ears. They have been used to engineer hard-tissue scaffolds such as knee menisci and intervertebral discs, and living skin to help treat and heal severe burns and chronic ulcers, as well as for cosmetic testing. One US company, Organovo, is even printing liver and kidney tissue to test new drugs before they are tested in humans. Dramatic growth Beyond tissues, 3D printers have been used to create everything from pills to 3D-printed casts. Incorporating pulsed ultrasound to reduce bone healing times is also a possibility. “3D printing is getting bigger and bigger,” said Dr Khademhosseini. “If you look at hospitals, more and more of them are having 3D printers at the

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hospital. Particularly over the past five years it’s taken off.” No surprise then, that the 3D printing market has grown dramatically. Pete Basiliere, research vice president at research firm Gartner, said worldwide shipments of 3D printers reached 455,772 units in 2016 – more than double those shipped in 2015. He estimates 6.7 million units will be shipped in 2020. Once a niche market, 3D printing has continued its rapid transformation into a broadbased mainstream technology embraced by consumers and enterprises around the world, Dr Khademhosseini said. It involves creating a 3D object by building successive layers of raw material. Objects are produced from a digital 3D file, such as a computer-aided design (CAD)

Customisation is what has driven 3D printing technology, which was only just emerging in the 80s and 90s said Khademhosseini. “There is the possibility of making devices that are the same dimensions that you need for the patient or can be more functional because they have better way of interfacing with the body,” he added. Certainly, many hospitals are printing prototype medical devices and implants, which can be altered until they are perfect, at lower cost than other methods. Take bioengineers and surgeons at the University of Michigan in the US and its affiliated CS Mott Children’s Hospital, who have been investigating all sorts of 3D-printed devices. They ended up collaborating to design and make a tiny splint for a baby who could not breathe. He was born without the necessary cartilage to keep

Surgeons are effectively customising their surgical procedures to individual patients by using 3D printing to help plan and practise complex interventions

drawing or a body scan, such as one produced through magnetic resonance image (MRI). The ink used is anything from biopolymers, such as polycaprolactone, to rubber and even human cells. The driving force The gradual layering from a digital file means 3D structures are highly accurate in size and colour. And, importantly, those digital files ensure that the implant is exactly the right size for the body for which it was intended. So, while much of the 3D printing industry creates identical copies of the same device – like car parts – 3D printers are being used to create devices unique to specific patients. It’s a customisable manufacturing process and that’s the key to success.

his airways open – a very rare condition called severe tracheobronchomalacia. The idea was that the splint would expand the bronchus and give it a skeleton to aid proper growth. Crucially, this tiny implant was created using a scan of the baby, so that it fitted exactly the size of the tiny windpipe, and was made with a 3D printer. And, because it could be made using special materials, it was designed to be gradually reabsorbed by the child’s body so that no further surgery would be needed. His breathing was much better after surgery, said the hospital. The importance of personalised medicine Customisation may lead to personalised medicine. 3D-printed pills, for example, enable different

FEATURE pill shapes to be created. Each shape completely alters the drugs’ release rates, research has found. And some researchers are even working on combinations of drugs within the same pill. Precise amounts of individual components could be tailored to individual patients, depending on their needs, they say. Importantly, customisation is absolutely vital for implants and prosthetics. That’s why 3D printing has been used in everything from cranial plates and hip joints to dentistry. Examples of 3D implants include dental restorative and prosthetic devices such as direct filling resins, dental cements, denture resins, orthodontic retainers, night guards, crowns, bridges and inlays. And, customisation explains why so many hospitals have been buying their own 3D printers from a range of providers including Stratasys, 3D Systems and Formlabs (General Electric Co. and Johnson & Johnson are new entrants too). 3D printers have been used everywhere from the Mayo Clinic in the US to the maxillofacial wing of Queen Elizabeth Hospital in Birmingham, UK, from Italy to India. Surgical planning and templates By far the most widespread use of 3D printing at the moment, however, is surgical planning and templates. Surgeons are effectively customising their surgical procedures to individual patients by using 3D printing to help plan and practise complex interventions. This is not an application for trainees, but for experienced surgeons, says Professor Shi-Joon Yoo, a cardiac radiologist at Toronto’s Hospital for Sick Children, also known as SickKids, and the department of Diagnostic Imaging, University of Toronto, Canada. 3D printing has become vital in this area because most significant congenital heart diseases require surgical treatment during infancy or childhood. It’s technically demanding because of the wide variation and complexity of pathological anatomy, relative rarity of the individual lesions, and the small size of the heart and vessels, said Professor Yoo. Mortality and morbidity are greatly affected by the congenital heart surgeon’s technical proficiency, as well as the number of surgical cases they’ve been given. The problem is, there is also limited training in such complex cases. “Learning surgical procedures has mostly been based on experience on patients,” explained Professor Yoo. “The major limitations include limited opportunities, patient’s risk and limited time available. 3D-print models allow ample opportunity for exploration, repeated rehearsals and modification without putting the patient’s health at risk. So, using 3D image data from CT or MRI, we make a cast and wall models of the heart.” The models help doctors with surgical management decisions and planning. In complex cases, they have an opportunity for surgical practice before beginning work on a patient. That’s why 3D printers have been used within SickKids for around nine years. Professor Yoo believes this so-called hands-on surgical training

(HOST) is necessary and will be a part of the Hospital’s standard training programme for surgeons, and hopefully, will be integrated elsewhere too. And, says Yoo, the hospital benefits in a number of ways. “There are more appropriate surgical decisions, reduced anaesthesia and surgery time, more precise surgical procedures. Although it is not easy to prove what is listed, all add up to better surgical outcomes,” he said. It’s thought that these surgical planning tools can actually save money too. Stefan Edmondson, consultant maxillofacial prosthetist at Queen Elizabeth Hospital in Birmingham, UK, said the ability to produce life-like medical models inhouse on a 3D printer translates to up to £20,000 per surgery in savings, with a reduction in surgical planning time of 93 per cent. He uses such tools for cancer patients who have had a surgical procedure to remove a tumour or bone fragment, and are often left with a space that must be bridged with another piece of bone or material. Usually, prosthetic plates or bone replacements are routinely used but getting them to the right size can be quite tricky; surgeons often have to make several alterations while the patient is on the operating table. Using 3D printers, however, a precise cutting template of the space can be made

not covered by most medical insurance packages). But researchers at the University of Miami, US, say they can do the same job on a 3D printer in a fraction of the time and cost. The undamaged side of the face is scanned, software creates a mirror image, and the final image is sent to a 3D printer, which creates an injection-moulded rubber suffused with coloured pigments matching the patient’s skin tone. The price differential that can be achieved is driving numerous applications. Field Ready prints surgical instruments – from tweezers to scalpels – in rural areas during humanitarian crises, such as after the earthquake in Nepal. And some organisations are attempting to create cheaper limbs for children, who often need many different sized limbs as they grow. Some individual devices can cost as much as $4,000 according to Dr Jorge Zuniga, assistant professor of Biomechanics at the University of Nebraska, US. He has designed a 3D-printed prosthetic hand named Cyborg Beast, complete with movable fingers and he reckons the cost of materials was about $50. Achieving vascularisation Similarly, Nia Technologies, a Canadian social enterprise, is working with clinical partners at four

The next step … is being able to bio-print entire organs such as livers, kidneys and hearts. That would revolutionise, and shorten, organ transplantation lists

in advance. That can be used to create a more precise bone replacement. Edmondson says it cuts down surgery time and risk to the patient too. Surgical planning is also finding applications in cosmetic surgery. One company, MirrorMe3D, that was launched by plastic surgeons fed up with working from 2D X-rays, creates 3D models that can be used as surgical guides in advance of surgery. There’s an added benefit, the company says, that patients can see what they might look like after surgery. Because 3D printing is an additive technology, meaning it is built up molecule by molecule, it is cheaper than traditional creative methods, which involve getting a larger piece of material and chipping, slicing or cutting away – and therefore create a great deal more material wastage. 3D-printed prosthetics 3D printing has proved to be life-changing for many patients requiring prosthetics, because they can be made more cheaply. Take facial prostheses that are usually made for eye cancer patients that have hollow sockets resulting from eye surgery following cancer or congenital deformities. They are created by an ocularist, an artisan who makes a mould of the face, casts it using rubber and then adds the final touches such as skin colour and individual eyelashes. Such prostheses cost up to US$15,000 and take weeks to produce (and are

sites to create prosthetics for patients in low and middle-income countries – Cambodia, Tanzania, and Uganda so far. Essentially, a residual limb is scanned, creating a 3D model. Nia believes a 3D model prosthetic can be printed from a digital scan in about six hours. Instead of plaster casting, the printer creates a leg from a plastic polymer called polypropylene. But while these 3D innovations proliferate, so has the focus of regulatory bodies, such as the US’s Federal Drug Administration. Many have started to approve certain 3D-printed items – from pills to implants – for critical processes and issued guidance to ensure these new inventions are both effective and safe. The next step, then, is being able to bio-print entire organs such as livers, kidneys and hearts. That would revolutionise, and shorten, organ transplantation lists says Khademhosseini, whose work centres on these much more complex structures that incorporate matrices of tiny blood vessels and nerve cells. This complexity, called vascularisation, will enable organs to be printed for implantation in humans. But nobody has managed to achieve this goal yet. This is the future, he says, but still many years off. “For simpler ones, like bone and skin-related structures, people are more at the clinical or close to pre-clinical stage. But for some of the most complex structures, this is definitely preclinical,” he said. l

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Virtual reality might be the latest Hollywood plaything, or the stuff of gamers’ dreams, but the ability to look at a make-believe world, and operate inside it, is actually helping hospitals from Australia to the US to treat patients. Tatum Anderson enters this exciting domain Consultancy PwC’s Health Research Institute predicted that virtual reality (VR) will be one of the disruptive technologies of 2017 and that the

of anatomical structures, organs can be modelled in motion, and functions and actions simulated – arteries can pulsate and cut blood vessels can bleed. As one VR expert put it: “We have created virtual patients for clinicians. So clinicians can screw up a bunch before they are get their hands on a real one.” By its nature, VR doesn’t just use visual images. It makes use of touch, smell and even feedback to enhance the feeling of reality. Trainee dentists, for

“We have a controlled environment that we can put people through and help them to confront their emotional memories and things that they fear.” healthcare industry will need to prepare for its expected impact on business models, operations and workforce needs at the very least. VR has, for many years, found a natural home in training students, from architects to paramedics. Doctors with VR headsets can obtain a 3D view

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example, use a system called HapTEL (haptics in technology-enhanced learning) to perform fillings on a set of 3D teeth using a virtual drill that replicates the movement and pressure of a real drill. Subtle changes of pressure help students to adjust their techniques.

The thinking now is that even qualified surgeons will benefit from VR. Existing procedures can be practised so that they are quicker and less risky. Hospitals are enabling surgeons to use VR to practise, plan or rehearse a range of complex surgical procedures; paediatric cardiac surgeons at Lucile Packard Children’s Hospital Stanford – who carry out thousands of operations every year – use virtual imaging technology to digitally convert CT (computed tomography) and MRI (magnetic resonance imaging) scans into 3D images that can be viewed prior to surgery, as well as in the operating room using a VR display. But, importantly, patients and their families can put on a VR headset and use handheld controllers to look inside a virtual heart to better understand heart defects, and how their doctor will be closing up a hole in a septum, for example. This beats trying to understand their doctor’s incomprehensible diagrams, plastic models and hand-drawn sketches before a procedure, said

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the hospital. Although it is in its early stages, the logical next step might be remote surgery. Surgeons have already tried to operate on a patient located 400 km away using VR and remote surgical equipment. VR mind games Telesurgery may be futuristic, but actually VR is not a new technology. It has been used clinically since the 80s, when it was first used to combat phobias, including fears of flying, lifts and heights. Clinical VR scientists have constructed virtual airplanes, skyscrapers, spiders, battlefields, social settings, beaches, fantasy worlds, and the very ordinary, such as schools, offices, the underground train, the cabin of a plane or a supermarket. These environments are helping patients deal with all sorts of mental health problems, from depression to paranoid delusions and eating disorders.

Patients can be helped to face uncomfortable situations – those that trigger stress and anxiety – through the controlled environment of a VR headset; those afraid of heights are taken at their own pace to the top of a high building, for example. Some patients are completely immersed in the environment, and even subjected to smells, using a VR helmet and body-tracking technology that helps doctors understand where their patient is looking. Others stand inside a room-sized 3D cube, surrounded by up to six screens on which images are projected around them while they wear 3D glasses. Some applications are not immersive – so-called augmented reality – so that they can still see the real world, but with realistic images superimposed on it; in application, developed in New Zealand, arachnophobic patients see massive red-and-white hairy striped spiders crawl all over their hands. Every action of the spiders can be controlled, for example aggression, as well as the number of spiders. Things to touch (such as a pole of a tube train, when treating people with a fear of travelling on

the underground train), rumble pads and other stimuli heighten the sense of presence in the virtual world far more than watching television or movies, or playing a 2D handheld videogame or game console, say VR experts. Navigating the real world in VR VR to treat post-traumatic stress disorder is on the rise and has been used to treat Vietnam veterans and World Trade Centre survivors. Dr Skip Rizzo, director, medical VR at the Institute for Creative Technologies within the University of Southern California, US, and colleagues, have developed Bravemind, which repeatedly exposes traumatised soldiers to different scenarios, with a qualified psychologist. “We have a controlled environment that we can put people through and help them to confront their emotional memories and things that they fear,” said Dr Rizzo. “We have an evidence-based trauma-focused exposure therapy and leveraged the principles of what works in the real world to deliver the treatment effectively in VR.” The treatment is available at more than 100 sites in the US including Veteran Health >>

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Administration hospitals, clinics and private facilities. Now, Bravemind is being extended to the treatment of military sexual trauma. But Dr Rizzo sees it as a viable treatment for all kinds of sexual and non-military trauma – from urban violence and kidnapping to earthquakes. “We

designed to help burn patients, and developed at the University of Washington HITLab in collaboration with Harborview Burn Center, burns victims can adventure in a cold world, and hide in huts made of snow. This helps to calm and distract the patient and block pain signals when bandages are changed, wounds are cleaned or staples removed. The creators believe VR dramatically reduces excruciating pain, more intensively than mere gaming – such as giving a child a Nintendo to play with while their dressings are changed.

“We can make a case for treating civilian trauma, from first responders and police to victims of terrorist attacks, sexual trauma, motor-vehicle trauma, bad weather or hurricanes” can make a case for treating civilian trauma, from first responders and police to victims of terrorist attacks, sexual trauma, motor-vehicle trauma, bad weather or hurricanes. There’s a hell of a lot of trauma in the world,” he said. While getting people to face their fears may be one application of VR, others aim to distract them. That’s because distraction is now known to attenuate pain perception, anxiety and general distress during painful medical procedures, such as wound care, chemotherapy, dental procedures and routine medical procedures. Some burns specialists are even starting to view VR as a form of anaesthetic. Using Snowworld, a game

Pain control applications are expanding quickly and are interesting hospitals around the world. From Cedars-Sinai Medical Center, which is looking at patients with a range of conditions – from abdominal pain from pancreatitis to chest pain from pneumonia – to Stanford, which plans to trial VR in labour and delivery. Several hospitals are trying VR by rolling out patient and calming orientation and distraction applications within children’s hospital units. My MRI at King’s College London in the UK guides children through the events on the day of a forthcoming MRI scan, from arriving at the hospital to entering the scanner. The technology

Hospitals are enabling surgeons to use VR to practise, plan or rehearse a range of complex surgical procedures

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helps them understand how it feels inside the MRI scanner and helps them to learn to keep still for the duration of the scan. Distraction technique Toronto’s Hospital for Sick Children has even created a space dedicated to virtual and augmented reality to help children with the boredom of being in hospital by sending them on virtual trips to outer space and providing augmented reality mobile games. Its Childlife VR allows children to visit operating rooms, recovery rooms and X-Ray suites, allowing them to get used to the unfamiliar sights and sounds of these strange environments. At Stanford Lucille Packard Children’s Hospital, children may choose a VR helmet with a game especially designed so that they will move just their heads, and not their arms – which need to be still – during an IV insertion. There is no death or dying in these games, and the level of distraction can be increased by the doctor just at the point when they insert the needle. So, as well as destroying aliens in space, children will start to see hamburgers and fries flying at them at the very point when the needle is inserted. One reason many of these technologies are finding themselves more widely used, is that the cost of technologies has plummeted says Dr Tom Caruso, co-founder of this distraction VR programme, called CHARIOT. “As the cost of these technologies such as VR headsets have come down they become more available to innovators and there are many uses for these within the hospital,” he commented.

FEATURE For example, headsets from Samsung, Oculus Rift, and HTC cost hundreds rather than thousands of dollars now. And, the US$15 VR headsets coming onto the market from companies like Google are even cheaper. Creators and doctors are using offthe-shelf VR developer software, to help build applications too. The VR headsets are affordable. For example, children with a scheduled cardiac catheterisation procedure are sent home with a VR headset so they can learn about the procedure and practice relaxation techniques. The technology may be becoming cheaper, but there are limitations says Caruso. For example, some are covered in cloth, which cannot be disinfected, or the area that touches the eyes cannot be replaced – which may be necessary in patients that have particular infections. Developers say they can’t see what the patients are seeing and would like to be able to manage what patients are seeing remotely. Similarly, the straps aren’t designed for children, let alone different children with different head sizes. The Stanford Lucille Packard Children’s Hospital has, therefore, recruited student engineers and other designers from Stanford University to customise commercial handsets. This means VR is out of reach for many smaller hospitals, who cannot customise this kit, they say. Augmented reality finds a place Augmented reality technology is further behind VR, although Apple, Google and Microsoft have all jumped into this space recently and experts say the technologies are improving fast. With new,

cheaper headsets and smartphone applications, it will be far more accessible, however. “Now the

Many forms of rehabilitation are being attempted; from navigation and spatial training in children

children with a scheduled cardiac catheterisation procedure are sent home with a VR headset so they can learn about the procedure and practise relaxation techniques system is becoming smaller and more affordable, people are starting to explore other applications,” said Albert Kwon, the paediatrician who together with co-founders, has created a company trialling augmented reality applications for rehabilitation from stroke to amputation patients. “I think the future is augmented reality.” Kwon’s company, Augmentx is exploring a variety of therapeutic applications including mirror therapy using a VR headset. Here, a patient can watch a mirror image of one working limb in order to help them recover movement in the other, paralysed limb. Importantly, augmented reality, rather than complete immersion, may work better for people who may be unstable on their feet, so need to see the world around them in order to prevent falls. Augmentx is one of several organisations, including USC, that are attempting to incorporate rehabilitation exercise and teaching exercises for people who need to get moving again. With movement tracking, they can also measure how well patients adhere to rehabilitation programmes.

and adults with motor impairments to functional skill training and motor rehabilitation in patients with central nervous system dysfunction after traumatic brain injury, spinal cord injury, cerebral palsy and multiple sclerosis. Kwon envisages a world where hospitals give patients augmented reality headsets while they are still in hospital, and they are then able to take them home where they can continue to recover and do their exercises at home. It may also be useful for knee replacement, hip replacement and postsurgical recovery, for example, or after concussion. As USC’s Rizzo says: “Rehab is very boring, repetitive and frustrating. We make it more game-like and capture those changes over time.” It appears VR will become a standard part of patient life in the not-too-distant future, assisting with boosting the morale of paediatric patients, making surgery safer and less risky, as a useful tool in therapy, and enabling patients to recover from the comfort of their own home. What once seemed like a wild fantasy is now becoming, virtually, reality. l

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FEATURE Anthony Harrington looks at the global threat posed by drug-resistant bacteria and asks whether the measures being implemented to alleviate challenges are sufficient There is just about universal agreement among medical experts that the threat posed by drugresistant bacteria – so-called ‘superbugs’ – is getting worse. The most frustrating thing about this problem, which has the potential to become catastrophic, is that the reasons it is intensifying are extremely well known, yet the problem is close to intractable. Almost every paper and article surrounding the topic seems to end with a homily on the importance of hand-washing in a clinical setting. Of course, hand-washing and improving ward

“A general reduction in the use of antibiotics is needed. Using them only when absolutely necessary and using them properly, which means not abandoning a prescribed course, would drive down selective resistance.” cleanliness in hospitals helps to combat the spread of bacteria from person to person. However, in the real world, where nursing staff have more duties than there are hours in the day to carry them out, slips are virtually inevitable. This is true even when there are alcohol gels available on every ward. And when it comes to micro-organisms, the naked eye cannot discern when a particular surface has just been coated with toxic microbes by a careless hand. To be sure, there are now sprays that will stain bacteria and enable their presence to be seen, but these sprays are generally applied after the fact, and sometimes, quite a long time after the fact. In that timeframe, multiple hands could have touched that spot and gone on to touch patients. Even when nursing staff are extremely vigilant, hospital visitors, coming in droves each visiting hour to see their loved ones, are generally less aware about the spread of infection. Impenetrable defences Hospital acquired infections (HAI) – generally as a consequence of infection by one or another superbug – have become so common that there is now real cause for concern for anyone going into hospital for even minor surgery. This is not just a UK, US or a European problem. In a briefing note on HAI, the World Health Organization (WHO) comments: “Based on data from a number of countries, it can be estimated that each year hundreds of millions of patients around the world are affected by HAI.” (The WHO term is Healthcare-Associated-Infections, or HCAI). WHO goes on to point out that the burden of HCAI is seven-fold higher in low- and middleincome countries than in high-income ones. The blatant overuse and over-free prescribing of antibiotics the world over, for both animal and human use, has brought us to this point.

Populations of bacteria have the ability, over time, to recognise antibiotic components to produce enzymes that can surround antibiotic molecules and eject them from the organism, leaving the bacteria free to thrive. How these enzymes are produced – how the ‘enzyme factories’ inside the bacterium work – is a focus for research, but much remains to be done. Yet another defence some bacteria have is the ability to produce a myelin sheath that surrounds the colony once a sufficient population has formed. This protects the enclosed bacteria from both antibiotics and the body’s own immune cells. The medical profession and drug companies are still struggling to work out how to break through the defences that superbugs can throw up. Growing concerns Professor Robin May, director of the Institute of Microbiology and Infection at the University of Birmingham and professor of Infectious Diseases, points out that, on the positive side, research that is currently going forward on several fronts could result in a major breakthrough. “Very few of these studies have so far generated results that are ready to be used in medicine, but the signs are positive!” he stated. “The avenues being explored range from strategies to discover new antibiotics to novel approaches that aim to render current antibiotics more effective by, for example, blocking the so-called ‘efflux pumps’ which some bacteria use to get rid of antibiotics. Then there are completely different approaches, such as phage therapy which uses viruses that kill bacteria, or immunomodulation, which is all about stimulating the patient’s own immune system so that it can kill the infection.” While he remains optimistic that the research currently going forward in multiple labs around the world will generate results, Professor May emphasises that the world is facing a serious problem. Overuse of antibiotics is endemic in many parts of the world. “Selected areas are making progress in terms of improved antibiotic stewardship, but this is a drop in the ocean relative to the global impact of widespread antibiotic use,” he said. Professor May argues that the dangers presented by drug resistant bacteria are generating concern in at least three ways. First, the medical profession is already seeing individuals who are displaying ‘untreatable’ infections, which means that they are unresponsive to any antibiotics that doctors try on them. “Whilst the numbers displaying untreatable infections are still low, for the individuals concerned this is obviously a disastrous scenario,” he noted. The majority of these cases tend to involve patients with so-called ‘secondary’ infections following operations or who have underlying conditions such as cystic fibrosis. Second, there is a serious concern that transmissible primary infections that are spread from person to person may gain antibiotic resistance. “This has already happened to some extent with TB, where multidrug resistant strains are spreading, but the >> prospect of widespread community-acquired

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FEATURE infections, such as streptococcal infections, for instance, becoming untreatable, is pretty apocalyptic,” Professor May explains.

many surgical procedures that are routine today, but essential to the patient’s survival or quality of life, will become impossible because the risk of

“Selected areas are making progress in terms of improved antibiotic stewardship, but this is a drop in the ocean relative to the global impact of widespread antibiotic use.”

Third, there is the awful possibility that antibiotic resistance will become so widespread that the use of antibiotics becomes pointless. Professor May points out that, at present, antibiotics are essential to the success of many surgical interventions. We could be looking at a near-term future in which

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infection would be too high for the procedure to be undertaken. A holistic view Professor Colin Garner, CEO of Antibiotic Research UK, points out that WHO recently

took a long, hard look at R&D drug research related to drug-resistant bacteria. It produced a report on its findings, which concluded that there are insufficient drugs being developed to have a chance of making a significant difference to the downward spiral in the effectiveness of antibiotics. “Today, if you pick up an HAI, you have a reasonable chance of a good outcome. We still have quite a wide range of antibiotics that doctors can call on to treat most HAI instances. However, there is no doubt that the situation is getting worse,” he said. One of the charity’s major concerns is its belief that the present situation could actually be much worse than reported figures suggest. “We think that there is widespread under-reporting of infections stemming from drug-resistant bacteria,” Professor Garner noted. If a patient succumbs to a drug-resistant bacterial

FEATURE infection and dies of pneumonia or sepsis, the report on that death may well simply list it as a result of pneumonia or sepsis, and the role of drug-resistant bacteria in that instance will just not appear in the records. “It is estimated that about 10 per cent of the Earth’s population are walking around today with antibiotic resistant bacteria in their bodies. This doesn’t matter until they get ill or something affects their immune system. Then suddenly things can get bad very quickly and treatments can be hard to find,” said Professor Garner. He believes what is needed is a holistic view of the problem, and this is something the charity is concerned to promote. “This needs tackling on several levels,” he notes. A general reduction in the use of antibiotics is needed. Using them only when absolutely necessary and using them properly, which means not abandoning a prescribed course,

would drive down selective resistance. It is also necessary to look at repurposing or repositioning existing drugs to see if they can help break down a particular bacterial strain’s drug resistance. “We also want to set up a one-stop-shop website

antibiotic treatments. As the authors of the report note, the time has passed when such research could be left entirely to the market and to individual decisions by top pharmaceutical companies. Such decisions were

for several years now there has been a firm, global realisation at government and national chief health officer level, that drug resistant bacteria represent a massive threat to provide the general public with detailed information about antibiotic resistance,” noted Professor Garner. “This would bring together all the links and leaflets that various laboratories and organisations are producing. That is part of our public education remit as a charity.” The final piece of the jigsaw would be putting together a patient support network for those impacted by the consequences of drug resistant bacteria. “The main point for people to grasp is that bacteria have been on the planet for far longer than humans. They have fantastic survival mechanisms. We still do not understand the multiple resistant pathways that bacteria deploy,” warned Professor garner. “The danger is that so many of our major procedures, be it in cancer treatment, organ transplants or heart or bowel surgery, are absolutely dependent on antibiotics. They play a critical role even in childbirth, so to be without them would fundamentally degrade our medical capabilities.” Prioritising R&D On the positive side, for several years now there has been a firm, global realisation at government and national chief health officer level, that drug resistant bacteria represent a massive threat. The WHO’s global priority pathogens list (PPL), released earlier this year, was put together at the request of member states, specifically to help in prioritising R&D into new and more effective

always driven by a variety of factors, ranging from perceived unmet medical need, pressure from investors, market size, the potential of certain research lines to be rewarding and so on. National PPLs, such as those drawn up by the US and Canada, tended to reflect the concerns of particular countries relative to the threats they saw themselves as facing. WHO’s list has the distinction of being global. It also used a very carefully thought through ranking system, with a number of checks and balances, to generate the list (see boxout below). The aim, as Professor Evelina Tacconelli, who chaired the group drawing up the report, notes, is to inform and shape policy initiatives, and to incentivise basic science and advanced R&D by encouraging public funding agencies and the private sector to channel antibiotic investment to where it is most needed. Perhaps the only controversial thing about the WHO PPL is that it left off Mycobacteria, including mycobacterium tuberculosis, because the WHO decided that drug resistant TB was already sufficiently recognised globally as a threat. Malaria and HIV were also not included as they are caused by viruses, not bacteria. Humankind’s war against lethal microbes continues. Although the issue of superbugs is universally recognised, the challenges they pose are numerous and intractable. So, who will emerge the victor is, at this point in time, anybody’s guess. l

The WHO PPL Priority 1: CRITICAL Acinetobacter baumannii, carbapenem-resistant Pseudomonas aeruginosa, carbapenem-resistant Enterobacteriaceae*, carbapenem-resistant, 3rd generation cephalosporin-resistant Priority 2: HIGH Enterococcus faecium, vancomycin-resistant Staphylococcus aureus, methicillin-resistant, vancomycin intermediate and resistant Helicobacter pylori, clarithromycin-resistant Campylobacter, fluoroquinolone-resistant Salmonella spp., fluoroquinolone-resistant Neisseria gonorrhoeae, 3rd generation cephalosporin-resistant, fluoroquinolone-resistant Priority 3: MEDIUM Streptococcus pneumoniae, penicillin-non-susceptible Haemophilus influenzae, ampicillin-resistant Shigella spp., fluoroquinolone-resistant

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Milan Korcok explores healthcare provision in the UK and Canada Ask any given group of Canadians about ‘privatising’ medicare – their national system of publicly–funded provincial health insurance plans – and you’re sure to hear primal screams from a majority: “No way!” It would be as blasphemous as calling for a TV blackout of hockey on a Saturday night. Medicare is the great unifier: the national icon that differentiates Canadians from Americans (who just can’t seem to get their healthcare right). It’s what Canadians brag about to people of other nations. But it’s also what they increasingly complain about at home, among themselves, for its shortage of family physicians, long wait times for specialist care, hospital bed crowding and emergency room backlogs. Sound familiar? You have only to look at the UK’s NHS, to find a doppelganger – sort of. Back in the 1940s, when Britain’s health secretary Aneurin Bevan was launching the publicly–funded National Health Service and Tommy Douglas, Premier of Saskatchewan was setting the model for what would become North America’s first universal healthcare system – to be known 20 years later by all Canadians as medicare (small m), there was enthusiastic public support for a social experiment that would provide all necessary healthcare to all people ‘free’ at the point of service without their having to endure the humiliations of ‘charity’ care. (Actually, Saskatchewan introduced universal hospital insurance in 1944, four years before Bevan launched the first NHS hospital in Manchester). Two separate, national plans, both premised on a similar principle that healthcare was a national responsibility to be paid for by public funding out of tax revenues – with little intrusion by private sector (i.e. for-profit) interests dedicated to making money off the sick and bereaved (as some more zealous proponents for mission purity would often put it). Though similar in intent and ideology, there are some major differences in the two systems: one especially key one being that Canada’s medicare

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bans private health insurance for core medical services (virtually anything medically necessary). There is one regional exception – we’ll deal with that later. But essentially, private insurance is allowed only for supplemental items like dental and eye care, elective services, executive checkups, pharmaceuticals (except for the elderly), and some adjunctive services like chiropractic or naturopractic. The same but different Unlike the NHS, the vast majority of Canada’s hospitals are private, non-profit entities funded largely by global budgets provided by health ministries; and doctors are private business owners – mostly paid for their services by one single payer, the government. In the UK, parallel private health insurance is allowed, and about 10 per cent of the population takes advantage and pay fees for it. Private practitioners, mostly specialists, provide the services in privately-owned hospitals and clinics where many NHS-salaried physicians also ‘moonlight’ to supplement their NHS pay. Though both systems are solidly supported by their publics – poll after poll attests to that – their evolution over the years has generated powerful reactions by many groups, most vociferously by doctors’ organisations fearful of restraints on their relationships with patients, their own working conditions, their abilities to control use of resources and not least, their own earnings. Both systems have spawned a history of physician strikes, work stoppages, opt-out schemes, acrimonious labour negotiations worthy of the surliest of coal miners’ disputes and yet, they have survived, and grown and grown. And there’s the rub. Have they grown so much over the years that they threaten their own basic, fundamental values and mission: to provide all necessary healthcare to their respective populations without discrimination based on age, health status or financial circumstances and at public expense? Have they just become too expensive for the public purse alone to sustain – or perhaps more pertinent, are there other ways governments choose to spend

tax money? Relations between NHS trusts and their doctors – more work, less pay, longer hours; and the hatefilled fee-setting negotiations between physicians and government healthcare administrators – are deteriorating in Canada’s largest province, Ontario, in recent years. Fast forward According to the NHS’s own data, it deals with over 1 million patients every 36 hours – it caters to a population of 54.3 million and employs around 1.2 million people – a workforce which, it explains, is one of the top five largest in the world along with the US Department of Defence, McDonald, Walmart and the Chinese People’s Liberation Army. Canada’s medicare can’t match those numbers, but it can boast of being one of the developed world’s (OECD) top seven spenders on healthcare (more than 11 per cent of GDP), and of having more healthcare government bureaucrats per population than any other OECD country with a universal healthcare system. According to original research by Matthew Lister, senior director strategic planning with the Ontario Medical Association, Canada’s 32,000 healthcare bureaucrats account for a ratio of 0.9 per 1,000 population. By comparison, Sweden has 0.4 healthcare bureaucrats per 1,000 population, Australia 0.255, Japan 0.23, and Germany (one of the most effective and efficient systems tracked by the OECD) has just 0.06 per 1,000 population. Stalwart though they are, and firmly rooted in the sanctity of public funding and accountability, neither the NHS nor Canada’s provincial health insurance programmes can avoid the ravages of underfunding and its fractious effects on hospital services and staffing, physician availability and access, technological obsolescence, and public frustration with accessibility. According to the highly-respected British think tank The King’s Fund, there are approximately 240 NHS and foundation trusts providing NHS ambulance, hospital, community and mental health services in the UK. Just five years ago, in 2010/11, only five per cent of those trusts

FEATURE overspent their annual budgets. The most recent figures show that 51 per cent of all trusts are planning to end the 2016/17 year in deficit, and last year 66 per cent actually ended their year in deficit. Nearly three-quarters of these trusts are acute care hospitals. Furthermore, in 2012/13 NHS providers recorded a surplus of nearly £600 million in aggregate. Since then, provider finances have deteriorated sharply with an overall deficit of £2.5 billion recorded in 2015/16. And according to the Royal College of Physicians, the NHS in 2016 was: underfunded – 85 per cent of physicians believed that current health service funding was not sufficient to meet demand; underdoctored – falling numbers of medical students and a shortage of doctors were training to be medical specialists; overstretched doctors in training were working an extra five weeks a year on top of rostered hours. A similar picture of public underfunding exists in Canada where healthcare spending for 2016 is projected at CA$228 billion, up 2.7 per cent over 2015, amounting to 11.1 per cent of GDP and equalling $6,299 spent per each individual Canadian. That puts Canada among the top seven highest OECD spenders – most of whom have hybrid or mixed public/private funding sources:

well behind the US, which spends a whopping 17 per cent of its GDP on healthcare, but in a cluster with France, Switzerland, Germany, Sweden and the Netherlands. (The UK is down at around 9.9 per cent of GDP – about the average of all OECD countries.)

country with universal healthcare, for which comparable inventory data is available.” The number one target But what is perhaps most significant, according to the Fraser Institute’s annual tracking of patient

The challenge to the ideology of ‘free’ medical services for all – in the UK or Canada – is whether it can be advanced without degrading health services or diminishing those who must provide them As analysts at the Canadian think tank the Fraser Institute have noted, for a country that spends so much on healthcare, “Canada has substantially fewer human and capital medical resources than many peer jurisdictions that spend comparable amounts of money on healthcare. After adjustment for age, it has significantly fewer physicians, acute care beds, and psychiatric beds per capita compared to the average of OECD countries,” and while it has the most gamma cameras per million population, “it has fewer other medical technologies than the average high–income OECD

wait times for consultations to specialists and referral to appropriate services, is that at any given time, almost one million Canadians (out of a total population of 35 million) are on waiting lists for necessary medical services – a record exceeding that of any other OECD country with a universal healthcare system. Despite such waiting lists, and with provincial governments all fighting growing budgetary deficits, it’s inevitable that healthcare, which accounts for 30 to 40 per cent of any province’s budget, is the number one target for politicians >>

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FEATURE and bureaucrats wielding budget restraints, and the methods used are not subtle. In the province of Ontario, which is home to some 30,000 physicians – the vast majority of whose earnings are based on publicl-negotiated fee schedules – vehement arguments over fee cuts and other restraints in 2015, 2016 and 2017 have almost drawn blood from dissident groups in the Ontario Medical Association who feel their own association (the OMA) has capitulated to health ministry bureaucrats in its fee negotiations. The tensions between the factions earlier this year surfaced in ugly social media exchanges that resorted to obscenities and even physical threats. In a warning shot fired in January 2017, OMA president Dr Virginia Whalley asserted: “It is with profound disappointment that we (Ontario’s physicians) must consider job action in order to achieve binding arbitration, which is necessary to right the current power imbalance with the government ... the government is knowingly underfunding the medically necessary care that patients need and have forced the creation of long waiting lists for tests and treatment.” The OMA ultimately won the right to binding arbitration: the results yet to be known. At the NHS, strikes, boycotts and battles between doctors fighting for what they believed was their right to retain independent contractor status rather than become salaried employees have dated back to the earliest days of the system, 1947, and have resurfaced regularly in the interim. Jack Saunders, a research fellow on the Cultural History of the NHS Project at the University of Warwick writes in an article for The Guardian: “Over its 67 years of existence, doctors in the NHS have forged an increasingly strong relationship to

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the service and to colleagues. Decades of working together for an embattled public institution seems to have forged a new solidaristic collectivism, enabling them to now use ‘defence of the service’ and inter-occupational solidarity as an increasingly important weapon in their collective action.” On both sides of the Atlantic, therefore, the ‘us vs them’ mentality is strong and thriving among medical professionals and the services in which they work. Early this year, after the UK Treasury rebuffed a request for more funding, NHS England’s chief executive Simon Stevens approached hedge fund investors to borrow up to £10 billion to update hospital buildings and equipment systems, improve specialist care at GP surgeries, develop quicker treatment for cancer and mental illness, and a whole range of other critically needed fixes. The revelation of his appeal alarmed privatisation sceptics, especially media who characterised the advances to private lenders as ‘supping with the devil’ or worse – one step closer to privatisation. Indeed, the NHS has a not altogether happy history of dealing with hedge funds and other private investors and some of these activities have resulted in bottom line losses to the service in the recent past. In revealing Stevens’ approach to hedge fund investors, The Times commented that the Treasury has a poor opinion of NHS financial management skills, particularly in dealing with fiscally sophisticated hedge fund ‘bosses’. Referring to a programme of Private Funding Initiatives (PFIs)from the Tony Blair era, The Times noted that “Although this helped dozens of shiny new hospitals get built, many believed that they would have been cheaper in the public sector. The NHS is still paying £2 billion a year under PFI deals, with

some hospitals claiming that they have had to cut other services to meet inflexible repayments.” In Canada, even though private insurance is banned for core medical services, 30 per cent of healthcare costs are covered by private sources through supplemental insurance, out-of-pocket charges for drugs, eyeglasses, dental and elective services, and, increasingly, private clinics, some of which contract their services to public sector facilities. Private clinics, such as MRI facilities and outpatient surgeries, are also emerging in more locations, allowing people who can afford out-of-pocket services to ‘beat the queue’ and avoid waiting months for scans at their public community hospitals. Can the ‘free for all model’ be recaptured? Though the expansion of such entities appears to be irreversible, it continues to stoke hostility by anti-privatisation constituencies who see private funding as an attack on the very ideology that spawned public healthcare. Many opponents of privatised services complain that it’s unfair to allow people who can afford to pay for certain services any advantage over those who can’t, the consequence of which is to disadvantage all. In 2005, the Supreme Court of Canada, took up a case in which Dr Jacques Chaoulli and a patient who had to wait several months for a hip replacement sued the province of Quebec claiming it was unjust to disallow citizens buying private insurance for publicly insured health services that couldn’t be accessed. In a surprise verdict, the court sided with Dr Chaoulli and ruled that the provincial government could not prevent people from paying for private insurance for healthcare procedures covered under medicare, that ‘access to a waiting list is not access to care’. The case emboldened supporters of private healthcare funding across the nation: in Winnipeg, a privately funded surgical centre offers MRIs for $695 to people exhausted by waiting for diagnostic services in the public Queue. The MRIs are done by technologists who left the public service. In Quebec, the government itself is allowing private medical insurance for higher quality treatments. The governments of Nova Scotia and Alberta are exploring the use of private facilities to bolster their public services. And in British Columbia, private clinics offering outpatient surgery and other services are thriving. One of them is directed by Dr Brian Day, a past president of the Canadian Medical Association, now a leader of what he terms is “Our constitutional challenge against government laws that ban private insurance for medical services…” The challenge to the ideology of ‘free’ medical services for all – in the UK or Canada – is whether it can be advanced without degrading health services or diminishing those who must provide them. One must be able to support one’s ideology, or if the money isn’t there, be prepared to compromise – even if it means supping with the devil: an exercise in having it both ways. l

FEATURE

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FEATURE

The collapse of talks aimed at reuniting a divided country might just be a blessing in disguise for the Turkish Republic of Northern Cyprus and its hospitals sector. But the TRNC’s ramshackle bureaucracy is not making it easy for investors. Robin Gauldie reports The Turkish Republic of Northern Cyprus (TRNC) should look like a good bet for international hospital developers looking for new horizons. It has a well-educated, multi-lingual workforce, which includes a high proportion of medical and surgical staff, an enviably high rate of economic growth compared with most eurozone countries, and a location close to potentially lucrative medical travel sources in the Middle East, Russia and the European Union (EU). Yet, despite the ambitions of its several homegrown private sector hospital companies and their partners in nearby Turkey, development in the international hospital sector has not been the success story some have hoped for. Obstacles include a bureaucracy that some sources believe does not do all it could to smooth the way for investors. Governance is another concern. Because of its ambiguous status, EU regulation and legislation does not apply in Northern Cyprus (as it does south of the ‘Green Line’ that separates the island’s two political entities), so the TRNC is literally a law unto itself and has a reputation for sheltering some shady characters, such as Asil Nadir, the Cypriot-born millionaire jailed for fraud in the UK in 2012, who returned to his native land after release from prison in 2016. Ongoing discussions Meanwhile, EU- and US-based hospital companies that might otherwise be tempted to dip a toe in Northern Cypriot waters are reluctant to be seen to be doing business in what the legitimate Republic of Cyprus proclaims an illegal state. The current TRNC government makes the right noises. Tourism minister Fikri Ataoglu claims that the TRNC attaches great importance to medical travel.

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Earlier this year, Ataoglu spoke of new bilateral co-operation agreements with ‘various countries’ and said legislation would be implemented ‘soon’ to develop the sector. However, there is no real indication that this is more than wishful thinking. Parliamentary elections are due early next year, and with up to a dozen parties in play prime minister Huseyin Ozgurgun’s government is more concerned with electioneering than with the small print of legislation aimed at developing private health infrastructure. Discussions between the Republic of Cyprus and its breakaway neighbour rumbled on through 2016 and 2017, with interventions from interested or neutral parties including the United Nations (UN), EU, Turkey, Greece and Britain. Amicable settlement turned out to be a mirage. Hopes of an end to the rift that opened in 1974 were dashed in July when talks ended without agreement. Each side, predictably, blamed the other for its intransigence. Reunification is now off the table for the foreseeable future, perhaps forever. The TRNC must now abandon hopes of joining the EU – with the economic benefits that would bring – and start to plan a different future. Its leaders are now likely to seek wider recognition of the TRNC as a legitimate state, paving the way for inward investment and easing access for visitors. That could make it an attractive investment option for international hospital groups – but only if the TRNC can get its act together. With a population of 314,000, the TRNC, created after Turkey’s invasion of the island in 1974, is recognised only by Turkey, which maintains a significant military presence. The EU recognises the Republic of Cyprus, which joined the EU in 2004, as the only legitimate government of the island and regards the North as Turkish occupied territory to which EU legislation and regulation does not apply. Northern Cyprus’s peculiar status makes it difficult for any except local and mainland Turkish investors to invest in developments such as private hospitals.

A further disincentive is the issue of obtaining clear title to real estate, as many of the ethnic Greek Cypriots who were driven out of the North in 1974 maintain claims to property in the TRNC. In the southern part of the island, the Republic of Cyprus has been actively trying to develop itself as a medical travel destination for some years, admittedly without runaway success despite its membership of the EU and the eurozone, which ease access to European source markets, sources of private investment and EU development funds. In the North, lack of direct access from potential overseas markets, more limited access to investment funds and uncertainty over the breakaway state’s future status have all held back growth in the international hospitals sector. Overcoming obstacles One significant obstacle to growing medical travel is the long-standing international embargo on all direct flights to Northern Cyprus, which forces airlines flying into the North’s Ercan International Airport to make a token touchdown in Turkey – the only country that flouts the ban. In June 2017, the UK tightened its rules to insist that all passengers flying between the TRNC and Britain must disembark and undergo luggage screening in Turkey en route. Since 2004, it has become easier for visitors to enter Northern Cyprus from the Republic of Cyprus. With seven border crossing points now open and streamlined border procedures between North and South, it is relatively easy to travel from the UK, Germany and other EU countries to Northern Cyprus using flights to Larnaca in the Republic of Cyprus, with land transfer to Girne (Kyrenia) typically taking around 90 minutes. However, such travel could be limited or banned at the whim of either government. Now that reunification is no longer a realistic goal, Northern Cyprus may be drawn into an even closer political and economic relationship with Turkey, where hospital development by entities like Acibadem Hospitals Group (majority-owned

FEATURE by the giant Malaysian-Singaporean group IHH Healthcare) and Medical Park International have expanded rapidly. Turkey has more than 40 Joint Commission International (JCI)accredited hospitals, according to the Turkish Association of Private Hospitals and Health Institutions (OHSAD). According to some sources, the supply of hospital services in Turkey now exceeds demand. That may have prompted Acibadem’s announcement last year of plans to acquire Bulgaria’s largest private hospital and expand into Russia and Romania. There are already signs that some Turkish hospital groups see the TRNC as a new frontier, not least because state healthcare provision is struggling to cope with the needs of a growing population. Doctors and other health workers have warned of staff shortages at hospitals such as Girne’s Akcicek state hospital. In June, doctors called a ‘lightning strike’ in protest at staff shortages, saying the hospital no longer has the

Near East University Hospital to meet a perceived shortage of well-equipped hospital beds to serve growing numbers of patients. The new complex includes 38 private wards, eight operating theatres and three intensive care units (one for newborns) and cardiogram and radiology units, and specifically aims to pioneer international health tourism to the TRNC, according to its spokesman Dr Ozgur Turk. The Dr Suat Günsel Hospital took just under a year to complete. Another, more ambitious project is taking longer. In 2013, the Turkish hospital group Florence Nightingale announced a joint venture with Istanbul Bilim University and Girne American University to build the €160-million Smart Health and Medical Center complex in Girne, Kyrenia, which would offer a range of specialist services and, claimed GAU chairman Serhat Akpinar, make Northern Cyprus a regional hub for international patients. “This project will be the biggest health investment project that has ever been made for

There are already signs that some Turkish hospital groups see the TRNC as a new frontier, not least because state healthcare provision is struggling to cope with the needs of a growing population capacity to meet demand. Akcicek has 17 physicians to serve 75 beds, compared with 23 doctors and 56 beds in 2003, according to Sila Usar, leader of the TRNC doctor’s union. Recognising progress As in Turkey, most of the TRNC’s private hospitals are linked to the country’s eight universities. Founded in 2010 in Nicosia, Near East University Hospital, a pioneer of medical travel to the TRNC and still the largest in Northern Cyprus, has 209 private single-patient rooms, eight operating theatres, a 30-bed ICU and a full portfolio of support and diagnostic services. One healthcare supplier that has already made some progress in pioneering the international medical travel sector in Northern Cyprus is Turkey’s Kolan Hospital Group. Kolan British Hospital in Lefkosa, Nicosia, the newest in its portfolio of 10 clinics and hospitals, opened in 2013. With 100 beds, three operating theatres and 35 ‘VIP’ rooms, it offers diagnostic procedures including MR and TK technology, ultrasound, mammography and bone density scanning and treatments including cardiovascular and bariatric surgery, infertility treatment, plastic surgery, hair transplantation, and dentistry. Kolan has forged a relationship with Esti Tour, a Polish specialist medical and cosmetic surgery tourism facilitator that advertises the ‘cheapest medical solutions worldwide’ and promotes medical travel to hospitals in Poland and Turkey, claiming standards of care and treatment that match those in Western Europe, but at prices that can be 60 per cent lower. Other recent developments in Girne include the Dr Suat Günsel University of Kyrenia Hospital, opened in 2017 by former staffers of Nicosia’s

TRNC,” Akpinar stated. The complex, planned to include 12 polyclinics, an emergency room and intensive care units, and an addiction and rehab centre, was scheduled for completion in 2015 as the first of six hospitals to be managed by Group Florence Nightingale in Northern Cyprus. In 2016, Akpinar said it would accept its first patients in February 2017, and also announced plans for future hospital developments in Nicosia, the TRNC’s capital and largest city. However, the project has been plagued by delays, blamed by its developers on TRNC bureaucracy. In a statement, GAU’s health investment co-ordinator Günhan Nalbantoğlu said bureaucratic obstacles to investment had meant the new complex would

open some 18 months later than planned. “We are not the source of the delay,” Nalbantoğlu insisted, implying that the TRNC government had not smoothed the way for the project’s inward investors. “Of course there will be procedures and bureaucracy, however all the services with investment should have been prioritised.” Unknown impact The TRNC’s problematic relationship with its southern neighbour and with the rest of the world, the lack of any objective local media coverage, and an endemic lack of transparency make it hard to determine that status of the project. Neither Group Florence Nightingale nor Girne American University were willing to comment to the International Hospitals & Healthcare Review (IHHR) on whether it will, in fact, go ahead as originally envisaged. The lack of transparency surrounding the GAU hospital project also extends to international accreditation. Launching the Girne project, Serhat Akpinar implied the new hospital would meet ‘European Union health structures general criteria and JCI accreditations criteria’, but neither entity appears to have been involved at this stage. Similarly, Near East University Hospital claims that ‘the criteria set forth by the JCI have been adopted in advance in order to be recognised as a world-class health center offering the best possible medical and other relevant services’. However, JCI in fact lists no accredited hospitals in either the TRNC or indeed in the Republic of Cyprus. It is still too early to tell what long-term impact the failure of reunification talks may have on the TRNC’s private medical sector. However, it is clear that despite the ambitions of hospital developers and politicians, uncertainty, bureaucracy and lack of transparency will continue to be formidable obstacles that must be removed if the TRNC is to attract the foreign partners and investors that it needs to fulfil its dream of building a thriving private medical infrastructure that will attract an international clientele. l

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INTERVIEW

ranked US academic and research hospitals of The WorldCare Consortium. While other providers seem to be losing sight of the human element, our members are our number one priority. Our company was founded on the belief that everyone deserves access to the best healthcare and we continue to remain steadfast in our commitment to making this happen. We are proud of our member satisfaction rating, which is above 98 per cent and we will continue to work hard every day to keep it at this level and even try to make it 100 per cent.

Dr Richard Heinzl, global medical director of WorldCare International, Inc discusses the company’s continued evolution and how it is positively impacting on healthcare outcomes worldwide How and why was WorldCare established? Founded in 1992, WorldCare was originally focused on technology and telemedicine operations emanating from Massachusetts General Hospital (MGH). As the pioneer in the field, MGH was the first hospital to test teleradiology in 1968. As an off-shoot of MGH, WorldCare was the first company to obtain Food and Drug Administration (FDA) clearance for wavelet compression, which allowed diagnostic quality images to be compressed and sent digitally. Thus, we were able to send

Why is there such a large proportion of misdiagnosed patients? Medicine is highly complex. Differences in diagnosis and treatment decisions are part of the fabric of medicine. Therefore, there are many reasons why one in 12 adult patients is misdiagnosed. With over 10,000 diseases and only 200 to 300 symptoms, primary care physicians are simply not able to diagnose their patients with the accuracy and precision that the medical specialists and sub-specialists of the world’s leading research and academic hospitals have, as these generalists do not have access to the most recent clinical research and most cutting-edge medical information. On the other hand, the physicians in The WorldCare Consortium have particular expertise with rare and complex conditions as well as access to clinical trials and experimental treatments, which helps reduce the chances of misdiagnosis. Other contributing factors to misdiagnoses include incorrect radiology and/or pathology readings

The physicians in The WorldCare Consortium have particular expertise with rare and complex conditions, as well as access to clinical trials and experimental treatments, which helps reduce the chances of misdiagnosis medical records quickly and securely, providing second opinions within days of receipt of complete medical records and even within hours if necessary. As we evolved, we continued to adhere to the highest-quality standards, initially working with only Harvard Medical School affiliated physicians to provide critical illness medical second opinions. WorldCare is recognised as the world’s leader in providing the highest quality, virtual medical opinions for serious illness. Our mission was, and continues to be, to improve healthcare outcomes of our members worldwide by connecting our clients to the foremost medical experts at the top-

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and reviews related to the limited availability and access of sub-specialists in these two fields and inaccurate, lost or unreported test results. In addition, overconfidence in the abilities of one’s own doctor is also a contributing factor, with a recent Gallup poll indicating that 70 per cent of Americans do not feel the need to check for a medical second opinion. What more can be done to improve the situation? The correct diagnosis of a serious illness can be a complex process, due to the fact that the

diagnosis might need a multidisciplinary team approach, similar to the tumour board process in the case of a cancer diagnosis. Treatments for serious illnesses are constantly being refined and updated based on new medical research and innovation. Obtaining a medical second opinion from a team of specialists at a world-class research and academic hospital will ensure that the diagnosis and recommended treatment plans are based on the latest information and research available, along with the expertise of specialists and sub-specialists whose knowledge is focused and precise. To improve the situation, medical second opinions from top-ranked hospitals, such as those of the WorldCare Consortium, can be obtained and delivered, along with a wealth of relevant information, to patients and their treating physicians, in order to confirm or modify a diagnosis and implement the most effective treatment plan going forward. How does WorldCare ensure it remains at the cutting edge of medical technology, research and information, and why is this important? The WorldCare Consortium hospitals are at the forefront of medical research, with access to over 20,000 medical specialists and sub-specialists with more than US$4 billion dollars in annual biomedical research funding. These hospitals conduct advanced clinical trials, have access to state-of-the-art technology and are spearheading the collection and publication of the most upto-date research and information. The hospitals of The WorldCare Consortium lead the world in identifying and treating rare, serious and complex medical conditions, and have access to the most current and advanced disease treatments. Our unique relationship with these hospitals dictates that our team maintain a high level of knowledge of the most advanced medical remedies, which enables us to provide our clients and their members and treating physician with direct access to this information so they can make informed decisions about how best to proceed with their care. With the rapidly advancing science of medicine, having access to this calibre of research, technology and expertise cannot be replicated and helps to improve medical outcomes. What are some of the key issues facing diagnosis and treatment? Due to the very nature of critical illnesses, one physician cannot possibly have all the answers or access to the research and technology available to effectively diagnosis these ever-evolving diseases. Plus, the rapidly changing treatments available

INTERVIEW make it nearly impossible for physicians to stay abreast of the latest protocols. That is why good medicine today is a collaborative effort between teams of physicians working together in the best interests of their patients. How is WorldCare working to help tackle these? What progress has been made? We break down these boundaries for treating physicians by providing access to teams of specialists and sub-specialists at The WorldCare Consortium hospitals, which have access to the latest research and protocols. Thereby empowering treating physicians with the information and resources needed to make optimal treatment choices for their patients. As a result, in 26 per cent of the cases we have reviewed we have changed the diagnosis and in 75 percent of the cases we reviewed we have recommended a change in treatment plan, ultimately improving outcomes while reducing costs. Can you tell us about WorldCare’s unique disease management approach? Tertiary care medicine, which deals with complex medical illnesses, is always managed by a highlyskilled group of medical specialists and subspecialists (tumour board process for a cancer diagnosis) operating under one roof of an advanced

medical institution. We are the only provider who replicates this process by using a unique disease management approach that digitally recreates the experience of a patient walking into one of these advanced medical institutions in the US to provide the highest-touch coaching, virtual medical second

Northwestern Memorial Hospital and UCLA Health. WorldCare’s unique, contractual, strategic, technological and operational relationship with the hospitals of The WorldCare Consortium enables us to have multi-disciplinary teams of the top specialists and sub-specialists review each and

Our company was founded on the belief that everyone deserves access to the best healthcare and we continue to remain steadfast in our commitment to making this happen opinions available worldwide. This is done by first collecting, reviewing and consolidating each member’s medical records into a concise history and ensuring they meet our strict quality standards before selecting the most appropriate hospital to review each case based on the diagnosis. Then, once the hospital is selected, a team of specialists and sub-specialists within the selected hospital is established to provide a clinically deep review of the case. Including, if necessary, re-reading radiology and re-doing pathology in order to ensure the diagnosis is accurate and to provide optimal treatment plan recommendations. Then, if needed we go a step further and have yet another team of specialists at another leading hospital review the case if the diagnosis varies from the original diagnosis or treatment recommended. It is this collaborative, team approach to medicine that is unique to WorldCare; other providers simply have only one physician review the case. We will always go as far as needed to ensure our members and their treating physicians receive complete and exceptional guidance. All of which is completed within days of receipt of complete medical records and even within hours if necessary. What is the WorldCare Consortium and what makes it unique? The WorldCare Consortium is a network comprised of the top-ranked academic and research hospitals in North America, including Harvard-affiliated Brigham and Women’s Hospital, Massachusetts General Hospital, Dana Farber Cancer Institute and others including: Mayo Clinic;

every case. We average around four specialists reviewing each case. This depth of clinical rigor is unmatched in the industry, and, because of our direct link into the Consortium hospitals, we are able to submit our cases past the hospitals’ firewalls directly into their daily workflow, resulting in consistent turnaround times of days of receipt of complete medical records, and if necessary within hours. And, in cases where the diagnosis varies from the original diagnosis or treatment, we have yet another team of specialists from another hospital within The WorldCare Consortium provide an additional review of the case for an added level of clinical-rigor. If requested, we also facilitate a conversation between the treating physician and the specialist within 30 days of completion of the medical second opinion. What will WorldCare’s focus be in the coming five to 10 years? We are working with our clients to develop laserfocused medical second opinions that address the key issues their covered members/employees are facing. This includes adding new levels of reviews to our existing medical second opinion service that specifically address mental health issues, pain management, speciality drugs and disability. These will improve patient care needs while also introducing ways of containing healthcare costs, which are increasing dramatically. We will also continue to expand The WorldCare Consortium to meet the increasing demand for our services and expand our investment in the infrastructure; technology and staffing needed to support this demand. All while never losing sight of our priority: improving healthcare outcomes for our members while reducing costs. Can you discuss your hopes and expectations for the future of patient care and diagnosis? Medical science is advancing rapidly, some would say exponentially, and this is bringing tremendous potential for improving human health. The institutions we work so closely with are at the forefront of these changes. WorldCare takes these profound capabilities and knowledge and puts it in the hands of the referring physician and our members. As medicine continues to evolve, WorldCare will be uniquely positioned to lead in this regard worldwide. l

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FEATURE

Accreditation is more than just a marketing tool for international hospitals, reports Robin Gauldie As the international medical travel sector expands and matures, accreditation – the internationally recognised evaluation and assessment by independent organisations of hospitals and other providers – has become an important tool for healthcare providers seeking to expand their services into international markets. Accreditation has expanded rapidly since the 1980s. Its growth was initially driven in part by adverse media coverage of quality failings and an increased perception of the need to emphasise patient safety, and it has become a key part of the health provision strategy of more than 70 countries. By providing independent constructive criticism, its proponents say, accreditation can in some cases be of value to a national public health service that seeks to improve its performance and the quality of healthcare it provides. Several European governments dabbled with the concept, but none except France – which subjects all public-sector and private health service providers to external review – have rolled it out at national level or made it mandatory. The accreditation game In part, this is because adopting state-operated accreditation is not a comfortable fit with most European health systems, which typically rely on state provision of hospital and other medical services, in partnership to a greater or lesser extent with private providers – unlike the US and many

developing nations, where the private sector plays a much bigger role. “Government accreditation is somewhat of a contradiction in terms, since a third party is needed to guarantee independence. In addition, government accreditation tends toward regulation – that is, the traditional emphasis on aspirational standards gives way to an emphasis on compulsory minimum requirements,” note the authors of a report published in 2002, as the concept of international accreditation was beginning to gain traction. So, on a global basis, accreditation is the province of non-governmental organisations like the USbased Joint Commission, a prime mover in rolling out accreditation to hospitals worldwide since launching its international wing, Joint Commission International (JCI), in 1999. In turn, the major accreditation organisations are themselves accredited by the Dublin-based International Society for Quality in Healthcare (ISQua), which examines their organisation, standards and training, and is keen to emphasise that this provides end users with further assurance that their scrutiny of candidate hospitals is exacting and reliable. “Being accredited by ISQua means that we have been thoroughly evaluated against international standards. We have earned all three of ISQua’s accreditation awards – for our organisation, our standards, and our surveyor training programmes,” stated Accreditation Canada. The gold standard The non-profit JCI now conducts around 90 per cent of international accreditations, and by its own estimation is considered the gold standard in global

“I wouldn’t get on a plane unless there were standards and checklists. And I certainly would be very, very concerned if a hospital I, or someone I knew, was entering indicated they did not evaluate their performance against standards.” 30

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healthcare. In a rapidly expanding sector of the international healthcare industry, it rubs shoulders with a number of other accreditation organisations based in countries where private and public sector hospitals are implicitly recognised as setting the standards that those elsewhere must meet in order to access international medical travel source markets. They include the Australian Council on Healthcare Standards, Accreditation Canada, and the UK’s QHA-Trent, a successor to the Trent Accreditation Scheme. Almost 700 hospitals in 90 countries worldwide have received JCI’s seal of approval and more are being added at the rate of around 20 per cent annually. To an outsider, accreditation may seem like just another marketing tool, designed to boost an accredited hospital’s reputation and inspire trust. However, accreditation organisations say its benefits are more extensive than that. “Are standards necessary?” asks Dr Christine Dennis, CEO of the Australian Council on Healthcare Standards. “Clearly, yes. I wouldn’t get on a plane unless there were standards and checklists. And I certainly would be very, very concerned if a hospital I, or someone I knew, was entering indicated they did not evaluate their performance against standards.” The ACHS created its international offshoot, the Australian Council of Healthcare Standards International in 2005. It began by signing up hospitals and clinics in Hong Kong (where it now lists 34 institutions), then expanded into Macau, China, Taiwan, Indonesia and Singapore. More recently, it has accredited hospitals in India and has moved into the Arab world, accrediting hospitals in Bahrain, Saudi Arabia, Oman, Qatar, and the UAE. It now lists a total of 81 institutions and continues to expand. Accreditation, Dr Dennis says, provides an opportunity for health services to be reviewed by peers and to receive feedback on how they are performing against the standards. “We do not >>

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FEATURE actively market, but rather respond to organisations that contact us because they have decided to seek accreditation. Their motive may be compliance with a directive from a funding body or regulator, or that the leadership team see value in having an independent perspective,” she said. Dr Dennis is firm that accreditation cannot be a one-time rubber stamp of approval, while at the same time, responsibility for standards must always remain with the hospital. “Accreditation should not assume a fixed or continuing status, as it is ongoing. The leadership around standards and patient safety needs to be part of the organisational culture. Accountability cannot be outsourced to an accreditation agency,” she said. Meanwhile, the proliferation of accreditation agencies “provides healthcare services with a choice and ensures providers deliver services based on the organisation’s needs.” A growing market Like Dr Dennis, Dr Paul Chang, JCI’s vicepresident, accreditation, standards and measurement, maintains that the spread of accreditation by international organisations is driven by demand from the hospitals themselves. He points out that while accreditation and quality control at national level may meet the requirements of hospital users domestically, hospitals and other treatment providers that want to forge relationships with international users need a seal of approval that is quickly recognisable to potential clients such as health insurance companies. He believes it’s not a question of national programmes being unable to provide adequate quality control but more of recognition. “National schemes need to cater to up to 100 per cent of their local market, so depending on how homogeneous your local market is that may not be something that can easily be met by a national system.” Some providers, Chang says, feel that their national system does not provide enough recognition outside their country. “We have had operators who tell us that they know that that they provide high standards and a high level of care but that they find it difficult to initiate a conversation, for example with major international insurers, without the

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higher level of credibility that certification by an organisation like JCI gives.” Chang also concurs with Dr Dennis that a greater number of accreditors operating globally can be a positive influence. “What we have seen is that there are more operators that want to enter the international accreditation market. Some have looked at the success of JCI and hope to emulate that and we are perfectly fine with competition. The market is big enough to accommodate the current players or even more players,” he said. “I do think that having more providers is better than having fewer – with the caveat that that the providers coming into the market are not flyby-night operations who see easy money but are sustainable and long term, not proving certification or accreditation too easily.” An ongoing process Liz Brownhill, chief operating officer of QHATrent, a UK-based for-profit accreditor, agrees that to be effective accreditation should be ongoing. She too says that the spread of international accreditation is driven by demand from hospitals. “The whole process briefly is that usually a hospital or clinic expresses interest in accreditation. Some want to attract medical tourists, others want to show [the domestic market] that they provide the highest level of care by being externally evaluated,” she said. “All the hospitals have found that the way we have worked with them has been developmental and helpful. It is encouraging to the staff to see the praise the surveyors include in the reports and it gives them motivation. Accreditation also provides reassurance to government, the public and patients about the level of care.” QHA Trent was launched in the UK in 1993 to meet a perceived need to monitor quality of care in smaller community hospitals in central England. Initially, it was an independent scheme under which hospital staff were trained to survey other hospitals against set standards. In 1999, the scheme expanded to include 12 private hospitals in Hong Kong. “It was clear that the method worked very well with large hospitals outside the UK,” commented Brownhill. “Eventually all the work was overseas, so in 2010, it was agreed it was

no longer appropriate for it to continue within the [UK] National Health Service. Accordingly, clinicians who had been surveyors established QHA-Trent as a commercial company. Full accreditation is for two years but recommendations are always given to enable the hospital to develop further. There are options for shorter times if there appears to be any risk to the organisation,

accreditation organisations should be sensitive, within limits, when dealing with different cultural expectations staff or patients. The philosophy of developing organisations and people remains one of the crucial parts of QHA accreditation. Our standards are all based on UK guidelines, Royal Colleges advice and professional guidelines as well as international ones.” However, Brownhill points out, accreditation organisations should be sensitive, within limits, when dealing with different cultural expectations. “We do not impose ways of working,” she said. “It is possible to meet the standards in the way which best suits the hospital or clinic. We can also amend the standards to meet local cultural practice where this does not impose a risk to the organisation. For example, in Hong Kong, care of newborn babies is very different from that of UK and we took account of that and accommodated it in how we assessed them. The standards are rigorous.” Benefits aplenty According to Accreditation Canada, another organisation that has added a growing number of hospitals in Asia, Latin America and the Caribbean, the Middle East and Europe, (where it is particularly strongly represented in Italy and Slovenia) the process of accreditation ‘demonstrates credibility and a commitment to quality and accountability,’ ensures an acceptable level of quality and ‘improves an organisation’s reputation among end-users and enhances their awareness and perception of quality care’. Other benefits, according to Wendy Nicklin, Accreditation Canada’s president and CEO, include: providing a framework that improves and sustains operational effectiveness and advances positive health outcomes, better internal and external communication, stronger interdisciplinary team effectiveness, efficient and effective use of resources; enables ongoing self-analysis of performance in relation to standards; provides healthcare organisations with a well-defined vision for sustainable quality; stimulates sustainable quality improvement efforts; and increases healthcare organisations’ compliance with quality and safety standards. So the case for hospital accreditation is convincing, and it is clear that hospitals worldwide perceive a need for it. Expect more institutions to acquire such credentials in the future. l

FEATURE

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DESTINATION SPOTLIGHT

THAILAND The country is an attractive destination for international patients writes Tatum Anderson With one of the fastest growing universal health systems in the world, Thailand is ensuring its citizens can access health services free at point of access. It’s working hard to make itself an attractive destination for international patients too. The country’s medical facilities are less expensive than neighbouring destination Singapore, but more pricey than other destinations in the region, such as Korea or Malaysia. “Thailand is cheap but not the cheapest, Thailand is advanced but not the most advanced in all fields, but Thailand, in my biased opinion, has the best overall package – price, quality, speed of service and hospitality,” said Danny Quaeyhaegens, head of the international insurance department at Bangkok Pattaya Hospital in Thailand. Thailand attracts a wide range of different patients too, according to Nicolas Leloup, assistant director, international marketing at Samitivej Hospital, based in Bangkok. “Our neighbouring countries do not have quality medical providers and their most affluent system will seek healthcare in Thailand or Singapore,” he said. He also stated that Thailand appeals to many expatriates whose employers have set up their South East Asian offices in Bangkok. Establishing a global centre Since 2003, the Thai Government’s strategy has attempted to make Thailand a global centre for medical travel through efforts such as international road shows and tax exemptions for investment in new health facilities that target international patients. Most recently, it has been pushing wellness businesses. In August, its Tourism Authority of Thailand (TAT) launched the ‘Thailand: Paradise for Longevity’ campaign to promote the kingdom as a destination for products and services for a longer life. It is also attempting to encourage public hospitals to develop international standards of care to service both domestic and foreign customers (there are around 3,000 hospitals, many of varying quality according to the Medical Travel Quality Alliance (MTQUA)). Most of its medical travel business is conducted via private

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hospitals. University hospitals are understood to have requested additional budgets to invest in infrastructure to cater to this market. In March, the government also approved 90day visas for patients and medical visitors from Cambodia, Lao PDR, Myanmar and Vietnam (CLMV), as well as from the People’s Republic of China, in a bid to boost medical travel in Thailand. Interestingly, long-stay 10-year visas are now available for senior nationals of 14 countries including: Japan, Australia, Europe, Canada and the US. Growing accreditation Thailand now has 58 Joint Commission International (JCI)-accredited hospitals. And perhaps the most high-profile is Bumrungrad International Hospital, which has become synonymous with Thai medical travel. The largest outpatient facility in the world, it boasts 12 stories, 1,200 physicians and dentists, 900 nurses and 580 inpatient beds. It treats over 1.1 million patients each year (outpatient and inpatient). Over 520,000 are international patients from over 190 different countries, it estimates, with a turnover of US$477 million in 2013. The Bangkok Hospital group also benefits from

it’s difficult to quantify the real number of international patients, experts say business from international patients. It is a chain of hospitals owned by Bangkok Dusit Medical Services (BDMS), which originally began life providing medical services to American soldiers during the Vietnam War. It operates throughout the country, from Bangkok to Chang Mai in the North, and coastal areas in the south too. Samitivej Hospital – another BDMS hospital – has been recorded as one of the best hospitals in the world, according to MTQUA. It was one of the first private hospitals to obtain JCI accreditation – in 2007 – and believes around 44 per cent of its revenue comes from international patients. The Hospital has created a Japanese service centre,

to aid largely Japanese expatriates living in the surrounding area said Leloup. Here, it provides Japanese interpretation, processes documents, liaises with hospitals and medical personnel in Japan, and has a Japanese doctor, as well as Thai medical staff who have spent time in Japanese hospitals. This model has been extended to Arabic, Myanmar and Chinese service centres. Samitivej Hospital also has affiliations with hospitals in Japan and the US, including a neonatal unit. An influx of international patients Generally, international patients are drawn to Thailand from the Middle East and Asia. The highest numbers of international patients in Thailand in 2010 came from the United Arab Emirates (UAE), followed by Bangladesh, the US, and Myanmar, according to a report from the London School of Tropical Medicine and Hygiene. Bangkok receives more international patients than any other part of Thailand. Many expats work in Bangkok; there are many visitors from Oman and Qatar based within Bangkok’s Middle Eastern district of Nana. Coastal resorts such as Samui attract more wealthy holidaymakers and independent travellers from western Europe and Scandinavia. Russians used to come almost exclusively to Pattaya, but now visit many more parts of Thailand. And Pattaya sees more retirees and groups of Asian travellers – especially the Chinese, who have been visiting in record numbers, said Quaeyhaegens: “For nearly two years, we have been seeing groups of Chinese coming with 60 to 100 or more at time for antiageing check-ups.” Quantification challenges However, it’s difficult to quantify the real number of international patients, experts say. The government believes 2.35 million people received treatment in 2014. But some studies have called into question the accuracy of figures. The discrepancy arises because many hospitals fail to distinguish between international patients, expatriates, immigrants and tourists who have simply fallen ill or been injured while on holiday in Thailand. Thai hospitals also report foreign patients by counting the number of visits, rather

DESTINATION SPOTLIGHT

than the number of patients, said Thinakorn Noree of the Ministry of Public Health’s International Health Policy Program (almost 105,000 international patients visited the five

Americans most frequently purchased cosmetic surgery procedures, followed by orthopaedic operations (musculoskeletal) and eye operations (laser surgery and intraocular lens implants are

“The trend we are seeing is a shortage of qualified medical staff. Without good doctors, it is not possible to provide quality healthcare.” biggest private hospitals in Thailand in 2010 according to one study). The fact is, international patients in Thailand do not form a homogeneous group. They are retirees who wait until they reach Thailand for their sixmonth stay to have treatments, those who travel with serious health issues, and those seeking minor treatments while taking a holiday.

popular). Australians arrive for plastic surgery too. Patients from the UAE primarily purchase services such as cardiac catheterisation, angio-cardiograms, other cardiovascular procedures and gastric bypasses, however.

Future challenges Previously, international patients from North America and Europe were assumed to be seeking complicated procedures when they travelled to Thailand for medical care. The reality is, most come for minor elective procedures, such as cosmetic surgery. UK visitors, for example, prefer relatively cheap procedures at the end of their holiday, rather than dedicated medical travel trips with a few days of leisure tacked on. Medical procedures vary with nationality too.

Despite the size of the industry, medical travel generates the equivalent of just 0.4 per cent of Thailand’s gross domestic product. And it has exacerbated the shortage of medical staff by luring more workers away from the private and public sectors towards hospitals catering to foreigners, say researchers. A future challenge will be to ensure there are enough medical staff, in a country with over 22 medical schools and one of the oldest medical schools in the region. Many go abroad said Samitivej’s Leloup, who says his hospital invests in overseas training for doctors. “The trend we are seeing is a shortage of qualified medical staff,” he said. “Without good doctors, it is not possible to provide quality healthcare.”l

Increasing trend of international patient visits

2008

2009

2010

2011

2012E

2013E

2014F

2015F

2016F

2017F

2018F

2019F

Source: Economic Intelligence Center, SCB and Ministry of Commerce

International patients on the rise Procedures (In USD)

USA

Singapore

Thailand

Malaysia

India

Coronary Artery Bypass Graft

88,000

54,500

23,000

20,800

14,400

Valve Replacement with Bypass

85,000

49,000

22,000

18,500

11,900

Hip Replacement

33,000

21,400

16,500

12,500

8,000

Knee Replacement

34,000

19,200

11,500

12,500

7,500

Spinal Fusion

41,000

27,800

16,000

17,900

9,500

Gastric Bypass

18,000

13,500

12,000

8,200

6,800

Source: Patients Beyond Borders 3rd edition by Josef Woodman (2015)

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INDUSTRY VOICE

It was a sunny day on 11 December 2015 when I woke up ready for a partial hip replacement. By the end of the day, I was a catastrophic claimant … or maybe a victim of excessive healthcare provider billing and fraud. You’ll be the judge. The surgery lasted less than two hours and required a one-night hospital stay. In summary, I was in the hospital for less than 24 hours after the surgery. The hospital bill came to about US$140,000. The health insurance and reinsurance industries have seen a significant increase in catastrophic claims as well as overall health insurance costs. Is excessive billing and healthcare fraud a driver of this trend? Well, I believe fraud accounts for onequarter to one-third of total costs, and excessive healthcare provider billing is a significant driver of cost increases. Note that current or previous healthcare bills, along with Patient Protection and Affordable Care Act (PPACA), have not addressed this issue. If we want to reduce the cost of health insurance premiums, then we need to have a meaningful impact on the underlying claims costs driving those premium increases. I challenge you to take the quiz below and come to your own conclusions. When you do, if your reaction is similar to mine – read on – I urge you to share your views with politicians and regulators, to encourage them to take meaningful action against excessive provider billing and fraud, which combined are arguably the main driver of high medical costs and insurance premiums in the US. Question #1: Are you surprised by this bill? If you answered ‘yes’, then you might wonder, why was the bill so high? The answer is simple. I was charged for items not provided. The list is long but here are a few examples: • I received one implantable device manufactured

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by Smith & Nephew but the hospital billed me for 11. The hospital confirmed that this was not a clerical error. • I was billed for multiple physical therapy visits, which were billed at excessive rates, but had none. Had my surgery not been delayed more than five hours due to an overcrowded emergency room (a common event in this hospital, I was told), then I would have had the first day’s physical therapy post-surgery. The problem was that I did not get into my hospital room until very late in the evening, so the physical therapy did not take place the day of the surgery. It didn’t take place the next day (Saturday) since the physical therapists were not on duty on the weekend. • I was charged for someone else’s durable medical equipment. The patient was a woman. I guess the hospital violated the other patient’s HIPAA (Health Insurance Portability and Accountability Act of 1996) rights, but maybe that patient doesn’t mind since someone else was asked to pay her bill. If your answer is ‘no’ then you have probably become jaded by the industry when you hear stories about hospitals and healthcare providers, including this one, and you believe that these are standard billing practices. The reader of this article will come to learn that a significant amount of excessive billing fraud occurs with in-network providers and the insurance industry has lagged behind, and in some cases, been an enabler of these actions. Question #2: How much does an implantable device cost? The cost of the device to the hospital is approximately $1,500. This estimate was validated

by the manufacturer and the hospital. The hospital charged $70,456.48 for it and stated that this is their standard billing practice. This is 47 times the amount of the cost to the hospital, and is clearly excessive. This claim was paid as an in-network benefit, which is equally disturbing since the rule of thumb to the consumer is to go in-network in order to save money for both the consumer and the insurance company, which also benefits the consumer through lower future health insurance premiums. In the health insurance industry, we used the term R&C which stands for either ‘reasonable and customary’ or ‘ridiculous and criminal’. You decide. Question #3: Why would the insurance company pay this claim? My insurance policy, a small group, fully insured product, contains a patient bill of rights that allows for two appeals. The insurance company states that the claim was valid, even though they later confirmed with me after I discovered the facts that it was excessive and fraudulent. A little puzzling, but not without its positive aspects since this decision increased my chances of getting into the Guinness Book of World Records as the man with ‘11’ hips. I thought about applying for Guinness, but I figured that after reviewing the surgical report Guinness would find out I only had one hip surgery. Besides, common sense tells everybody that no one can have more than two hips. I spoke to the insurance company after the second appeal and asked why they were willing to pay so much for an item that costs only $1,500? The response was: “How do you know the costs?” I replied that the manufacturer disclosed the cost, which I validated with the hospital. The insurance company, instead of thanking me for alerting it

INDUSTRY VOICE

about an abuse and giving it a chance to investigate and reopen/correct the claim, wondered why I had called the manufacturer. My response was that I wanted to know the cost because $70,000 seemed excessive. In turn, I posed the following questions to the customer service department: • Why didn’t the insurance company research the costs of the device and procedure? No response was given. • Why wouldn’t the insurance company go back to the hospital and demand a corrected bill? The response was that the hospital bill passed the insurance company appeal process, which was two levels of review. • Can I review the sections of the provider contract that are relevant to my claim, given the fact that there are errors and the Explanation of Benefits does not provide details? The response was that nothing could be done other than contacting the local insurance department. An important question I did not ask is why the insurance company’s claims adjudication system did not reject a claim with astronomical utilisation?

After almost a year of back and forth, the insurance company acknowledged that it paid for 11 implantable devices instead of one. The hospital’s collection agent validated this finding as well as the hospital’s own staff. Despite my numerous requests, the insurance company still will not provide any supporting documentation on why these claims were deemed valid. Consumers should wonder whether the insurance company paid the claim (clearly, they cut a check to the provider for payment) or consumers did? Arguably, consumers paid it since they are held responsible for care not provided, and any resulting premium rate increases because of excessively paid bills. Unfortunately, my claim is one of many, which means that consumers across the country subsidise fraud through unnecessarily higher premium rates. Should the insurance company, once it is aware of fraud, do the following: • Require the healthcare provider to correct its bill? • Offset payments to the healthcare provider against these fraudulent dollars amounts? • Cancel the providers contract for fraud so that it is no longer an in-network provider, so that future members of the insurance company are less likely to go to this provider? • Have better checks and balances in its claims system to edit and pend future claims for excessive billing and fraud? Will holding the insurance company’s feet to the fire on fraudulent and excessive billing make a difference? Understandably, hospitals and insurance Read the full article at www.ccactuaries.org.

plans partner with the intention of offering a competitive product. But excessive billing and fraud should not be allowed to be part of the arrangement. Some regulators have shared with me that some hospital executives and some insurance company executives have hidden compensation arrangements such as kick-backs based on volume, which may be a reason why insurance companies are taking a ‘blind eye’ or ‘deaf ear’ to consumer complaints of fraud. Unfortunately, with healthcare fraud and excessive billing, consumers are the ultimate losers. Normally, one would think that if the insurance company overpaid a claim, then what is the harm? The harm is that insurance premium for consumers goes up. Furthermore, the migration of consumers to higher deductible plans results in an expectation that the healthcare provider, in my case, the hospital, is overbilling the patient for its share. Maybe the insurance company prefers to leave ‘sleeping dogs lying’ rather than contesting the claim, since some organisations may feel it is a winless battle for the insurance industry. When a patient goes to the doctor, the insurance company is not sitting in the room to observe what care is/isn’t provided, which is why excessive billing and fraud goes relatively undetected. At the time of writing, the questions I asked have not been answered satisfactorily or at all by the hospital that committed fraud against me, or the insurance company that helped enable it. I hope the insurance department’s fraud unit and the state attorney general will have better luck in getting answers than I did. l Michael L. Frank Michael L. Frank, ASA, FCA, MAAA is president and actuary of Aquarius Capital. He is also an adjunct professor of the actuarial department at Columbia University, US, as well as an instructor of the Society of Actuaries’ LEARN programme, designed for insurance regulators. He previously served as President of the Actuarial Society of Greater New York, and consults insurance companies, houses in multiple occupation (HMOs), employers, healthcare providers, municipalities, large corporations, and regulators in the insurance industry.

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TECH CORNER

Prime Medical’s chlorine-shielded product line Prime Medical spoke to IHHR about its innovative chlorine-shielded product line, how it is ‘changing the fabric of healthcare’, and its importance in the context of the rise of multidrug-resistant organisms and antibiotic resistant infections Can you introduce us to Prime Medical’s SAF-T textiles and apparel? Prime Medical is changing the fabric of healthcare for life with next-generation textiles and apparel that can be powered with chlorine bleach to continuously fight harmful pathogens. Under the SAF-T brand, Prime Medical manufactures cubicle curtains, patient gowns, bed linens, scrubs and lab coats – all made with a patented fabric technology that when washed with bleach, creates a chlorine shield on the products that can last for up to 120 days with every laundering. In the healthcare environment, soft surfaces including textiles and apparel are often overlooked as sources of contamination. However, just like the hard surfaces such as door handles, IV poles,

can bind chlorine for up to 120 days with each laundering in bleach – a valuable benefit for textiles/apparel held in inventory/storage before

Prime Medical’s chlorine-shielded products are transforming traditional healthcare apparel, curtains and linens into next-generation, germ-fighting tools to support a safer environment for patients and staff use. Each wash fully recharges the fabric with a chlorine-shield, so even at 75 industrial washes, it maintains full capability to bind chlorine. How did the idea come about and reach fruition? Prime Medical’s founder and senior vice president of manufacturing and product development Wayne Wilson discovered the BioSmart fabric technology while sourcing textiles at Milliken & Co. in Spartanburg, South Carolina, US. Wilson immediately realised the profound benefit this fabric technology could have in the healthcare environment for staff and patients. With the rise of multidrug-resistant organisms and the alarming global risk of antibiotic resistant infections, he launched the company on the premise of empowering everyday textiles/apparel with a shield of chlorine molecules – as a simple, safe and smart way to fight pathogens with every fibre.

bed rails and overbed tables, the apparel, linens and textiles worn and used in healthcare are just as capable and culpable in collecting and transmitting pathogens. Prime Medical’s chlorine-shielded products are transforming traditional healthcare apparel, curtains and linens into next-generation, germfighting tools to support a safer environment for patients and staff.

In what ways do Prime Medical’s products seek to support a healthier, safer environment for patients, visitors and staff? When you think about the sheer volume of fabric in the healthcare environment, it’s the primary surface that people are in contact with 24/7/365. With Prime Medical’s SAF-T line, this fabric becomes a surface that can actively kill pathogens like staphylococcus aureus, klebsiella pneumonia, hepatitis A, escherichia coli, salmonella and more. Just like hand-washing and hard surface disinfection, chlorine-shielded textiles/apparel add an important layer that can continuously fight germs. It’s simple – just add bleach to the laundry. It’s safe, causing no skin irritation or sensitivity. And it’s superior – chlorine bleach kills without pathogen mutation and the products are fully reactivated so they are just as effective at 75 washes, as the first wash.

How does the ‘chlorine-shield’ fabric technology work? The patented fabric technology is called BioSmart by Milliken. BioSmart works with bleach in the laundry cycle, providing a surface on the fabric that binds chlorine molecules. In the presence of pathogens, the chlorine retained on the BioSmart treated fabric releases to kill bacteria and viruses. BioSmart is a very durable fabric technology and

Does the product line offer any other advantages? Prime Medical fabrics are designed to be washed in regular bleach without any fading or degrading the fabric through the life of the product. Our scrubs are made with a premium weight 65/35 polycotton blend, providing softness, long-lasting wear and added warmth. What healthcare professionals find most surprising is the direction to launder their scrubs (black, charcoal, navy, hunter green,

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royal blue) in regular chlorine bleach and any detergent. There’s no fear of fading – just wash them like they’re white.

SAF-T scrubs are ideal for healthcare staff that launder their workwear at home. A recent UK study found that domestic laundering of scrubs was often inadequate to remove pathogens from the apparel – creating a risk of contamination for staff and patients. By using EPA-registered bleach in the domestic laundry process with SAF-T scrubs, there’s a greater assurance that garments are sanitised and shielded with chlorine for extended protection. For what healthcare facilities are the products suitable? Prime Medical products are ideal for any healthcare facility – acute care, long-term/rehabilitative care facilities, surgery centres, physician and dental offices. Prime Medical seeks to provide solutions to healthcare areas that serve the most immunocompromised individuals, including burn units, intensive care units, post-anaesthesia care units, dialysis facilities, transplant units and even emergency departments. In what ways are they superior to existing fabrics in the healthcare environment? Traditional antimicrobial fabric technologies have a tendency to lose effectiveness with subsequent launderings. What makes Prime Medical products unique is that each laundering in EPA-registered bleach not only sanitises the products in the laundry process, they become fully recharged with a chlorine shield. What’s next for Prime Medical? The question we’re asked most frequently is to develop a line of sheets and towels for consumer markets, hospitality and cruise lines, so we’re exploring opportunities within those categories. We’re excited to be at the forefront of nextgeneration chlorine-shielded products that work with the safe, trusted and effective power of chlorine bleach. In a complex world of dangerous superbugs and antibiotic resistant infections, there’s much truth to the adage ‘an ounce of prevention is worth a pound of cure’. Our products add another layer of prevention, and if you’re going to buy sheets, patient gowns, cubicle curtains and staff apparel – it’s time to choose a smarter solution that actively fights pathogens with every fibre. l

INTERNATIONAL HOSPITALS DIRECTORY In 2018, IHHR looks forward to bringing you a comprehensive listing of accredited hospitals who are recognised for their international patient care capabilities.

SERVICE DIRECTORY

Acıbadem Healthcare Group Berna Gür – International Network Supervisor Fahrettin Kerim Gökay Cad. No:49 34662 Altunizade İstanbul, TURKEY tel: 0090 530 9768398 website: www.acibademinternational.com email: ops@acibadem.com.tr

Children’s National Medical Center Washington, DC, USA

MedStar Georgetown University Hospital Washington, DC, USA

Cincinnati Children’s Hospital Medical Center Cincinnati, OH, USA

Memorial Healthcare System Hollywood, FL, USA Memorial Hermann Houston, TX, USA

City of Hope Duarte, CA, USA Cleveland Clinic

Cleveland, OH, USA

Cook Children’s Health System Fort Worth, TX, USA

Memorial Sloan-Kettering Cancer Center New York City, NY, USA Minnesota International Medicine Minneapolis, MN, USA

Duke Medicine Global Durham, NC, USA Moffitt Cancer Center Tampa, FL, USA Emory Clinic Atlanta, GA, USA Mount Sinai Medical Center Miami, FL, USA Florida Hospital Orlando, FL, USA

Anatolia Hospital Dr. Irfan Erdogan – General Coordinator Caybasi Mh 1352 Sk No 12 , 07100 Antalya, TURKEY tel: +90 242 249 33 00 fax: +90 242 311 67 78 website: www.anatoliahospital.com email: drirfan@anatoliahospital.com

Nationwide Children’s Hospital Columbus, OH, USA Hospital for Special Surgery New York City, NY, USA Houston Methodist Global Houston, TX, USA

Nemours Children’s Health System Wilmington, DE, USA

Indiana University Health Indianapolis, TX, USA

NewYork-Presbyterian New York City, NY, USA Nicklaus Children’s Hospital Miami, FL, USA Northwell Health New York City, NY, USA

Ann & Robert H. Lurie Children’s Hospital of Chicago Chicago, IL, USA

Jackson Memorial Hospital International

Baptist Health South Florida Jacksonville, FL, USA

Dominick Destefano – Associate Director of Sales 1500 NW 12th Avenue, Suite 829 East, Miami, FL 33136, USA tel: +305-355-1211 fax: +305-355-5545 website: www.jmhi.org email: Dominick.destefano@jhsmiami.org

Boston Children’s Hospital Boston, MA, USA Brigham and Women’s Hospital (Partners HealthCare International) Boston, MA, USA

Northwestern Medicine Chicago, IL, USA NYU Langone Medical Center New York City, NY, USA Ochsner Health System Jefferson, LA, USA Philadelphia International Medicine Philidelphia, PA, USA Princeton HealthCare System Princeton, NJ, USA Rehabilitation Institute of Chicago Chicago, IL, USA

James Cancer Hospital (OSU), The Columbus, OH, USA

Broward Health International Manuela Pujals – Manager Business Development 1608 SE 3rd Avenue, Ste 503-B, Ft Lauderdale, FL 33316, USA tel: +1 954 767 5587 fax: +1 954 888 3874 email: MPujals@browardhealth.org email: Sbaig@browardhealth.org

Cancer Treatment Centers of America Chicago, IL, USA Carolinas HealthCare System Charlotte, NC, USA CHI St. Luke’s Health Houston, TX, USA Children’s Health (Dallas) Dallas, TX, USA Children’s Hospital Colorado Aurora, CO, USA

Roswell Park Cancer Institute Buffalo, NY, USA Johns Hopkins Medicine International Baltimore, MD, USA

Rush University Medical Center Chicago, IL, USA

Kennedy Krieger Institute Baltimore, MD, USA

Scripps Health San Diego, CA, USA

Lahey Hospital & Medical Center Burlington, MA, USA

Seattle Children’s Seattle, WA, USA

Luz Saúde SA Eve Jokel, MPH – International Director Rua Carlos Alberto da Mota Pinto, 17-9.º 1070-313 Lisboa, PORTUGAL tel: +351 213 138 260 fax: +351 213 530 292 website: luzsaude.pt/en email: intlpatientservices@luzsaude.pt

Global Patient Services

Sharp Global Patient Services Jacquie Schwoerke – Vice President, Sharp GPS 8695 Spectrum Center Blvd., San Diego, CA 92123, USA toll free: +1 888-265-1513 tel: +1 858-499-4967 website: www.sharp.com email: Sharp.GlobalPatientServices@sharp.com

Children’s Hospital Los Angeles Los Angeles, CA, USA Children’s Mercy Hospital Kansas, MO, USA

Massachusetts General Hospital (Partners HealthCare International) Boston, MA, USA

Stanford Health Care Stanford, CA, USA

If you are an accredited hospital, working with international patients, a listing in IHHR’s International Hospitals Directory will place your facility in front of our global audience of travel and health insurance professionals. To discuss listing options for your hospital, please contact IHHRʼs sales team: sales@IHHR.global.

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