Medical Tourism Magazine Issue 22 by MT Association

Chicago Editorial

Destination

he world of medical tourism is growing quickly and while in the past years a lot of discussion has revolved around Americans, Canadians and British leaving their borders for more affordable or available care, it is important to remember that medical tourism is also a two sided coin in any country. High quality and modern technology attracts international patients to some of America’s top hospitals and medical facilities. American medical providers are placing their own stake in inbound and domestic medical tourism and are reaping the benefits. Some operate on large levels such as Cleveland Clinic, Johns Hopkins, Mayo Clinic and MD Anderson and others are more specialized in private clinics across the nation. This year at the 4th Edition of The World Medical Tourism & Global Healthcare Congress in Chicagoland, we have developed a dedicated track to Inbound and Domestic Medical Tourism to the US topics to bring greater participation and integration with the US healthcare industry. Long gone are the days where US healthcare providers can turn their heads away from the harsh reality that healthcare is more and more competitive. As patients have more high quality, affordable options, it is vital that American providers participate and create their own visibility on an international scale in the medical tourism industry. American Inbound Medical Tourism, where patients are traveling from other countries to the United States, is still booming and successful. It has gotten more competitive as some US hospitals tighten up their prices to compete during the economic recession against other US hospitals attracting foreign patients. US hospitals are continuing to report success and many are expanding their efforts and work to help expand and attract more patients to the US for high quality healthcare. But these days could be numbered without a long term strategy to enforce existing patient flows and generate new ones.

The Emergence of Healthcare Cities & Clusters We are also starting to see more and more the emergence of healthcare cities and clusters worldwide. The Medical Tourism Association has been assisting in this development through its free educational seminars held all over the globe. The objective is to assist in the creation of the governing body, establish quality criteria and to assist in making the clusters run fairly to promote the hospitals and clinics that participate and to focus on promoting the location. The newest development, however, is the emergence of these clusters within the US such as in South Florida, Texas, Nevada and Minnesota. Healthcare cities are the most effective ways for hospitals, clinics and countries to promote themselves. Healthcare cities and clusters are successful because it is nearly impossible

for one hospital to take on the responsibility of branding a geographical location. Forming a healthcare cluster may be one of the most important single steps in establishing a medical tourism destination and to enhance the location’s chances of success as a destination for medical tourists and increasing patient flow. All the stakeholders must work together to promote this image of high quality of healthcare to establish a “brand” name for the location throughout the world. This year, the Medical Tourism Magazine shall release its first edition of Destination Guides: Las Vegas. These publications are a series of healthcare and travel books destined to set a precedent. In our surveys, the vast majority of patients receive their information about healthcare and make their decisions from information acquired on the internet. With the management of MedicalTourism.com, the Medical Tourism Association will make this full color guide available to consumers at no charge so they can have the most up to date information about healthcare procedures, destinations and the details found in the Destination Guides at their fingertips. Through the collaboration between the Las Vegas Convention and Visitors Authority (LVCVA) www.lvcva.com and the Southern Nevada Medical Industry Coalition (SNMIC) www.snmic.com, Las Vegas will be explored for the first time through a healthcare point of view. For more information please go to http://www.medicaltourismassociation. com/en/destination-healthcare-guide.html

Why is Cluster Development Important? A healthcare cluster is generally an independent organization of hospitals, clinics, medical professionals and the government in a specific city, state, or region. A healthcare cluster is funded by all the participants in the healthcare cluster and represents the interests of all the members and the cluster may also be supported by government funding. Their purpose is to promote the members of the healthcare cluster and to build a reputation as having extremely high quality healthcare. Carefully targeted collective action by the members of the healthcare cluster often produces results that individual members are incapable of obtaining by or for themselves. Also, before patients travel to these destinations, there needs to be a belief and reputation that the location has extremely high quality healthcare, infrastructure support and governmental sponsorship. No one individual member can do this. A healthcare cluster can adopt and promote high standards of ethical and professional medical care. These standards will need to be developed based upon the existing medical requirements and licensure standards for the country, state and city. Marketing standards and goals for the cluster need to be evaluated and designated to the appropriate entity or groups. Advertising budgets need to be developed as well and tie in with

September / October 2011

Editorial the Department of Tourism, Economic Development, Trade and Investment and Department of Health for governmental support. Finally, appropriate aftercare systems need to be created to appropriately handle patients. This means that tourism organizations and hotels and/or recovery centers need to be incorporated into the cluster for the purpose of creating safe and reliable aftercare networks. In this way, the healthcare cluster can create self-regulation within the location to achieve its goals of being established as an independent arm of the healthcare and tourism sectors. While there is much speculation as to how the medical tourism industry will grow, several things are fairly certain. Medical Tourism is a fast growing industry as patients from all around the world travel from one country to another for healthcare. Insurance companies are offering international provider networks to insureds, employers using medical tourism facilitators and highly developed international patient centers. Market opportunities due to affordability and accessibility make just about every destination a potential for medical tourism to someone, somewhere. Baby Boomers will continue to provide the volume of patients which necessitates the development of more assisted living and retirement centers overseas and the need for healthcare access for these Boomers. Inbound and domestic medical tourism will continue to raise competition and keep domestic providers in check of their pricing and perhaps allow already strained systems the opportunity to become more efficient and affordable. And healthcare cities and medical clusters will facilitate the average patient’s search for high quality of care overseas and offer valuable solutions to current healthcare needs. For more information about MTA Cluster Development Programs, please go to: http://www. medicaltourismassociation.com/en/healthcare-clusters.html. n

Renée-Marie Stephano is the President of the Medical Tourism Association™ . Ms. Stephano is also the Editor-in-Chief of the Medical Tourism Magazine, Health Tourism Magazine and Healthcare Development Magazine. Having a background in international marketing and relations, health law and litigation, she provides a valuable service to the Medical Tourism Association™ in these fields. Ms. Stephano speaks regularly at international healthcare conferences on the Legal Issues Surrounding Medical Tourism and in the United States to employer groups, insurance groups and physician associations. Renée-Marie consults international government ministries, private sector organizations and NGO’s about the growth of the global healthcare industry and accreditation, providing marketing assistance to promote their countries high quality of care. Ms. Stephano works with governments and healthcare clusters in the development of their Medical Tourism Initiatives. Ms. Stephano recently is the co-author of three books : “Developing an International Patient Center: A Guide to Creating the Best Patient Experience”, the book “The Medical Tourism Facilitator: A Best Practices Guide to Healthcare Facilitation for International Patients” and the book: “Medical Tourism ~ An International Healthcare Guide For Insurers, Employers and Governments.” Ms. Stephano can be reached at Renee@MedicalTourismAssociation.com

This year, the Medical Tourism Magazine shall release its first edition of Destination Guides: Las Vegas.

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M E DI C A L T OURIS M Editor-in-Chief & Publisher

Renée-Marie Stephano, Esq.

ASSOCIATE EDITORS

Jonathan S. Edelheit Gabriella Vicuña Olivia Goodwin

ONLINE MAGAZINE EDITOR

Marinés Mazzari

REGULAR AUTHORS

Renée-Marie Stephano, Esq. Jonathan S. Edelheit Bill Cook Dan Cormany Dr. Prem Jagyasi Gabriella Vicuña Olivia Goodwin

CONTRIBUTING AUTHORS

Michael Sigler Eda Firat James Woomer Monty Cary Esther Napolitano David Brodner Linda Michalsin Horst Ferrero Julio Pow-Sang Rosanna Moreno Simon Hudson Maggie Bray Ben Moyar Rafael Lorenzana Liwen Williams Hashem Abu Sneineh Sonia Jones Jim Tate Myles Druckman Daniela Abratt

ART DIRECTOR

Renée-Marie Stephano, Esq.

ART DEPARTMENT

Dinier Quirós

MAIN OFFICES

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September/October 2011

Medical Tourism AT A GLANCE

Editorial

Destination Chicago

The world of medical tourism is growing quickly and while in the past years a lot of discussion has revolved around Americans, Canadians and British leaving their borders for more affordable or available care, it is important to remember that medical tourism is also a two sided coin in any country.

Renée-MARIE STEPHANO

Features

Domestic Medical Tourism ~ A Neglected Dimension of Medical Tourism Research

From a review of the academic literature on medical tourism, it is apparent that research on medical tourism to date has been largely conceptual in nature, and major gaps exist in the evidence base supporting this research. Medical tourism research to date has also focused almost exclusively on the import side of medical tourism – those who travel abroad to developing countries for medical services. It is time to take a closer look at domestic medical tourism.

Hospital Entrepreneurship

BY DR. SIMON HUDSON

By Jonathan Edelheit and Renée-Marie Stephano

Destination U.S.A. ~ Knowing the Right Questions to Ask

What we today call medical tourism can be traced back thousands of years. It was chronicled among the Egyptians, Romans and Japanese. But the true roots of today’s practice of seeking medical interventions in another country other than one’s own started in Egypt. The Egyptians practiced advanced forms of medicine, and in 1248 the Mansuri Hospital opened in Cairo. At the time, it was the most advanced hospital ever built, and it served everyone regardless of race, religion or financial status. Travelers came from all over the world to seek medical treatment at Mansuri because it offered the best, and sometimes the only care available.

Medical Concierge Programs ~ U.S. Medical Providers Creating a Bridge in Healthcare

By Franklin A. Shaffer, EdD, RN, FAAN

Clinical Research Studies at Northwestern University Feinberg School of Medicine & Northwestern Memorial Healthcare ~ Revolutionizing Medicine Worldwide

Consistently ranking among the nation’s top 20 medical schools, its medical specialties ranked amid the nation’s best, and six of those specialties ranked highest in Illinois by US News & World Report magazine, Northwestern University is an exemplary academic medical center. Northwestern University’s Feinberg School of Medicine is able to conduct medical and scientific research creating one of the most complete academically based Clinical Study centers throughout the U.S. and around the world.

BY GABRIELLA Vicuña

September / October 2011

There is something missing from the medical tourism industry. It is neither something they teach doctors in medical school nor nurses in nursing school. It’s called Hospital Entrepreneurship and it’s holding back the medical tourism industry. In this fast pace growing healthcare environment where many excellent hospitals and clinics have the potential of effectuating a boom in service and technology delivery, most fall short of such goals.

A number of hospital corporations, investors and real estate groups have expressed an interest in or are already building clinics, hospitals and comprehensive medical communities around the world. Differences in healthcare provider standards around the world have been recognized and medical tourism carries some risks that locallyprovided medical care does not. The quality of postoperative care can also vary dramatically, depending on the hospital and country, and may be different from U.S. or European standards.

BY R. MONTY CARY AND GABRIELLA Vicuña

U.S. Inbound Medical Tourism Competitiveness

Global challenges exist and a growing trend in healthcare competitiveness abroad will affect U.S. inbound medical travel programs in the future. The U.S. is no longer the only kid on the global stage in specialty healthcare nor is it the sole beneficiary of medical travelers looking for quality care, accessibility and affordability.

BY ROSANNA GOMEZ MORENO, J.D.

September/October 2011

Medical Tourism AT A GLANCE

Minimally-Invasive Solutions for Sinus and Allergy Sufferers ~ An Opportunity to Indulge in Palm Beach Living

It is estimated that more than 37 million Americans suffer from sinus infection (sinusitis) every year, making it one of the most common health conditions in the country. These numbers may be significantly higher, since the symptoms of sinusitis often mimic those of allergies and cold and many afflicted never see a doctor for a proper diagnosis and treatment plan.

BY DR. DAVID C. BRODNER

The Brazil of Futbol- The Brazil of Health

Exceeding Expectations ~ Domestic and Inbound Medical Tourism

Traveling abroad for medical treatment has become an established practice, but the United States is experiencing an increasing growth of domestic and inbound medical tourism. In domestic medical tourism, people are crossing state lines in search of better-quality health care. This is most common with specialized surgical treatments and procedures in the realm of cardiology, oncology and orthopedics.

BY EDA FIRAT and DANIELA ABRATT

Economics

US Health Insurance Medical Tourism Market Update

2012 will be a great year for US outbound Medical Tourism and there are big movements going on from Large Employers to Big Insurance Companies. The industry had a lot of momentum in 2009 as many insurance companies moved forward with their plans, but was derailed when Obama brought Healthcare Reform into the picture.

By Luiz Fernando Schreiner Moraes

The Impact of Applying International Standards to Quality Services Jordan’s Private Hospital Setting

The Wisdom in Considering a Great Vacation in Combination with Your Dental Work

News & Insights

The current shortage of healthcare providers around the globe is a well-known and often discussed problem. In some areas of the world, particularly in developing nations, the shortage of physicians, nurses, technicians, and other providers is at critical levels, creating untold suffering, delays in receiving emergency care, and limited access to care.

The private healthcare sector is considered to be one of the most profitable and flourishing industries in Jordan. A special attention was given to this industry due to the huge number of patients it treats, the exploration of the term “medical tourism”, and the growing number of expats in Jordan.

BY DR. HASHEM ABU SNEINEH

By Jonathan Edelheit

The Global Healthcare Provider Shortage and Medical Tourism ~ Impact and Solutions

The world is now beginning to discover the Brazil that is the 7th largest economy in the world, possesses monetary reserves allowing the country to overcome the global crisis in a much smoother fashion than other countries, has extraordinary petroleum reserves, holds 11% of water supply on the planet, is one of the countries that generates the greatest agricultural production in the world, has an emerging industrial sector and 200 million inhabitants with a purchasing power that grows each day.

Your dental work does not have to be an unpleasant experience. No matter how painless the procedure is or how good a surgeon´s hands are, a trip to the dentist causes anxiety, stress and discomfort. Turning your next appointment into time to relax and explore a new destination can put your mind at ease and make your trip to the dentist stress free.

BY RAFAEL E. LORENZANA

World-Class Cancer Care at Memorial SloanKettering Cancer Center

As one of the world’s oldest and largest private cancer center, Memorial Sloan-Kettering Cancer Center in New York City is committed to exceptional patient care, leadingedge research, and superb educational programs. Founded in 1884, the Center has made significant contributions to new and better therapies for the treatment of cancer.

BY JAMES WOOMER

Due Diligence in Facilitation

The Medical Tourism Industry has some great players in it. With amazing hospitals and clinics, a growing number of medical tourism facilitators using best practices and consultants, more and more players are in the news. But, who is doing their due diligence?

Health or Lifestyle: Medical Tourism Allows Both

During your search for quality health care, did you ever consider Googling the cost of your procedure in another country. Medical tourism has not grown exponentially in the past decade because of failure. Instead, it has flourished because people are happy with the results and the savings.

BY DR. MICHAEL SIGLER

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Medical Tourism AT A GLANCE

Children’s Hospital of Pittsburgh of UPMC ~ Advancing Pediatric Medicine with Innovation and Family Centered Care

Clinical excellence in pediatric transplantation, cardiac care services, and neurosciences; exceptional, healingfriendly new facilities; concierge services that help patients and families feel at home until they return home: Children’s Hospital of Pittsburgh of UPMC welcomes you to the one place where these elements converge to set new standards in complex pediatric care.

BY Mariel C. Garcia, MBA

Medical Travel ~ Voice of the iPatient

A Sweet Toothed Fat-Free Life to Obesity

Is it possible to naturally lower your cholesterol, reduce your high blood pressure, regain your energy, and reduce your weight for life? The answer is yes. Generally though, people decide to make major lifestyle changes only when they have reached a certain critical point in their lives, waiting until their health has deteriorated to such an extent that they have to do something about it.

BY SONIA JONES

Marketing Wellness Tourism in Las Vegas: AquaStretch – A New Wellness & Spa Service for the World

Staff at the University of Nevada, Las Vegas (UNLV) Wellness Center has developed an exceptional new wellness program and spa service that creates a remarkable opportunity for both health and medical tourism around the world. And with that opportunity comes the challenge of marketing this breakthrough technology, both to increase wellness and medical tourism to Las Vegas and to disseminate its existence internationally.

BY JIM TATE

New Outlook for Prostate and Urologic Cancers Treatment Advances Benefitting the Medical Traveler

Medical Tourism is a fast moving and incredibly challenging market place. There are many organizations wishing to jump on the bandwagon and there are many too who are falling off very quickly! Success requires a thorough understanding of ever changing patient demands.

Spain: The Heart of Transplants

In Search of Superior Healthcare in Asia

The growth of medical tourism has truly opened a world of options for patients and their families. In fact, there are so many options that the task of choosing the best provider for each situation requires disciplined research and analysis. In the course of reviewing hospitals for clients of medical tourism agency China Health Today, I’ve identified key characteristics that will aid clients in making smart decisions and assuring a successful experience.

BY LIWEN WILLIAMS

September / October 2011

While tourism is now booming, the transplant industry has been well established for years and even more so lately. Valencia has also been home to some of the first body part transplants in Spain and in the world. Dr. Pedro Cavadas and his team at La Fe Hospital have been responsible for performing Spain’s first partial face transplant, double hand transplant and now the world’s first double leg transplant.

BY OLIVIA GOODWIN

Understanding Medical Tourism: An Overview

By ADRIAN MYRAM

Saving Lives

Landmark new therapies for prostate cancer and genitourinary (GU) cancers of the bladder, kidney and testes are giving patients an enormous range of options that weren’t available just a few years ago.

DR. JULIO M. POW-SANG

By GEORGE EVERSAUL, A.P.

The Medical Tourism Sandwich ~ Satisfying Patient and Health Provider Demands

I first became aware of the concept of Medical Tourism about three years ago. At my 40th high school reunion an old friend mentioned he had just returned from Costa Rica. “I hope you had a great vacation”, I said. He replied, “Yes, it was fantastic and I paid for it with what I saved by having my colonoscopy there.”

Medical Tourism: When patients travel domestically or internationally to have a surgery or procedure. They travel for better quality, affordability and some procedures are only available in certain countries; depending on the patients needs. Traveling for medical care is becoming an international trend.

BY OLIVIA GOODWIN

Q&A

Medical Tourism Association TM for 2011

The Medical Tourism AssociationTM traveled to Las Vegas for one of the largest employer conferences in the country and conducted a survey of hundreds of top HR professionals nationwide. 65% of the attendee respondents surveyed had up to 1,000 employees in their company with another 25% having employees ranging from 1,001 to 10,000.

BY THE MEDICAL TOURISM ASSOCIATION TM

M E DI C A L T OURIS M

Exceeding Expectations ~ Domestic and Inbound Medical Tourism By Eda Firat and Daniela Abratt Traveling abroad for medical treatment has become an established practice, but the United States is experiencing an increasing growth of domestic and inbound medical tourism. In domestic medical tourism, people are crossing state lines in search of better quality health care. This is most common with specialized surgical treatments and procedures in the realm of cardiology, oncology and orthopedics.

eciding where to seek medical treatment may not only be a personal preference. Many employers are providing incentives to their personnel to encourage them to travel for medical treatments. In fact, a number of large businesses have signed contracts with large hospitals and medical practices to ensure the best deal for all parties involved.

The Exponential Growth of Domestic Medical Tourism Domestic Medical Tourism is when patients travel to a different city, state or region for treatment, rather than utilize their home healthcare facilities and providers. Patients that opt for this seek availability, accessibility and what they perceive to be high quality of care; many times involving innovative research and technology. Benefits of domestic medical tourism also include a decreased travel time, patient access to legal recourse, and an absence of a language or cultural barrier.

It may be much easier to facilitate coordination between the patient’s home physician and the treating surgeon in the selected destination. Some employers such as Lowe’s, which has a contract with the Cleveland Clinic in Cleveland, Ohio allows their workers to leave the comforts of the familiar to seek treatment for cardiac care, at what is considered one of the nation’s and perhaps the world’s finest Center of Excellence for Cardiology. These employers tend to cover travel costs for the patient and their companion(s). Although it may be costly to pay for travel expenses, organizations find such savings in investing in preventative and what they perceive to be the very best healthcare options for their employees and their families that they find themselves utilizing the savings of decreased absences due to medical conditions to pay for the travel costs. Employers can also work with insurance companies to waive deductibles and coinsurance.

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M E DI C A L T OURIS M Many hospitals also try to entice patients by promoting the tourism aspect of their cities. They seek to provide excellent treatment supplemented by the idea that patients can participate in the city’s life and entertainment before or after their procedures, depending on the level of invasiveness. Las Vegas, Miami, Seattle and Houston are great examples of exciting cities that offer endless activities for patients and their companion(s), with the proper planning.

Lake Nona Medical City ~ Orlando, Florida Orlando may be well known for its amusement parks but thanks to the building of the Lake Nona Medical City, it may now add the title of a medical destination to its credentials. This 7000-acre medical complex is anchored by The University of Central Florida Medical School. “Name any of the centers across the country where people get on airplanes to go get their care; they all have an academic center,” Deborah German, the medical school’s dean, told American Medical News. The complex includes Nemours Children’s Hospital, a 95bed main facility plus a pediatric clinic; the Veterans Affairs Medical Center, a 134-bed, inpatient facility for the U.S. Department of Veteran Affairs; the UCF College of Medicine Burnett School of Biomedical Sciences building used for research and instruction; the M.D. Anderson Orlando Cancer Research Institute, with 20 employees including 12 researchers; and the Sanford-Burnham Institute for Medical Research, which has one of the country’s few robot high-throughput screening centers, machines that can run a large number of biological tests very quickly. Orlando has always attracted doctors, ranking as the No. 1 destination for medical meetings averaged over the past 13 years by the Healthcare Convention and Exhibitors Association. German said she thinks the medical complex does not need to become the focal attraction in Orlando, but she believes it will be an added attraction for patients and establish more medical credibility for the city.

Inbound Advantages Not only American citizens understand the value of the medical treatments available across state borderlines. International patients from all around the world also appreciate America’s reputation of great healthcare, and have for decades. This is known as inbound medical tourism, when foreigners enter the U.S. for medical treatment. According to the Department of Health Systems Management, it is estimated that between 43,000 and 103,000 foreigners came to the U.S. for treatment in 2007.

In general, quality assurance is a draw for international patients. They seek accessibility to the best technology available for their treatments & procedures along with the services of highly developed, concierge-like international patient departments. The U.S. is home to a number of world-renowned hospitals, physicians and surgeons, and patients with the means to do so will travel to the U.S. seeking a specific name; University of Texas M.D. Anderson Cancer Center, Mayo Clinic, Mount Sinai Medical Center and Johns Hopkins Hospital.

Companies believe they can save anywhere from 20 to 40 percent from the switch to domestic medical tourism. There are a number of issues to consider when receiving foreign patients. It is imperative for hospitals to understand and prepare for the cultural and linguistic obstacles they will face. For this reason, most hospitals have an international patient department which works to make foreign patients feel welcome. The international patient department provides both onsite and offsite services. First, it creates marketing plans specific to each country from which it hopes to attract patients. It will also offer assistance with visas, travel planning, accommodation reservations, tours and other activities. The department will also review payment options with the patients and help them finalize their choice. Additionally, the department offers a variety of inhospital support. One of the main considerations are language barriers, so hospitals will often have specific reception offices staffed with employees who are fluent in the patients’ language along with educational materials and customized welcome packages. They might also have medical and registration forms translated into the language as well. Some hospitals also have doctors and nurses who speak the language and/or have a highly developed interpretation program. It is extremely important to make these patients feel comfortable in this new environment. As much as a hospital relies on its reputation to attract patients, it also relies on wordof-mouth marketing, which remains the strongest influencer of the purchasing of all products and services in the world according to a study by Bazaarvoice, a social marketing leader. If patients have a good experience, they will pass that on to their family and friends back home. The international patient departments will thus often have an orientation session with the patient and physician to ease any concerns of the unfamiliar before any treatment is administered. The use of a MTA Certified Medical Tourism Facilitator, such as Medvoy, Debson Medical, and Surgical Trip, is highly recommended. They are able to connect international patients with top facilities and providers in the U.S. for services and procedures and treatments such as joint replacements, cardiac care and spinal surgeries. They communicate directly with doctors to insure the best quality of care is ensured to the patient and provide clarity to their concerns before and after treatment.

Survey of U.S. International Patient Departments According to an inbound medical tourism survey done by MTA member, Stackpole & Associates, two-thirds of the hospitals it surveyed in 2010 offered these types of services. The survey also found that those hospitals provided services for special dietary needs, pre-arrival medical assessments and coordination of post-treatment care but less than half reported providing assistance with transportation needs and/or tourismrelated activities.

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The same survey also found that the largest percentage of patients came from Mexico (21.18 percent), the Middle East (14 percent), South America (12.33 percent), Central Americaexcluding Mexico (11.25 percent) and Europe (11.23 percent). In regards to the treatment sought, the highest percentages were in oncology (31.69 percent), cardiology (14.17 percent) and neurology (11.75 percent). Defined as a wide variety of surgical and medical specialties, “other” was 23.26 percent. The research indicated that 62 percent of the hospitals surveyed provide specialized training in cultural sensitivities to the staff of the international patient department. It also showed that the price of health care was the greatest obstacle for international patients and obtaining a visa was the second. The U.S. is trying to ease that pressure and find ways to increase inbound medical tourism. So in November 2010, the U.S. Department of Commerce awarded the Rush University of Chicago, in partnership with the University HealthSystem Consortium, a three-year $500,000 Market Development Cooperative Grant to help boost medical travel to the country. The idea is to stimulate growth through better data that tracks international patients and services, networking across institutions and the implementation of the best strategic business development practices. The grant is intended to support President Obama’s National Export Initiative, which aims to double exports (any form of U.S. medical care purchased by people outside the country) by 2015. The aim is to create millions of U.S. jobs with the influx of thousands of patients with a vast array of needs. n Resources http://www.stackpoleassociates.com/resources/articles/inboundmedical-tourism-executivesummary-10-06-15-2.pdf http://www.ncbi.nlm.nih.gov/pubmed/20619919 (Department of Health Systems Management) http://www.bazaarvoice.com/resources/stats

About the Authors Eda Firat is a Global Congress Representative with a focus on marketing and communications for the Medical Tourism Association. She graduated Florida State University with a Bachelor of Arts in International Affairs and a Minor in Business. Due to her Turkish background, Eda provides recruitment, coordination and retention support for members of the MTA in the European region. She contributes articles to the Medical Tourism Magazine and Health Tourism Magazine. Eda is a full time employee at the Medical Tourism Association. She can be reached at Eda@MedicalTourismCongress.com Daniela Abratt is a Communications Intern with a focus on Journalism for the Medical Tourism Association. She is currently pursuing a Bachelor of Science in Journalism with a minor in International Development and Humanitarian Assistance at the University of Florida, where she is also a member of the Golden Key International Honour Society. She has worked as a freelance writer for the Independent Florida Alligator and has had pieces published in newspapers such as The Gainesville Sun, The North Florida Herald and other publications associated with The South Florida Sun-Sentinel. Daniela writes for MTA’s Medical Tourism Magazine and Health Tourism Magazine. She is an intern at the Medical Tourism Association.

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M E DI C A L T OURIS M

World-Class Cancer Care

at Memorial SloanKettering Cancer Center

As one of the world’s oldest and largest private cancer center, Memorial Sloan-Kettering Cancer Center in New York City is committed to exceptional patient care, leading-edge research, and superb educational programs. Founded in 1884, the Center has made significant contributions to new and better therapies for the treatment of cancer.

emorial Sloan-Kettering’s excellent reputation attracts outstanding doctors and researchers from many nations. The close collaboration between the Center’s physicians and scientists is one of its unique strengths, enabling its experts to provide patients with the best care available today as they work to discover more-effective strategies to prevent, control, and ultimately cure cancer in the future. “A patient at Memorial Sloan-Kettering benefits from receiving care at the very place where physicians and scientists pioneer new treatments, refine standard approaches, and use sophisticated combinations of therapy to increase the cure rate of cancer,” said distinguished cancer surgeon Murray F. Brennan, MD, Vice President for International Programs at Memorial Sloan-Kettering. “Our patients have access to leading-edge diagnostic and treatment options that are often not available at other institutions.” Memorial Sloan-Kettering’s world-renowned physicians have an extraordinary depth and breadth of experience in

diagnosing and treating all forms of the disease, from the most common to the very rare. Each year, we treat more than 400 different subtypes of cancer. “This level of interdisciplinary specialization can have an often dramatic effect on a patient’s chances for a cure or control of their cancer,” said Dr. Brennan. “As has been demonstrated nationally and internationally, institutional volume is associated with improved patient outcomes, and fewer complications,” he added. During the past decade, Memorial Sloan-Kettering has made impressive advances in understanding the causes of cancer, particularly the genetic basis of many common cancers, and

Each year, we treat more than 400 different subtypes of cancer. September / October 2011

M E DI C A L T OURIS M in developing new approaches for prevention, early detection, and treatment. Its doctors and scientists have published close to 10,000 peer-reviewed articles in medical and scientific journals, including results of hundreds of groundbreaking clinical trials. Physicians and cancer patients from around the world consult the Center’s doctors every day, and thousands choose Memorial Sloan-Kettering for treatment. In most cases, the first encounter they have with the hospital is through the Elmer and Mamdouha El-Sayed Bobst International Center, whose aim is to coordinate the clinical and personal needs of Memorial Sloan-Kettering’s international patient population with skill, warmth, and concern. “The Bobst International Center was established to simplify the lives of international patients who are away from home and our staff helps make their visit as comfortable as possible,” said Dr. Brennan, who also serves as Director of the Bobst International Center at Memorial Sloan-Kettering. Before a patient’s arrival, the specially trained staff at the Bobst International Center helps coordinate the information Memorial Sloan-Kettering physicians need to arrange for an opinion by mail, an on-site second-opinion consultation, or medical care. Once medical care is arranged and a schedule is in place, patients receive a portfolio of information that includes confirmed appointments as well as other information to help them better prepare for their trip.

Its doctors and scientists have published close to 10,000 peerreviewed articles in medical and scientific journals.

The Center’s guest services staff provides international patients with information and guidance about hotel accommodations or other lodging close to Memorial SloanKettering and assistance in making travel arrangements and accessing ground transportation. They can also arrange for translation services and interpreters to assist during medical consultations and non-medical encounters throughout the city, and assist in offering business and concierge services.

Our patients have access to leading-edge diagnostic and treatment options that are often not available at other institutions. In keeping with the goal of assuring high standards of cancer care for its international patients, Memorial Sloan-Kettering has established relationships with institutions around the world, including AmMed International (Hong Kong); Chulabhorn Cancer Research Center (Bangkok, Thailand); Hospital Sírio Libanês (São Paulo, Brazil); Metropolitan Florence Nightingale Hospital/American Cancer Center (Istanbul, Turkey); Raffles Medical Group (Singapore); and St. Luke’s Medical Center (Philippines). The Bobst International Center welcomes inquiries and can be reached by phone at 212-639-4900 or contacted via e-mail at intnlprg@mskcc.org n For more information about the Elmer and Mamdouha ElSayed Bobst International Center Memorial Sloan-Kettering Cancer Center, visit www.mskcc.org/international.

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September / October 2011

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September / October 2011

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Understanding

Medical Tourism:

An Overview By Olivia Goodwin

Medical Tourism: When patients travel domestically or internationally to have a surgery or procedure. They travel for better quality, affordability and some procedures are only available in certain countries; depending on the patients’ needs. Traveling for medical care is becoming an international trend.

Types of Patients: • Inbound- Patients traveling into a country from other countries in search of advanced technology and innovative research. • Domestic- Patients traveling within their country to receive medical care outside their geographic area, typically to a center of excellence in another state or region. • Outbound- Patients traveling to other countries for a better value or quality of service.

An Informed Perspective Mentioning medical tourism attracts a lot of questions and bias’ it can often be associated with going to another country and having a procedure botched. Attempting the unknown can be scary to some; and since this topic hasn’t been widely discussed the majority of people only have tidbits

of information to base this on. Once patients and companies educate themselves they may see that it is a legitimate and sometimes better option; and are more willing to consider it. Some also have the opinion that the U.S. is the best place to receive healthcare, while that can be true in some cases; it has been proven to be worth the time to look into other options. The quality of care is a question many have when looking into this. Many of the physicians practicing abroad have trained in the U.S. and have earned U.S. Board Certification. Some countries or states have a lower patient to nurse ratio, equal or superior facilities and equipment. Further research into medical

Once patients and companies educate themselves they may see that it is a legitimate and sometimes better option; and are more willing to consider it. September / October 2011

M E DI C A L T OURIS M tourism will also show that some insurance companies have implemented the option to travel for medical care. Studies conducted by the Medical Tourism Association TM have shown that companies can save up to 90% in some cases by the patient choosing to have a procedure done in another country. Some companies that have offered this as an option have also offered cash incentives or covered travel expenses for the patient and companion; even covering those expenses and the procedure it is still a huge savings.

The Market for Medical Tourism While some insurance companies have jumped on board with medical tourism, the uninsured is still a major market for this. According to the U.S. Census Bureau there are more than 50 million Americans that do not have health insurance; this number is said to rise with the increasing cost of health insurance. This is a large number of patients that could choose to leave the U.S. for healthcare and when savings and quality prove to be significant; it’s an option many will take. The underinsured makes up a part of this market as well. While they do have insurance; it isn’t always enough to cover their needs in full. Dental insurance typically covers the basic preventative dental care such as cleanings and treatment of cavities; those that seek more major dental care such as implants will not be covered. In 2000 The U.S. Administration on Aging found that there were 35 million 65 year olds; and that number has and will continue to increase; making the need for dental implants and surgery a booming industry. Back to the insured; ethnic employees are an untapped market for this industry. The thought of going to another country for a surgery can be scary to some people; language barriers, cleanliness, safety etc, but for ethnic Americans it can be preferable. They already speak the language, they don’t have to overcome fears of safety and cleanliness and it would be an opportunity for them to visit extended family and recover in their home country. In 2008 Deloitte Centers for Health Solutions conducted a survey Medical Tourism: Consumers in Search of Value; this survey showed that in 2007 an estimated 750,000 Americans traveled abroad for medical care. They estimated that this number would increase to six million by 2010, then revised for recession to 1.6 million in 2010.

Studies conducted by the Medical Tourism Association TM have shown that companies can save up to 90% in some cases by the patient choosing to have a procedure done in another country. starting to market their country as a destination for healthcare. This has also become a new market for travel agents. Given the state of the economy research has shown that people are not leisurely traveling as much as they use to, traveling for medical care combined with tourism is a new option for them to promote. Instead of planning just a trip for fun, organizing the hospital stay and aftercare would be the extra things to consider. Leaving home for medical treatment is not for everyone, being educated on the details of this industry is the first step in considering it. n About the Author Olivia Goodwin serves as Communications Coordinator and Assistant Editor for the Medical Tourism Association and Magazine. She travels around networking and developing ideas for the Magazine and the Association. Olivia holds a degree in Multimedia Journalism from Florida Atlantic University. She may be reached at Olivia@MedicalTourismAssociation.com

A Growing Industry People have been traveling for medical care for years, it’s just in the past few years it’s becoming a more and more well known option. Some high profile patients have been featured in the news drawing more attention to the industry. Actress, Farrah Fawcett had a very public struggle with cancer and traveled to Germany to receive treatments not available in the U.S., this was covered in a two hour televised cancer journal. More recently, the L.A. Lakers super star Kobe Bryant traveled to Germany to get platelet-rich plasma therapy in hopes of repairing his injured knee, reported the L.A. Times. According to the Orthohealing Center PRP therapy offers a possible solution to accelerate healing of tendon injuries and osteoarthritis naturally. This therapy will merge cutting edge technology with the body’s natural ability to heal itself. Blood is made of red and white blood cells, plasma, and platelets. A small amount of blood is drawn and spun in a centrifuge to isolate platelets then are guided by an ultrasound and injected into the injured area to try to stimulate the tissue repair. Beings this is a relatively new procedure, more studies need to be conducted to prove its effectiveness. Golfer, Tiger Woods and tennis pro Rafael Nadal are among other athletes that have tried this therapy. Medical tourism is already a huge industry and it hasn’t even hit every home in America or abroad to its full potential, yet. Some countries are developing healthcare clusters made up of hospitals, governments and tourism boards and are really

September / October 2011

M E DI C A L T OURIS M

Hospital Entrepreneurship By Jonathan Edelheit and Renée-Marie Stephano

uring this past year, consistent strains of thought have been passed around amongst facilitators, insurance agents, employers and insurance companies relative to the concern that hospitals and clinics are not running themselves as efficient businesses. Where is the entrepreneurship unifying the hospital system, Medical Director, Administration and Marketing Team to achieve long term investment goals? Does a failure to see ROI in year one dignify a halt in program execution over the long haul? Are we that short sighted?

Lack of Logic Where is the source of the problem? Hospitals are claiming that they want to achieve good revenue flow from medical tourism without investing or reinvesting in brand development. Marketing 101 would tell you brand development, strategy and delivery is a timely process which requires intelligent, consistent, continuous and in some cases, repetitive efforts to achieve goals. These goals must be broken out into deliverables over a predetermined length of time such as one, three, five and

ten year goals. Without reinvesting in brand development and marketing, all past efforts can be lost, dropping pre-established brand value down to a never seen before loss of return on investment. Amazingly, there has been a significant drop in investment at the exact time that marketing investment should be on the rise. Where is the logic in the policy that because we provide healthcare services and there is in fact a huge demand for those services, that advertising is not necessary? Try selling healthcare services to a potential patient who, let’s face it, has

Brand development, strategy and delivery is a timely process which requires intelligent, consistent, continuous and in some cases, repetitive efforts to achieve goals. September / October 2011

M E DI C A L T OURIS M never heard of your hospital or clinic? Good luck. While word of mouth reputation is a tremendous source of patient referrals, it is not often you will hear people sitting around talking about how they want to go get a passport, get on a plane and travel to New York or Moscow for a surgery. It requires the demand, the availability of the information about the supply, the confidence in the brand, and the potential for delivery of services. This is accomplished through effective Hospital Entrepreneurship, Branding and Marketing.

Field of Dreams One facilitator handling hundreds of patients annually gave a case example of the Latin American Hospital which made net millions in profits over the past year from just the services and patients provided through their company. This same hospital invested less than $20,000 for the year in global branding and marketing. The result? Another hospital offering the same services came into competition with it and now has taken the lion’s share of its previously enjoyed success. What is the difference between the two hospitals? In the first case, the hospital is operating almost with blinders on, expecting that word of mouth reputation will be the most sustainable measure of success. In the case of the second hospital, a focused strategy for investment in brand development and delivery allowed it not only to compete, but to surpass the first hospitals success over the longer period of time. Now the first hospital needs to spend more to accomplish what should have been done in the beginning: create a sustainable long term marketing plan. Unlike the well known Kevin Costner movie Field of Dreams, building a baseball stadium in the middle of a corn field is not the recipe for long term success. That only happens in the movies. Hospital Entrepreneurship and investment in brand is necessary to keep up with the fast pace global healthcare environment.

If you haven’t met them in person and developed a relationship, the potential for receiving international patients from them is significantly reduced. Hospitals and Physicians alike would do well to realize that a business will require branding and marketing. If all hospitals offer the same or similar services at the same or similar prices, common economies of scale require the quality and delivery of the brand to bring one competitor above another and, in the case of healthcare, to receive new clients or patients.

Unrealistic Expectations What about realistic expectations? For some crazy reason, many hospitals and clinics expressed delusions of an investment of $5,000 or $10,000 to achieve hundreds of thousands of dollars or millions in the first year. Moreover, upon lack of instant gratification in achieving these results, they terminate the program or discontinue their efforts. Brands and marketing don’t work that way. You need to consistently market and build your brand over a couple year period. You need to have a long term plan and be committed to it. No one can build an overnight brand or a long term brand in 1 year or year 2. You have to work at and most importantly “sustain” that brand. You have to create a long term strategy, work at it and be patient. How does a hospital or clinic sustain and then grow their patient flow? Good question. In addition to unrealistic expectations, there are other cases of just plain laziness. Spend a year or two to develop a brand and then wait to see what happens? Good luck. Well, this is a wakeup call for everyone who believes that, as it has never worked and it never will.

September / October 2011

The brands that fall asleep at the wheel will be the facilities that lose patients and also run the risk of losing the international brand they took those years to develop. Take for example the case of some hospitals in India. Many have a high quality of care and excellent reputation for care in the American and Canadian market for a few years. Very little investment has been made by the governments to support the initiatives of the private hospitals in India and, as a result, more and more American patients are now traveling to Latin America. This is in part due to closer proximity, but also because many Latin American hospitals are developing their brands, marketing, and effectively delivering their brands and services to patients who are in need of brand identity to provide the confidence they need to make educated healthcare choices. Government support of medical tourism initiatives is proving to add to the consumer confidence by providing accountability to the hospitals’ services.

Throwing Mud at the Wall The cycles of branding and marketing are simple. If you don’t invest in your brand and marketing and your competition does, your clients that you have today, will be the clients of your competition tomorrow. There are typically no second chances up at bat. Persistence, consistence and patience are your friends. On the opposite spectrum or extreme, some hospitals and governments that have larger budgets are throwing mud up against the wall to see what sticks, randomly spending money on a variety of services which have no deliverables and do not create a consistent message. Having a lack of rhyme or reason with inconsistent strategies or, worse yet, a lack of strategies, can prove to be futile without ever seeing a return on investment. Mismanagement of large budgets happens on the other extreme, where a hospital or government which previously invested and achieved an international brand, let it slip away by using a shotgun approach as to how it marketed and spent its money.

Face to Face Contact Experience in the health insurance industry demonstrated that it took two to three years to get a new insurance product off the ground, and 5 years to where it was really successful - where potential business partners come to you instead of you hunting them down. It is not made successfully just by opening the doors for business: it requires an investment in effort. How did it succeed? Persistent outbound marketing, conference participation, networking, and new business to business development were the primary means. What is to be achieved at a conference? It’s not likely to walk into a conference with result being instant dollar sales. It’s about building relationships and know you are going to keep coming back to build on those relationships and your brand. In the medical tourism industry, often you will not see hospitals treating this as a business or entrepreneur. At our 2010 conference, one facilitator met with one of the MTA member hospitals and because of that meeting, that hospital received 500 patients in 2011. This isn’t going to happen to everyone, but what if that hospital was you? What if that facilitator wasn’t there? How much lost business is lost just due to a failure to create opportunity? Do you really think that facilitators, insurance companies or employers are going to send patients to your facility in another country because you have a nice website or you sent them an email? Let’s be realistic, if you haven’t met them in person and developed a relationship, the potential for receiving international patients is significantly reduced.

Are you Alive? The main complaint we have received is that hospitals are not acting like businesses or entrepreneurs in their daily routines. They are not updating their websites or brochures and in some cases, don’t even have them done professionally. Another complaint is a lack of good response time to inquiries and also a lack of transparency. If the hospital isn’t responsive to the facilitator or other buyer, then they try to move their business elsewhere. The main message is that buyers of healthcare want to be treated with the same level of service that patients are getting of the hospital, and they simply are not always receiving this. This means they are constantly looking for other hospital partners to replace their existing ones or ones that will be “backups” when things don’t go right with the existing hospital. Individuals at hospitals need to treat the international patient program it like it’s their own business and conduct themselves with that same passion and energy that they would have if they really owned it.

Pass it On! We know that hospitals and doctors are meant to provide the highest quality of healthcare for the patient with the best outcomes and least complications. This is a given and this should be the hospital and providers’ top priority. But, that does not mean that they should therefore have no entrepreneurship spirit or conduct their operation like a “true” business. At the end of the day Hospitals are business; they have profit and losses and need to have balanced books. Medical Tourism patients provide hospitals with an increased level of profit that can be used in many ways from investing in infrastructure and technology, to expanding, or even to providing lower prices to local patients. The more foreign patients a hospital receives (if it has capacity for them), the more investment a hospital can make that will positively affect local patients. And this is where it turns into “social” entrepreneurship with positive benefits and returns. Don’t just read this, forward this article to everyone you know. If you work in a hospital or doctors office, forward it to the nurses, doctors, administration and medical director. Make sure everyone in the organization understands it and how hospital entrepreneurship can have a huge impact on the growth of the hospital and the positive effects that growth will have on the local economy. And remember, if you never leave your chair in your office and you never invest anything sustainable into your marketing program, where will the patients come from and how will they learn about your hospital or clinic? n

About the Authors: Renée-Marie Stephano is the President of the Medical Tourism Association™ . Ms. Stephano is also the Editor-in-Chief of the Medical Tourism Magazine and Health Tourism Magazine. Having a background in international marketing and relations, health law and litigation, she provides a valuable service to the Medical Tourism Association™ in these fields. Ms. Stephano speaks regularly at international healthcare conferences on the Legal Issues Surrounding Medical Tourism and in the United States to employer groups, insurance groups and physician associations. Renée-Marie consults international government ministries, private sector organizations and NGO’s about the growth of the global healthcare industry and accreditation, providing marketing assistance to promote their countries high quality of care. Ms. Stephano works with governments and healthcare clusters in the development of their Medical Tourism Initiatives. Ms. Stephano recently is the co-author of three books: “Developing an International Patient Center: A Guide to Creating the Best Patient Experience”, the book “The Medical Tourism Facilitator: A Best Practices Guide to Healthcare Facilitation for International Patients” and the book: “Medical Tourism ~ An International Healthcare Guide For Insurers, Employers and Governments” Jonathan Edelheit is CEO of the Medical Tourism Association and assistant editor of the Medical Tourism Magazine. With a long history in the US health insurance industry, including running a national healthcare administrator, Mr. Edelheit was the first person in the US to implement medical tourism into health insurance plans. Mr. Edelheit is also editor of several leading US health insurance magazines and organizes one of the largest US healthcare conferences in the US for employers and health insurance companies, the Employer Healthcare Congress. Mr. Edelheit is the co-author of “Medical Tourism ~ An International Healthcare Guide For Insurers, Employers and Governments.” Mr. Edelheit can be reached at: Jon@MedicalTourismAssociation.com

Amazingly, there has been a significant drop in investment at the exact time that marketing investment should be on the rise.

September / October 2011

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New Outlook for Prostate and Urologic Cancers

Treatment Advances Benefitting the Medical Traveler By Julio M. Pow-Sang, M.D.

Technology and Research Thanks to tremendous high-tech advances, patients now can pursue treatment modalities ranging from roboticassisted surgery and high-intensity modulated radiotherapy, to cryosurgery, high-intensity ultrasound, targeted molecular therapy, new chemotherapy drugs and vaccines. Clinical trials continually bring new discoveries to the forefront, offering patients treatments that are less invasive, with fewer side effects and better outcomes. One of the biggest transformations has been in the area of surgery. Minimally invasive robotic-assisted laparoscopic surgery has quickly become the new standard of care, often replacing more traditional open surgery. This expanding technology offers many advantages. Important benefits from the patient’s point of view include smaller incisions, less blood loss, shorter hospital stay and postoperative recovery that is faster with less pain. For the surgeon, advantages of using a robotic-assisted system are extensive – better view of the anatomy, more flexibility and excellent dexterity to assist in removing difficult-to-reach tumors. The robotic system is designed to allow the surgeon to sit in a comfortable position at a surgical workstation, while manipulating a laparoscope with robotic arms. The robot functions as an extension of the surgeon’s hands and does the actual work of removing the tumor. Instead of standing at the patient’s side and trying to contort and maneuver the instruments into position, the surgeon can concentrate on the intricate details of the procedure while the robot does the labor. A tiny camera on the end of the laparoscope features advanced optics, offering three-dimensional (3D) images of the nerves,

blood vessels and tissue. The combination of an enhanced visual field and greater dexterity thanks to the robotics may also reduce complications by allowing the surgeon to protect the bundles of nerves on either side of the prostate gland, a “nerve-sparing” technique that helps maintain erectile function after treatment.

Applications in Robotics Expand Beyond Prostate Cancer Surgery While robotic surgery has been performed for more than a decade, much of the focus has been on prostatectomy. Some specialized centers, however, also are using it for partial nephrectomy and for cystectomy to remove the bladder. A partial nephrectomy removes the tumor only, while sparing the remaining healthy tissue in the kidney. There is strong clinical evidence to support robotic prostatectomy and nephrectomy, but robotic cystectomy is still an evolving technique. At this point, only about less than 10 percent of all cystectomies are done robotically, compared with 80 percent for prostate and about 50 percent for the kidney. Cystectomy is a complex surgery that often involves creating a urinary diversion reconstruction of the bladder. This makes it a much more technically difficult procedure. Robotics is also used in treating testicular cancer, which primarily affects young men, ages 15 to 34. This is a very treatable cancer with a high cure rate. In a small number of cases, however, the cancer may have spread to the lymph nodes in the abdomen, requiring removal via a procedure called retroperitoneal lymph node dissection. Most often, this is done as an open surgery with a large incision in the abdomen, but a few centers are using robotics for a more minimally invasive approach with smaller incisions and less trauma to the body.

September / October 2011

M E DI C A L T OURIS M Beyond Surgery ~ An Array Of Therapeutics In addition to expanded surgical options through the use of robotics, patients with prostate and other GU cancers are benefitting from the discovery of new and better medications that show much promise. Hormone therapy, more correctly defined as androgen deprivation therapy, continues to be a standard treatment to block testosterone and other male androgen hormones from fueling the growth of prostate cancer. It effectively starves the tumor. Hormone therapy can put the cancer into remission, but it is not curative. Many patients eventually become resistant to the therapy’s effect, which renders treatment ineffective and allows the cancer to progress. Until five years ago, there were few other options when hormone therapy failed. Now two new chemotherapy drugs – docetaxel (Taxotere) and cabazitaxel (Jevtana) – have been shown to extend life expectancy in men with recurrent or advanced stage disease. Docetaxel has been used for several years as a primary chemotherapy agent for hormone-resistant prostate cancer. Cabazitaxel received U.S. Food and Drug Administration (FDA) approval in June of 2010 for second-line use in men who have already been treated with docetaxel. Even more recently, a new hormone therapy has been introduced for men with late-stage prostate cancer who have failed other treatment options. The FDA approved the use of abiraterone (Zytiga) in April of 2011. Abiraterone is different from previously used hormone therapy in that it stops production of male hormones not just from the testes, but also at various sites throughout the body, making it potentially even more effective. Molecular therapy is another area that is making a difference for prostate and GU cancers. This type of therapy uses specially designed therapeutic agents to stop the cancer by inhibiting cell division and growth or by inhibiting formation of new blood vessels that “feed” the cancer cells. Clinical trials are underway at select cancer centers in the U.S. for advanced bladder and prostate cancers. In addition, a number of therapeutic agents have been approved for use in patients with advanced kidney cancer. These include sorafenib (Nexavar), sunitinib (Sutent), temsirolimus (Torisel), everolimus (Afinitor, Zortress) and pazopanib (Votrient). For the first time, a vaccine that boosts the immune system and enhances its ability to fight the malignancy has been introduced for prostate cancer. Provenge (sipuleucel-T) received FDA approval in 2010 to help fight advanced prostate cancer. This is not a traditional preventive vaccine, but rather a type of immunotherapy designed to strengthen the body’s natural defenses against cancer. The patient’s own immune cells are combined with a genetically engineered immunotherapy agent. The vaccine is then injected into the body to aid the immune system in seeking and attacking the cancer cells.

Focused, High-Energy Radiation Advances in the field of radiation therapy are changing the future of treatment for prostate and GU cancers. New technology makes it possible to dramatically increase the dose of radiation to improve long-term outcome, while shielding healthy tissue in the bladder and rectum from harm. Newer treatments are very focused with small, precise margins for greater accuracy. Think of the effect of a flashlight, which scatters the light in a dark room, compared to a spotlight, which can concentrate the light on a single object.

September / October 2011

Intensity-modulated radiation therapy treatments (IMRT) control the beam delivery by varying or modulating the radiation dose to different parts of the tumor. Higher doses can concentrate in the center of the tumor, with a lower dose to the outside margins that are closest to healthy tissue. Treatment planning also is becoming more high-tech and sophisticated. Because the position of the prostate can change day to day – it’s not fixed but moves around the bladder and the rectum – it’s important to check the position of the prostate frequently before aiming the radiation beam. Many centers are using IMRT with 3D computed tomography (CT) imaging for the most accurate beam placement. With CT guidance, the beam is aligned with the patient’s internal anatomy rather than relying on the more traditional external marker placed on the outside of the body. Careful attention to proper positioning ensures that the beam is placed on target every single time – sparing healthy tissue from radiation exposure. Stereotactic radiation therapy is yet another emerging radiation modality, one that has been compared to radiosurgery because of the ability of the physician to precisely sculpt or shape the beam, as well as change the intensity and angle.

For the first time, a vaccine that boosts the immune system and enhances its ability to fight the malignancy has been introduced for prostate cancer. This therapy significantly escalates the dose delivery to provide a very high-intensity treatment in a short period of time. Standard treatment protocol for radiation therapy usually requires daily treatment over a two-month period of time. Stereotactic radiation therapy can be completed in just a week. Not all radiation is delivered externally. Some patients with prostate or GU cancers may undergo brachytherapy, which delivers radiation internally directly to the tumor site. Brachytherapy can be performed as a stand-alone treatment or in combination with external radiation therapy. There are primarily two types of brachytherapy. A low-dose radioactive seed can be permanently implanted in the prostate to continuously emit radiation over time. Or, a small, needle-like device can be temporarily placed inside the prostate to deliver two or three high-dose treatments. It’s like a flash of radiation or an internal blast.

New Alternatives to Surgery or Radiation Two innovative minimally invasive treatments – cryosurgery and high-intensity focused ultrasound – now are offered by some specialized cancer centers in the U.S. for patients with prostate cancer. Cryosurgery is an alternative to surgery or radiation in treating some men with early-stage prostate cancer. It uses freezing temperatures to destroy the cancer cells through the formation of ice crystals. During the procedure, small probes are inserted into the prostate under ultrasound guidance to ensure correct placement. Sensors are placed internally to monitor the temperature of the tissue. The prostate is then gradually frozen while the urethra is protected with a warming catheter. Several periods of freezing and thawing of the prostate take place to ensure maximum effectiveness of treatment. High-intensity focused ultrasound (HIFU) uses sound waves to heat or ablate the tumor. During the procedure, a transrectal probe delivers high-intensity focused ultrasound waves of

energy to a small, targeted area of the prostate, which heats the tissues to a temperature high enough to destroy the cancer cells. The treatment currently is used in Europe, Canada and South America, and undergoing FDA trials in the U.S. While only select U.S. centers now offer the treatment as part of a clinical study, HIFU is expected to be approved for prostate cancer treatment by the FDA within the next year or two.

A Checklist for Patients Making the right treatment decisions can be challenging. There are pros and cons for each type of therapy. The patient’s age, lifestyle and expectations for quality of life, as well as tumor stage and location are all factors to consider. Compare treatment options by asking about potential complications, the safety record for the particular treatment, and statistics regarding cure rate. It is equally important to inquire about the facility where the treatment is offered. What type of advanced technology, cutting-edge treatments and clinical trials are offered? Are the physicians fellowship-trained specialists in their field? Does the center meet national criteria for attaining a certain threshold of cases performed? Checking the experience level of the facility and the physicians can be an important measurement of quality of care. Patients should also consider the value of obtaining care at a cancer center where treatment plans are developed by a multidisciplinary team of specialists in every modality, from surgery and medical oncology to radiation therapy and diagnostics. This type of collaboration and consensus will ensure that expert opinions from many different perspectives will contribute to the best and most appropriate care plan for each patient. n

About the Author

Julio M. Pow-Sang, M.D., is chairman of the Department of Genitourinary Oncology, chief of Surgery Services at Moffitt Cancer Center in Tampa, Fla., U.S.A., and director of the Moffitt Robotics Program. He has been a urological oncology surgeon for more than 20 years. Dr. Pow-Sang received his medical degree from the University of Autonoma De Guadalajara, Mexico, and completed residencies in general surgery and urology at the University of Miami School of Medicine. He pursued further training through a fellowship in urologic oncology at the University of Florida College of Medicine and later received a master’s of business administration from the University of South Florida. The Department of Genitourinary Oncology at Moffitt Cancer Center fosters an interdisciplinary approach to treating GU malignancies, which include cancers of the male and female urinary systems, including the prostate, testicles, penis, kidney, ureters and bladder. Physician-scientists participate in cuttingedge translational phase I and II Moffitt-initiated and national clinical research trials. Dr. Pow-Sang has a special interest in research involving molecular markers for prostate cancer and epigenetic changes affecting the prostate. In addition, he is studying nutritional supplements such as green tea, vitamin E and soy that may have an impact on premalignant changes in the prostate. A National Cancer Institute-designated Comprehensive Cancer Center, Moffitt treats patients from throughout the U.S. and internationally. The center is a leader in advancing personalized cancer care, an approach that seeks to tailor therapies to the biology of each patient’s disease. Moffitt Total Cancer Care™, a project to create one of the largest cancer tumor databases in the country, is furthering the understanding of personalized medicine and helping design more targeted cancer treatments to improve outcomes, reduce toxicity, prevent recurrence and preserve quality of life.

OUR MISSION IS TO CONTRIBUTE TO THE PREVENTION AND CURE OF CANCER

At Mofﬁtt we’re committed to the discovery, translation and delivery of personalized medicine. To accomplish this we’ve brought together some of the world’s brightest doctors and researchers. Finding cures for cancer is our pledge, our performance and our passion. Mofﬁtt’s International Referral Services provides patient- and familycentered assistance to our international patients, giving special attention to personal, cultural, and language needs. H. LEE MOFFITT CANCER CENTER & RESEARCH INSTITUTE, AN NCI COMPREHENSIVE CANCER CENTER INTERNATIONAL REFERRAL SERVICES | 12902 MAGNOLIA DR., MCC-INTL, TAMPA, FL 33612 813-745-INTL(4685) | Online Consults: MOFFITT.org/onlineconsults

MOFFITT.org/international

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Destination U.S.A.~ Knowing the Right

Questions to Ask

By Franklin A. Shaffer, EdD, RN, FAAN What we today call medical tourism can be traced back thousands of years. It was chronicled among the Egyptians, Romans and Japanese. But the true roots of todayâ&#x20AC;&#x2122;s practice of seeking medical interventions in another country other than oneâ&#x20AC;&#x2122;s own started in Egypt. The Egyptians practiced advanced forms of medicine, and in 1248 the Mansuri Hospital opened in Cairo. At the time, it was the most advanced hospital ever built, and it served everyone regardless of race, religion or financial status. Travelers came from all over the world to seek medical treatment at Mansuri because it offered the best, and sometimes the only care available.

edical tourism today was coined to describe the rapidly-growing practice of travelling across international borders to obtain health care. Ever since several of the larger insurance companies such as Aetna, Blue Cross Blue Shield, WellPoint, Swiss Re and others started pilot programs to determine the quality and cost of covering surgeries offered in other countries, medical tourism has become on of the fastest growing niches in the health care industry. In fact, over 50 countries have identified medical tourism as a national industry. i Although many people do not realize it, the United States is one of the prime destinations for the medical tourist. A McKinsey and Co. report from 2008 found that a plurality of an estimated 60,000 to 85,000 medical tourists were traveling to the United States for the purpose of receiving inpatient medical care.ii The availability of advanced medical technology and sophisticated training of physicians are cited as driving motivators for growth in foreigners traveling to the

ÂŠ Copyright Medical Tourism Association

U.S. for medical care, whereas the low costs for hospital stays and major/complex procedures at Western-accredited medical facilities abroad are cited as major motivators for American travelers. However, selecting an appropriate medical destination is not simply a matter of looking at attractive hospital buildings and deluxe accommodations, and it certainly is not an issue determined only by the prices charged. How does an agency get quality information? It requires less effort than one might think if the United States is the destination in question.

60,000 to 85,000 medical tourists travel to the United States for the purpose of receiving in-patient medical care. September / October 2011

M E DI C A L T OURIS M Transparency has become a mantra, and what used to be impossible can now be located with a little effort. Perhaps the easiest way to start is to determine whether or not a hospital is accredited. A little time trolling around the internet will yield a lot of information, if you know what you are looking for. You can visit Hospital Compare (visit www.hospitalcompare. hhs.gov) to find comparable information about key hospital metrics. To make reliable information about physician quality available to the public, the government started Physician Quality Report in 2006 and has been collecting data ever since. You can visit www.cms.gov/PQRS to find information on thousands of physicians measured on over 70 different quality metrics. If you are interested in how consumers rate hospitals, rehabilitation facilities and so forth, your can find this information, too. Hospital Care Quality Information from the Consumer Perspective (HCAHPs), can be accessed at http://www.hcahpsonline.org/home.aspx .

The availability of advanced medical technology and sophisticated training of physicians are cited as driving motivators for growth in foreigners traveling to the U.S.

Among the many reasons for improved patient outcomes, which lowers the risk associated with the care, are 1) careful selection of patients, 2) experienced, educated and certified nursing and rehabilitative staff, and 3) expert and experienced medical supervision. So, medical tourism companies may want to ask for specific information from patients as well as institutions.

How Safe is This Patient for Travel? Carefully screening “tourists” helps you make wise decisions. Medical patients need to be assessed thoroughly, and their medical and nursing needs ascertained precisely before embarking on a trip – or returning home. For safe outcomes, patients need not only expert physicians but also expert clinical care pre-intra-and post-surgery, as well as expert rehabilitation, preferably on site as long plane trips increase the likelihood of complications.

How Many of This Kind of Medical Procedure has the Medical Facility and Respective Medical Team Performed in the Last Year? Careful analysis of almost 1 million elective orthopedic surgeries shows that high-volume centers, which have extensive orthopedic surgical experience, have better outcomes than lower volume hospitals.iii

How Do You Measure the Quality of Nursing Care? Without doubt, nurses are chief among those who deliver care to patients, and their expertise is essential to positive patient outcomes. Registered nurses (RNs) typically specialize according to a particular work setting, a specific type of treatment, a specific health condition, organ or body system type, or population type. Some RNs may also choose to become advanced practice nurses, who work independently or in collaboration with physicians and may provide primary care services.iv, v Clinical nurse specialists provide direct patient care and expert consultations in one of many nursing specialties. Nurse anesthetists provide anesthesia and related care before and after surgical, therapeutic, diagnostic and obstetrical procedures. Nurse midwives provide primary care to women, including gynecological exams, family planning advice, prenatal care, assistance in labor and delivery, and neonatal care. Nurse practitioners serve as primary and specialty care providers, providing a blend of nursing and health care services to patients and families.

Does this Destination Provide Access to Nurse Experts? If the facility’s nursing staff does not compare favorably with comparable national data, you may want to direct your medical consumers elsewhere. According to the Health Resources and Services Administration, there were 3,063,162 RNs in the United States in 2008. In this study HRSA found that:

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• Half (50 percent) of RNs have achieved a baccalaureate or higher degree in nursing or a nursing-related field in 2008, this is compared to 27.5 percent in 1980 • The number of RNs with master’s or doctorate degrees rose to 404,163 in 2008, an increase of 46.9 percent from 2004, and up from 85,860 in 1980 • The average age of all licensed RNs increased to 47.0 years in 2008 from 46.8 in 2004; • An estimated 444,668 RNs received their first U.S. license over the period from 2004 to 2008. About 16% of the U.S. registered nurse workforce is comprised of foreign educated nurses vi (FENs) vetted by CGFNS International to ensure that their education, knowledge and experience is comparable to their counterparts in the U.S. CGFNS International, established in 1977, has reviewed and/ or certified the credentials of over 500,000 foreign educated nurses and other health care professionals for U.S. licensure and immigration. vii Section 343 of the U.S. Illegal Immigration Reform and Immigrant Responsibility Act (the IIRIRA) of 1996 requires specific non U.S. citizen health care professionals complete a screening program before they can receive either a permanent or temporary occupational visa, including Trade NAFTA status. CGFNS International was originally named in the law and continues to be the only authorized provider of this service for all health care professions affected: Registered nurses, licensed practical or vocational nurses, physical therapists, occupational therapists, physician assistants, clinical laboratory technicians (medical technicians), clinical laboratory scientists (medical laboratory technologists), speech language pathologists, and audiologists.

Are There Any Foreign Educated Nurses in the Facility, Which Demonstrates Cultural Competence and Commitment to Diversity? Culturally competent care is essential for high quality patient care, and the FEN has contributed much to the delivery of health care in the U.S. The FEN also has done much to increase cultural competence and understanding of diversity

As the demand for medical tourism, or as I prefer to say, medical consumerism, continues to grow the most important factor ensuring success will be patient outcomes. Thus the successful medical tourism company, and the most successful medical tourism destinations will do all possible to ensure their clients’ safety by carefully selecting the client and carefully matching him/her to the best providers of the particular services they need. The medical tourism industry would be well served by researching and initiating the development of desired patient outcomes in order to form a baseline for the measurement of the practice. n References: Africa and the Middle East: Israel, Jordan and United Arab Emirates. The Americas: Brazil, Canada, Costa Rica, Cuba, Mexico, Panama, United States, and Uruguay. Asia/Pacific: Brunai, China , Hong Kong, India, South Korea, Malaysia, New Zealand, Pakistan, Philippines, Singapore, Taiwan and Thailand. Europe: Czech Republic, Cyprus, Estonia , France, Germany, Hungary, Lithuania, Poland, Romania and Turkey

Allison Van Dusen, 2008 U.S. Hospitals Worth the Trip. Forbes May 29, 2008 http://www.forbes.com/2008/05/25/health-hospitals-care-forbeslife-cx_avd_outsourc ing08_0529healthoutsourcing.html accessed 9/4/11

among members of the nursing workforce in the United States by bringing new ways of thinking and serving a multicultural patient population.viii There can be no doubt that their presence in the workforce will help make foreign born medical consumers more comfortable by assuring that the care they receive is culturally appropriate.

iii Annals of Internal Medicine. 18 January 2011 http://www.acponline.org/journals/ annals/tipsheets/ 18jan 11.htm; http://www.upi.com/Health_News/2011/02/21/ Surgical-edge-goes-to-regional-hospitals/UPI-82731298265260/#ixzz1X1E3xjpK accessed September 3, 2011;Ko CY, Chang JT, Chaudhry S., Kominskey G 2002 Are high-volume surgeons and hospitals the most important predictors of in-hospital outcome for colon cancer resection? Surgery132:2 pp 268 - 73 iv Stanton, Mark W Hospital Nurse Staffing and Quality of Care. Research in Action. Issue 14 http://www.ahrq.gov/research/nursestaffing/nursestaff.htm accessed September 6, 2011

Bureau of Labor Statistics. http://www.bls.gov/oco/ocos083.htm accessed September 6, 2011

What is the Skill Mix of the Medical Team? How is Their Competency Assessed? Is the Medical Facility Committed to Continuing Education? What is the Tenure of the Facility’s Leadership and Personnel? The answers to these four questions say a lot about the quality of care that patients will receive as a result of the commitment to service, leadership, and learning.

HRSA Study Finds Nursing Workforce is Growing and More Diverse. March 17, 2010.

http://www.hrsa.gov/about/news/pressreleases/2010/100317_hrsa_study_100317_ finds_nursing_workforce_is_growing_and_more_diverse.html vii

http://www.cgfns.org/sections/about/ accessed September 6, 2011

Davis CR (2001) Foreign-Educated Nurses and the Changing U.S. Nursing Workforce. Nursing Administration Quarterly, Vol. 26, No. 2, Winter 2001. Lippincott Williams & Wilkins http://www.intlnursemigration.org/assets/pdfs/ForeignEducatedNurses_2002_Davis.pdf viii

Is this a Magnet Facility? In addition to accreditation, other important variables medical tourism companies should consider as they differentiate their package include becoming fully informed about the medical centers that have achieved Certification as a Magnet Recognized Facility.

What is the Nurse-Patient Ratio? Medical tourism companies should know some other important national and state specific metrics -- for example, a facility’s nurse patient ratio -- especially in states like California. Other forms of recognition, such as listed among the nation’s top 100 hospitals, will also add considerably to helping to assure clients of safe, quality care.

Is On-Going Follow-Up Possible? The continuum of care from point of entry to closure needs to be monitored. Families need to be included in the discharge planning and need to know what resources are available in the event that complications arise. Hospitals that are committed to technology in terms of an electronic medical record (an important tool that enhances a provider’s ability to follow the patient after discharge), online communication with physicians (MyChart.com), and telenursing offer access and care over the internet – and this is important, especially for those who may live very far indeed from their care providers. Medical transport services also need to be factored into the equation.

About the Author Franklin A. Shaffer, EdD, RN, FAAN, CEO, CGFNS International, represents the professional and global community as an expert on, leader in, and resource for health professional mobility, regulation, credentialing, certification, and health policy. He serves as a leading voice on issues regarding the global migration of the health professions and provides strategic leadership for the development of the enterprise’s programs that are designed to protect the health care consumer through credentials evaluation and standards development. He was previously executive vice president of Cross Country Healthcare and chief nursing officer for Cross Country Staffing where he worked closely with over 3,000 hospitals in the U.S. and the world. He was appointed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO or the Joint Commission) to serve on their Nursing Advisory Council. He was also the former deputy director for the National League for Nursing. Dr. Shaffer holds a doctorate of education in nursing administration from Columbia University. He was inducted into the American Academy of Nursing in 2002.` CGFNS International is an immigration-neutral, nonprofit organization globally recognized as a credentials evaluation and assessment authority on education, registration and licensure of nurses, health care and other professionals worldwide. For more information, go to www.cgfns.org.

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How can our internationally recognized experts help YOU achieve the winning formula? • Needs-based practice analysis to determine how you can best incorporate APNs to maximum advantage • Competency-based clinical training, including the use of high-ﬁdelity human simulation, for all levels of nursing staff to improve quality of care and systems efficiency • Academic educational program development and implementation • Healthcare accreditation standards development and compliance • Patient safety consultation and facility evaluation services APNI can provide the tools you need to ensure that you stand out in the new global healthcare marketplace. The Future of Global Healthcare is here.

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September / October 2011

M E DI C A L T OURIS M

In Search of

Superior Healthcare

in Asia

Spacious main lobby

By Liwen Williams

recent visit to Taiwan Adventist Hospital (TAH) illustrated many of these key points. This modern hospital is one of over 600 medical institutions in the worldwide Seventh-day Adventist Church. Since the hospital’s relocation from mainland China to the district of Taipei, this medical center has grown to become one of the country’s premier teaching hospitals with a growing, international reputation. Sabrina Wang, TAH’s Director of Marketing, gave me an eye-opening tour of the hospital facilities and campus, while providing valuable insight into their philosophy for healing and healthful living.

Ms. Wang noted that TAH provides a full complement of medical and surgical services characteristic of a teaching and referral center. The latest advances in medical equipment are evident throughout the center; including 4-D ultrasonography and low-dose, 128-slice computerized tomography to reduce radiation exposure.

A Higher Level of Care Beyond the advanced technology, medical and surgical treatment, TAH is perhaps best distinguished by the level of attention paid to patients and their families. Ms. Wang

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M E DI C A L T OURIS M explained that “TAH has special emphasis on the entire family for the entire lifetime. It is a Department of Health babyfriendly designated facility with a reproductive medicine and infertility center. At TAH, we have pediatrics and child health and rehabilitative services.”

Comfortable waiting area

Expanding on the full lifetime of healthful living emphasis, TAH has regular routine and “Executive” health assessments. There is also the NewStart Center, located in a pristine area on the outskirts of Taipei, that provides lifestyle instruction in health maintenance, exercise and nutrition; as well as providing recreational facilities for patients and their families to enjoy together. This attention to a patient’s companions is particularly important for medical tourists, who are often accompanied by friends or family members in their quest for medical treatment. Engaging everyone in the healing and rehabilitation process is critical to the patient’s long term health.

Serving International Patients Being part of such a world-wide organization and accustomed to the care of international patients, TAH operates a busy International Patient Center. The Center includes VIP accommodations, priority care services, and even a Celebrity Services Program. The Celebrity Services Program boasts a “Celebrity Wall” with autographs of numerous dignitaries from Taiwan, Korea, Japan, the United States, and beyond. The importance of these services cannot be overlooked in medical tourism, as we guide clients through different environments, customs, and protocols to provide the level of care and attention that they deserve.

Celebrity WALL

In the course of my tour of Taiwan Adventist Hospital, Ms. Wang and I spent a substantial amount of time educating one other about our respective organizations and developing processes to streamline and improve the travel and healthcare experience of visiting patients and their companions. For more information regarding medical travel and tourism experiences in Taiwan and Taiwan Adventist Hospital contact info@ chinahealthtoday.com. n

Patient Room Private patient room includes desk and couch to accommodate visiting family members and friends.

About the Author Liwen Williams graduated from Pittsburg State University, Kansas, with numerous honors and an M.A. in Communications. She has accrued valuable international business experience as a translator and administrator, while also serving as a translator and editor for a video production firm. Liwen Williams travels frequently throughout the United States, Taiwan, Japan, and China. She is co-owner of Golden Parts Retriever, an import/ export company based in Florida, and is associated with China Health Today (chinahealthtoday.com), a medical travel firm agency specializing in Taiwan, China, Hong Kong, and Korea. China Health Today is a member of the Medical Tourism Association.

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Medical Concierge

Programs ~ U.S. Medical Providers Creating a Bridge in Healthcare By R. Monty Cary PA-C, M.Ed., DFAAPA and Gabriella Vicuña

A number of hospital corporations, investors and real estate groups have expressed an interest in or are already building clinics, hospitals and comprehensive medical communities around the world. Surely, these groups and organizations recognize that the ambience and aesthetic beauty of these facilities and/or medical communities will not only draw the patients, healthcare providers and staff to run the facilities, but will also aid in the overall wellbeing and healing power of the patient. Consequently benefits such as technological advancements trickle down to the local community as well, creating a win-win situation!

First Things First ~ Challenges in Overseas Medical Travel

specific time could also add to problems for the medical tourist as they travel home by air.

Differences in healthcare provider standards around the world have been recognized and medical tourism carries some risks that locally-provided medical care does not. The quality of post-operative care can also vary dramatically, depending on the hospital and country, and may be different from U.S. or European standards. The issue of “continuity of care” and “after care” has been a long standing concern with overseas medical procedures and care.

By traveling outside of their home country for medical care, medical tourists may encounter unfamiliar ethical and legal issues. These legal avenues may be unappealing to the medical tourist. Should problems arise, patients might not be covered by adequate personal insurance or might be unable to seek compensation via malpractice lawsuits. Hospitals and/or medical providers in some countries may be unable to offer any sort of financial compensation.

Long flights and decreased mobility in a cramped airline cabin are a known risk factor for developing blood clots in the legs such as venous thrombosis or pulmonary embolus, better known as “economy-class syndrome”. An array of post-op complications such as wound infections requiring IV antibiotics, dehydration, and the need for medications at a

The issue of “continuity of care” and “after care” has been a long standing concern with overseas medical procedures and care. September / October 2011

M E DI C A L T OURIS M The worst case scenario, in the event that a post operative issue arises and there is a gap or a lack of communications between the attending physician (destination physician) and the family physician (home physician) the patient may be in danger of having a problem once returning home, or even worse during their trip home. If the family physician is unaware of the patient traveling overseas (s)he may be unwilling to care for the patient once home and a post operative complication arises.

Ensuring Continuity of Care The issue here is continuity of care for the patient after they have traveled overseas for their medical procedure. To date, most of the industry literature has alluded to the fact that the patient makes the decision to travel overseas to have a medical procedure done, is recovering from that procedure and has now traveled home to do well. However the concerns of “after care” still remains.

Benefits such as technological advancements trickle down to the local community as well, creating a win-win situation! One scenario which could provide a solution to the “after care” of the patient is a model in which either a medical provider or a group of medical providers, surgeons in most cases, form a corporation, identify a destination overseas and build a medical facility in that destination; perhaps even forming a partnership or affiliation with local providers in the destination, as well as government support where at all possible. The facility would be built to internationally accredited standards, specifications and specialty. Hospital affiliations tend to result in higher medical knowledge and more thorough patient care. Major U.S. hospital systems, such as Johns Hopkins and Harvard Medical, are affiliated with hospitals in countries all around the world. Ideally the destination would be just a short distance, three to four hours, from the city of origin of the entrepreneurial medical providers, as well as their targeted patient population.

Medical Concierge Programs & U.S. Providers As medical tourism continues growing the need for a Medical Concierge Provider becomes a necessity as well. The Medical Concierge Provider should be a mid-level provider such as a Physician Assistant who is educated in the same medical model as the Physician. Experienced Physician Assistants have the training, knowledge, education and communication skills necessary to assist in the care of the patient as they travel globally for their medical care. The Joint Commission International (JCI) requires that international patients receive post-operative and after-care instructions in a language in which they can understand. Patients coming from English speaking countries such as the United States, England and others would benefit greatly by having a Medical Concierge Provider working on their behalf before, during and after their clinic or hospital stay. Before the medical treatment is rendered, the Medical Concierge Provider would make contact with all physicians involved to review the pre-operative instructions and planned medical or surgical treatment. During the hospital stay the Medical Concierge Provider would be a patient advocate as well as ensure that the post-operative instructions were followed by the hospital medical staff. Upon discharge home the Medical

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Concierge Provider would write the discharge instructions and after-care plans making sure they are fully understood by the patient. In addition the Medical Concierge Provider would be available to educate the hospital staff on the surgical procedures performed, the post-operative care expected for a successful outcome as well as the discharge and aftercare planning of the patient. Through the insertion of a Medical Concierge Provider into this potentially confusing global equation, the patient, all involved medical providers and the treating facility or hospital will engage in seamless communications leading to the best possible outcome in patient safety and care. n

About the Author

Mr. Cary has been a Physician Assistant for 36 years and has been active in both the clinical and educational aspects of the medical profession. He held an Adjunct Faculty position at Penn State from 1987 to 1994 and the College of Southern Nevada from 1999 to 2006. Currently he is on the Physician Assistant Advisory Committee at the Roseman University of Health Sciences. In addition Mr. Cary is on the Physician Assistant Advisory Committee to the Nevada State Board of Medical Examiners. Mr. Cary is a co-founder and past president of The American Academy of Physician Assistants in Legal Medicine founded in 2000. He was on the Conference Education Planning Committee and in the Leadership Class of The American Academy of Physician Assistants, 2009 – 2011. He is a co-founder of Cary and Associates, LLC and holds a position as Senior Partner. Mr. Cary is a member of the Medical Tourism Association and is interested in developing the concept of Medical Concierge Provider, Patient and Staff Education. He can be reached at medlaw_us@yahoo.com

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September / October 2011

M E DI C A L T OURIS M

The Brazil of Fútbol

The Brazil of Health By Luiz Fernando Schreiner Moraes The image of a Brazil associated only with football, with the Amazons, with the “favelas” of Rio de Janeiro and with samba, is becoming a thought of the past. The world is now beginning to discover the Brazil that is the 7th largest economy in the world, possesses monetary reserves allowing the country to overcome the global crisis in a much smoother fashion than other countries, has extraordinary petroleum reserves, holds 11% of water supply on the planet, is one of the countries that generates the greatest agricultural production in the world, has an emerging industrial sector and 200 million inhabitants with a purchasing power that grows each day.

razil, however, was not founded yesterday. Some of its greatest surprises have been forged over the last decades, or even centuries. This is the case with medicine and health. There are 17 Brazilian hospitals accredited by Joint Commission International (JCI), in three cities; São Paulo, Rio de Janeiro, and Porto Alegre. However this fact does not reflect the lack of quality in the today’s healthcare system. One of the largest networks of medical educational institutions in the world is based in Brazil, with 181 schools, many of which are connected to hospitals that are more than 100 years old. Brazil has a labor force of more than 350,000 physicians (one for every 549 citizens), many of them specialized abroad. By comparison, according to the World Health Organization’s Global Health Observatory Data Repository, Costa Rica has 5,200 physicians, Thailand 18,900, and Singapore 8,300, to cite some well-known Medical Tourism destinations.

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Renowned Hospitals The number of internationally accredited hospitals in Brazil is a reflection of the acknowledgement of those looking to embrace the medical tourism industry, not necessarily implying all around quality in Brazil’s healthcare system. We see those numbers steadily growing as more providers and healthcare leaders become educated on the opportunities available to them. This situation begins to change when Brazil enters the international Medical Tourism market, drawing on the pioneering experiences of a number of Brazilian institutions. This is the case with São Paulo’s Albert Einstein Israeli Hospital, inaugurated in 1971 and today is one of the largest and most important health and medical teaching institutions in Latin America with 7,500 staff members and 6,000 accredited

doctors. The Albert Einstein Israeli Hospital has already been investing in Medical Tourism for some time. Another point of reference is the Oswaldo Cruz Hospital in São Paulo, founded in 1897 by German immigrants. Today it has a built area of over 72,000 m2, 1,500 staff members and 2,500 accredited doctors. In Rio de Janeiro the Ivo Pitanguy Clinic has been in operation since 1963. Doctor Pitanguy became internationally renowned for his work in plastic surgery and is responsible for the growth in this specialty that Brazilians adore. Today, in Brazil, approximately 1,700 plastic surgeries are performed every day. In Porto Alegre there are institutions such as the JCI-accredited Moinhos de Vento Hospital and Santa Casa, founded in 1803, which encompasses 2 general hospitals and 5 specialized hospitals with 6,300 staff members and 2,500 accredited doctors, as well as a college of Medical Science.

Today Brazil is a country with a consolidated democracy and an economic, social and political stability. We are aware that medical quality is a basic prerequisite for any country that intends to take part in Medical Tourism, but it’s not all. Brazil is also growing in the other important areas. For example in relation to cost, it is possible to undergo an elective surgery in a hospital with advanced technological infrastructure and highly specialized doctors, spending 50% less than you would spend in the United States. But we also know that there are other important factors beyond the quality of medicine and cost.

Stability and Diversity Today Brazil is a country with a consolidated democracy and an economic, social and political stability. In the 90s, President Fernando Henrique Cardoso implemented an economic stabilization plan that created the basis for this new period of growth. President Luiz Inácio Lula da Silva continued the work of his predecessor. The strengthening of social programs has lifted 30 million Brazilians from poverty to middle class, creating an explosion in internal consumption that is allowing the country to take great strides in many different areas. Brazil is certainly the face of diversity, and as in any other large metropolis in the world, inevitable can exist. Luckily patients and their companion(s) simply need to follow some basic tips in order to have a tranquil stay and they will not be surprised by violent public demonstrations or strikes during their time in Brazil. Due to this, the patient, instead of just choosing a health institution or a doctor, can choose one of the many other “countries” that exist within Brazil, each with its own culture. To cite some examples, in the Northeast, the patient will discover the Brazil of beaches, of white sands, of high temperatures, and of the joy of dance. Rio de Janeiro, with its incomparable landscape, is the fusion of the core of Brazil, of its beaches, the heat, bossa nova and cultural life. The patient does not need to remain in the capital. Before or after treatment, depending on the procedure, they can enjoy marvelous beaches throughout the state, such as the famous Búzios. São Paulo, by contrast is the Brazilian California, the locomotive of Latin America. The capital is one of the largest metropolises in the world and there is nothing you cannot find there. Make a wish and São Paulo grant it; from the most basic to the most luxurious. Porto Alegre, the capital of the far south, has a pleasant climate and a European

feel in its architecture, people and culture. It is here that we find the Gaucho Highlands, one of the most visited tourist regions by Brazilians, with its low temperatures, chocolate factories, wines and abundant Italian and German-inspired gastronomy.

Dealing with Bottlenecks Despite these unique features, Brazil is still in the process of becoming fully equipped to appropriately embrace the Medical Tourism sector. The Ministry of Foreign Affairs practices what it calls a “policy of reciprocity” in relation to the granting of visas. As the USA demands that all Brazilians apply for visas, all North Americans require visas to enter the country, however not Europeans. This is a small hurdle, but it does not mean that it is not possible to begin forging connections between the major players in the market. Nevertheless, the Brazilian parliament is considering legislation in order to create a special visa for medical patients, which would greatly facilitate growth in this area. The 2014 FIFA World Cup host country has some other difficulties in tourism in general, and especially for mega events. A great number of the country’s airports are already operating over capacity, precisely due to Brazil’s economic development. The number of domestic flights has increased in between 20% to 30% annually, which has created an imbalance between the increase in demand and the government’s capacity to expand airport infrastructure, which is all state owned, accordingly. Presently, three airports have been transferred to the private area to see if this can help the country speed up the expansion of these structures. Many hospitals are in the education process of establishing best practices and their opportunities within the medical tourism industry. This includes developing or qualifying their International Departments, setting up linguistically competent teams to deal exclusively with foreign patients and adjusting aspects of their contracting and systems for payment between countries. The Federal Government and entities from relevant sectors should keep working to facilitate the granting of visas and a system of quality assurance to ensure that healthcare institutions and professionals who are not adequately prepared to enter the medical tourism market are identified, educated and guided through the process of offering international patients and our local population, the very best healthcare possible. Nevertheless these are all steps that need to be taken in the development of any new market sector. It is always seems like a long road; however, Brazil already has the most important factors in place: quality in medical and healthcare services. Brazil also has the greatest quality that lies in a different area, which is the joy and energy of the Brazilian people, who love to receive their visitors as well! n

About the Author Luiz Fernando Schreiner Moraes is a journalist and secretary of Tourism for the city of Porto Alegre, capital of the state of Rio Grande do Sul, Brazil. For 4 years, he’s been president of the Brazilian Association for Municipal Secretariats of Tourism. He is a member of the National Tourism Council, a body linked to the Ministry of Tourism, and is the founder and advisor to Porto Alegre Healthcare Cluster, the first Brazilian organization in the Medical Tourism sector. He is also the architect and founder of the recently created Brazilian Association for Medical Tourism - ABRATUS.

September / October 2011

M E DI C A L T OURIS M

Medical Travel ~ Voice of the iPatient

By Jim Tate

If You Have Medical Insurance, Why Travel Abroad? Upon further questioning he told me his private insurance had a $3500 annual deductible and he had called several places clinics in his hometown of Atlanta, GA and received quotes that ranged from $2200 to $3400. Needless to say, whatever the cost, it was going to come right out of his pocket. He researched alternatives and located a hospital in San Jose, Costa Rica that quoted him a price of $500 for the procedure. Further investigation on his part revealed that the hospital was accredited by Joint Commission International which definitely helped him feel more comfortable about traveling to another country for diagnostic testing. Within a month he was on a plane to San Jose where he was met at the airport by a representative of the hospital, taken to his hotel, and given instructions for the upcoming test. The next day he had his coloncopy at the hospital, reviewed the results with the gastroenterologist who performed the procedure, and then left for the beach with his

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medical records in hand. After five days at a beach in Costa Rica he flew back home. Total cost of the medical care, airfare, lodging, and all other expenses was $2100. When I saw him at the reunion he still had his tan.

Traveling for Healthcare ~ My Experience The concept of traveling outside one’s community for wellness and healthcare services is nothing new. Patients travel based on such reasons as economics, better access, or perhaps the location of specialist. Over the past few decades we have

An entire industry has emerged to provide support and resources to iPatients. © Copyright Medical Tourism Association

seen the rise of a phenomena in which patients are able to travel the globe in search of health care options. I have a name for these medical travelers. I call them International Patients or iPatients for short. An entire industry has emerged to provide support and resources to iPatients and I wanted to experience what was being offered. As someone with a background in health care my expectations are very high and are based on over thirty years of health care delivery in both hospitals and medical practices. I’ve done my share of taking care of patients as well as being a patient. My trip abroad for health care was not based on one of the usual motivators for an iPatient. I have adequate insurance and access to extremely high quality health care in my home town of Asheville, NC. I didn’t need a knee replacement and my Medical Travel journey was not based on an urgent medical condition. It was simple curiosity, personal and clinical, that led me to schedule my trip. I’m not saying my trip was typical, but I would like to describe it to you. I chose to schedule an Executive Physical with a large private hospital in Costa Rica that has a long history and reputation for caring for iPatients. I checked to make sure they had received and maintained an active certification from an international accreditation body. By email I contacted the hospital’s international department and requested information about scheduling an outpatient appointment. Within two hours I received a reply outlining the process, cost, and included suggestions about scheduling. The promptness of the response was just the first of many surprises that lay ahead. I was assigned a case manager who became my primary contact through the entire process. I let her know I didn’t need to be met at the airport. I scheduled an appointment and we made arrangements to meet in three weeks in the lobby of the hospital on a Tuesday morning at 8 AM. She handled the scheduling of all my appointments.

Being from the United States, I’m used to technicians doing these types of diagnostic procedures. In this case it was a physician. The Executive Physical I had scheduled included lab work (chemistry and urinalysis), chest x-ray, ultrasound of the abdomen, EKG, bone density testing, and consultation with a physician. Upon arriving at the hospital I met my case manager who directed me first to the laboratory. Since some of my lab work required fasting for twelve hours she arranged for that to occur first and then directed me to the cafeteria for breakfast. She provided me with a coupon for the meal. I was grateful to finally be able to eat. The omelet was excellent. Next was the chest x-ray which took almost no time and then on to the ultrasound. This was another big surprise. Being from the United States, I’m used to technicians doing these types of diagnostic procedures. In this case it was a physician. As he performed the ultrasound he drew my attention to a computer monitor and showed me exactly what he was seeing and how it looked. He covered it all in his real time review: kidneys, gall bladder, aorta, prostate, liver, and spleen. When we were through he dictated a formal report on the ultrasound and the chest x-ray into my electronic health record. My case manager then gathered me up and took me for bone density testing which took less than 10 minutes and then I was on to my session with a physician. My consultation with the physician took well over an hour, proceeded at a leisurely pace, and was conducted entirely in English. He performed an EKG and reviewed it on the spot. A thorough physical exam followed, as complete as any I have

ever had. He then turned to a computer monitor and brought up my electronic record. Every test performed that day was there. He reviewed the ultrasound, lab work, and bone density results with me in great detail and answered all my questions. He asked probing questions about my medical, social, and family history. At the end of our session he made a few lifestyle recommendations; drop a few pounds and get more exercise. My case manager next took me to the financial department where I received another big surprise. The entire process including all procedures, tests, and physician consultation was $520 which I paid with US currency. As we were walking to the exit I casually asked if I could have the medical records that were generated that day. Within 10 minutes I had them all which included copies of the actual ultrasound, EKG, bone density and chest x-ray images, lab results, interpretations, and the final summary from the physician. My report was in Spanish and I requested it to be translated into English so I could give it my provider in the US. I received the English translation three days later via email. The next day I decided to visit a major dental clinic that specialized in treating patients from the US and Canada. I scheduled an appointment for an assessment and cleaning. When I arrived at the clinic I was amazed at first by the flat screen television in the waiting room and then by the view of the mountains from the dental chair. I received a full set of x-rays, digital photographs, diagnostic gum testing, and then a cleaning. Although there was a technician present, everything was actually performed by the dentist who spoke excellent English. My visit ended with a review of all images and findings. My final bill, in total, was $110 which I paid in US currency. Ninety-eight percent of their clients come from the US and Canada. I can see why. In many ways I’m sure my foray into medical travel was not typical. I went to experience the process and receive diagnostic and preventive services. Most iPatients travel to receive treatment for existing problems. It was very clear to

September / October 2011

M E DI C A L T OURIS M me that the two healthcare providers I chose to visit had ample experience in the care of patients who were from another country. Many of the problems I thought I would encounter by being an iPatient simply did not exist. There was no problem scheduling appointments based on my convenience. Everyone, from the health care professionals to the scheduling and billing staff, spoke English. I was able to obtain all my medical records to bring home. Waiting times were minimal. Complimentary access to computers with internet was widely available. The hospital had Wi-Fi, which I used with my laptop to communicate with my wife by using SKYPE. A case manager helped keep me on track through numerous appointments. I could go on and on but I think you have the picture.

I chose to schedule an Executive Physical with a large private hospital in Costa Rica that has a long history and reputation for caring for iPatients.

In summary I must say that all my expectations were exceeded. I received high quality and personal health care and at an amazing value in pricing. I do not know if my experience is at all representative of what iPatients typically experience in terms of support. However, I can say without reservation that I was truly surprised at the level of service and value I received. I was not expecting that. I look forward to looking deeper into some of the other aspects of what an iPatient can expect. What about rehab facilities after a knee replacement? What about lodging for a fellow traveler of an iPaient? What about complicated dental work that could take several weeks in total? How do services in other parts of the world compare with Costa Rica? I look forward to exploring all aspects of the robust and maturing field of medical travel and I can see why it has become a valid option for many iPatients. n

About the Author Jim Tate, President and Founder of the Medical Travel CommissionTM www. medicaltravelcommission.com, has a 30 year history in health care delivery in both Inpatient and Ambulatory environments. He has worked directly with over 135 Health Information Technology organizations on their projects and has led numerous health care system implementations in the United States and Asia. Jim has worked across borders, languages, and cultures with health care clients in the US, India, Pakistan, China, Ireland, Scotland, Israel, South Korea, Sri Lanka, and Peru. Jim founded The Medical Travel CommissionTM out of a need for a neutral entity to bring credibility and transparency to the Medical Travel industry and advocate for patient safety and support. The need for Medical Travel Certification is driven by the expanding phenomena of patients seeking health care outside their community for economic or accessibility reasons. The Medical Travel Commission has developed a certification process that includes reviews, audits, and recommendations based on Best Practices for hospitals who are addressing the needs of Medical Travel. International travel in pursuit of health care options has the best chance of delivering on the promise of safety and economy if backed by a clear set of standards. All rating criteria are directly traceable to patient care and support. The MTC certification brings credibility to countries that promote national Medical Travel initiatives, improves the care and services delivered by hospitals, and assists in the constant improvement in the experience and outcomes for patients.

September / October 2011

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M E D I C AL T O U R I S M

Medical Tourism Association TM

Survey Results 2011

Medical Tourism AssociationTM Survey Results for 2011

largestYou Know Large Insurance The Medical Tourism Association TM traveled to Las Vegas for one of theDid employer conferences in the country and conducted a survey of hundreds of top Humanare Implementing Medical Companies Resources professionals nationwide.

Tourism? Did You Know Large Insurance 65% of the respondents had up to 1,000 employees in their company with another 25% having are Implementing The Medical Tourism Association traveled to Las VegasCompanies for one of the largest employer in the Medical country and employees ranging from 1,001 to 10,000 No conferences Yes conducted a survey of hundreds of top HR professionals nationwide. Tourism? Respondents - The Size of the Companies They Represent TM

Number Employees Number ofof Employees Up to 1,000 Employees 1, 001 to 10,000 Employees Other

Did You Know 25% Large Insurance Companies are Implementing Medical Tourism?

Yes

25%

10%

75%

25%

75% 65% Did You Know a Large Amount of Americans Would Travel for Medical Care? Have You Heard the Term Medical Tourism?

72% of the respondents did not know that in some cases, over half of Americans surveyed 42% of the respondents had heard of Medical Tourism before that the conference, had for medical care, while 28% wouldn’t. they would while travel58% overseas An overwhelming 75% of the respondents did not know that not. Well Point Blue Cross Blue Would Shield Travel & otherfor insurance 65% of the respondents had up to 1,000 employees in their Did You KnowAetna, a Large Amount of Americans Medical Care? company with another 25% having employees ranging from companies have implemented medical tourism for employer groups, allowing employees travel overseas for surgery, 1,001 to 10,000 72% of the respondents did not know that into some cases, over half of Americans surveyed while 25% did know. that they would travel overseas for medical care, while 28% wouldn’t.

Did You Know a Large Amount of Have You Heard the Term Medical Americans Would Travel for Medical Tourism? Have You Heard the Term Medical Tourism? Care? Did You Know a Large Amount of Americans Would Yes No Did You Know Large Amount of Travel fora Medical Care? No Travel Yes Americans Would for Medical 42% Care? 58%

28% No 28%

Yes

72%

42% of the respondents had heard of Medical Tourism before the conference, while 58% had not.

72% Did You Know Large Insurance Companies Are Implementing Medical Tourism? 72% of the respondents did not know that in some cases, over half of Americans surveyed said that they would travel overseas An overwhelming 75% of the respondents did not know that Atena, Well point Blue Cross Blue for medical care, while 28% wouldn’t. Shield & other insurance companies have implemented medical tourism for employer groups, allowing employees to travel overseas for surgery, while 25% did know. © Copyright Medical Tourism Association September / October 2011 41

guarantee of the same quality to their employees but save up to 90% off the cost, while 6% health insurance but 35% think it is enough. would not be interested.

Will a Higher Taxation/Fine for the Are You Interested in Saving M E DI C ACost L T OURIS M Uninsured Force People to Buy Health Without Quality? Are YouSacrificing Interested in Saving Cost Will a Higher Taxation/Fine for the Uninsured Force Insurance? Without Sacrificing Quality? People to Buy Health Insurance? Yes

Yes

35%

65%

94% 63% of the respondents think that a tax/fine for not buying health insurance increasing from $95 for an individual in 2014 Healthcare Reform ~ Destroying to $695 in 2016 isthe notUnderwriting a large enoughProcess incentive to force people to buy health insurance but 35% think it is enough. 94% of the respondents would be interested or may be Healthcare Reform ~ Will it Increase the Cost of Health Insurance? 65%of ofwhether the respondents think that starting from 2014, if any person can wait until they are sick interested in letting their employees have the choice to purchase health insurance (rather than purchasing when they are healthy), it will destroy the or not to travel their medical there is the 42% of the respondents believeoverseas that the for healthcare reformcare will if significantly increase the guarantee of the same quality to their employeesunderwriting but save up to ~ process while 35% thinkHealthcare that it wouldReform not. insurance cost and another 33% believe it will increase health insurance cost. 13% of the 90% off the cost, while 6% would not be interested. Destroying the Underwriting Process respondents said it would keep health insurance at the same cost while 12% thought it would Yes No lower the cost. Significantly Increase Increase

Healthcare Reform ~ Destroying the Underwriting Process

Healthcare Reform ~ Will it Increase the Cost of Health Insurance? Healthcare Reform ~ Will it Increase the Healthcare Reform ~ Will it Increase the Cost of No Change Lower Cost ofHealth Health Insurance? Insurance? Significantly Increase 12% No Change 13% 12% 13%

Increase Lower

35%

42%

65% 42%

33% 65% of the respondents think that starting from 2014, if any person can wait until they are sick to purchase health insurance (rather than purchasing when they healthy), it will destroy Healthcare Issues ~ are The Most the underwriting process while 35% think that it would not.

Healthcare Issues ~ The Most Important Sources of Gathering Important Sources of Gathering Information

33% Healthcare Reform ~ Will it Benefit/Hurt Your Business?

42%believe of the that respondents believe that will the affect healthcare reform Healthcare Issues ~ The Most Sources of Gathering Information 56% respondents the healthcare reform their business negatively and Important Information significantly increase the insurance cost and another Healthcare Issues ~ The Most Important Sources of 44% believeReform itwill will affect it positively. Healthcare ~ Will it Benefit/Hurt Your Business? 33% believe it will increase health insurance cost. the Gathering 67% 13% of theofrespondents feel that News, internet news,Information resource websites and social media are the Internet Resourse Websites and Social Media respondents said the it would keep reform health will insurance atimportant the samesources 56% respondents believe that healthcare affect their business negatively and most for gathering information on healthcare issues while 33% disagree. Disagree Internet News, Resourse Websites and Social Media cost while 12% thought it would lower the cost. 44% believe it will affect it positively. Disagree

Healthcare Reform ~ Will it Benefit/ Hurt Your Business? Healthcare Reform ~ Healthcare Will it Benefit/ Will it Reform Benefit/Hurt~ Your Business? Affect Affect Positively HurtNegatively Your Business?

34%

66%

Affect Negatively 44% 44%

66%

Affect Positively 56% 56%

67% of the respondents feel that internet news, resource websites and social media are the most important sources for gathering information on healthcare issues while 33% disagree.

56% respondents believe that the healthcare reform will affect their business negatively and 44% believe it will affect it positively. Will a Higher Taxation/Fine for the Uninsured Force People to Buy Health Insurance?

Will a Higher42 Taxation/Fine for the Uninsured Force People to Buy Health Insurance? September / October 2011

ÂŠ Copyright Medical Tourism Association

M E DI C A L T OURIS M

Domestic

Medical

Tourism ~

A Neglected Dimension of Medical Tourism Research

By Dr. Simon Hudson From a review of the academic literature on medical tourism, it is apparent that research on medical tourism to date has been largely conceptual in nature, and major gaps exist in the evidence base supporting this research. Medical tourism research to date has also focused almost exclusively on the import side of medical tourism â&#x20AC;&#x201C; those who travel abroad to developing countries for medical services. It is time to take a closer look at domestic medical tourism.

Preparing for the Challenge Considerable hospital revenue is being lost to U.S. hospitals from patients traveling overseas. Deloitte Center for Health Solutions estimated that the U.S. lost $15.9 billion in domestic consumer spending to medical tourism in 2008, and this would rise to $68 billion in 2010. However, in recent years, a number of medical tourism experts have suggested that competition introduced from abroad may stimulate improvement in health care offerings at home, and lead to an increase in domestic medical tourism. Some hospitals in the U.S. are offering discounted bundled care for particular procedures in order to compete with overseas medical providers. Galichia Heart Hospital in Wichita, Kansas, for example, decided that it could break into a market monopolized by overseas hospitals, and offer high-quality more-convenient care to patients. After conducting medical tourism research in other countries, the

ÂŠ Copyright Medical Tourism Association

hospital decided to challenge itself to see if it could offer comparable prices on heart procedures and other services. By cutting prices, the hospital found it was attracting an additional two medical tourism cases a week, or approximately 100 a year, which generates $1million in incremental revenue per year. Other states in the U.S. are promoting domestic medical travel. Oklahoma is positioning itself as the medical tourism

By cutting prices, the hospital found it was attracting an additional two medical tourism cases a week, or approximately 100 a year, which generates $1million in incremental revenue per year. September / October 2011

M E DI C A L T OURIS M destination for oncology care in the U.S., and Missouri is seeking to attract medical tourists from neighbouring states for both intervention and intervention-type treatments. Missouri’s Hospital Association recently commissioned a study into domestic medical travel, suggesting that it created over 3,000 jobs and generated $124 million in non-medical travel expenditures in 2009. The report suggests that the tourism industry should work with the healthcare community to inform potential patients about the opportunities Missouri offers in the state’s largest cities – St. Louis, Kansas City and Springfield.

The Facts In 2010 the home improvement retailer Lowe’s struck a deal with Cleveland Clinic making its cardiac care available to employees. This is the first time that a national company has selected one specialist hospital. The incentive for employees is that they incur lower out-of-pocket expenses for heart procedures at the clinic.

Bob Ihrie, Senior Vice President, Employee Rewards and Services for Lowe’s and Michael McMillan, Director of Market and Network Services of the Cleveland Clinic presenting their case study at the 3rd Annual World Medical Tourism & Global Healthcare Congress in 2010. Another reason for the potential growth of domestic medical tourism is the aging population and the baby boomer cohort in particular. With life-expectancy over 80, there will be 115 million people 50 or older in the U.S. by 2020, 50 percent more than now. Seventy-six million of them will be baby boomers, those born between 1946 and 1964. Boomers control more than 83 percent of consumer spending and account for over half of trips abroad. Boomers are making healthy aging both a priority and the norm, as they wish to remain productive and useful, stressing both physical and mental health. These priorities are leading to an increase in medical tourism. Health and wellness centers are expanding all over the world, and spa tourism is seeing significant growth; spa tourism is worth over $255 billion globally. Fried and Harris (2007) indicate that hospital leaders in the U.S. can take several steps to meet the challenge of competition from medical tourism overseas. The first is to demonstrate that the quality of services is worth the extra cost. Second, managers must reduce costs and improve the efficiency of operations. Third, U.S. hospitals could take concrete steps to improve their patients’ privacy as well as the perception of receiving more personalized care. Finally, they suggest that U.S. hospitals should emphasize that patients treated in many foreign countries have limited legal remedies in the event of an adverse outcome caused by medical malpractice.

September / October 2011

Medical Tourism Integration As seen by a few examples above, some individual hospitals and regions in the U.S. are beginning to position themselves as medical tourism destinations, but few stakeholders have recognized the opportunities in bridging the gap between hotels and healthcare. In order to match the two sectors and develop strategies for a thriving medical tourism industry, research is required. We have built on previous frameworks and models to provide a new model of medical tourism to guide future research, one that depicts not only the demand and supply perspectives, and the intermediaries that bridge them, but also the growing trend towards the provision of an integrated medical tourism facility, a hybrid institutional form that incorporates features of both a hospital and a hotel (see Figure 1). Recognizing this overlap or relationship between medical and tourism stakeholders makes this model unique, as does the acknowledgment that medical tourists can be both domestic and international. The left-hand side of the model is dedicated to the medical tourists themselves, influenced, according to the literature, by affordability, availability, the opportunity to vacation, privacy and anonymity, advanced technologies, better quality care and quicker access to medical procedures. These medical tourists will in turn be influenced by source market externalities such as the state of the economy and political system in their country, and their current health system. Although some medical tourists may seek medical tourism providers via direct channels, the importance of intermediaries has already been acknowledged, so the middle part of the model shows the various channels a customer might use to arrange his or her medical tourism experience. One such channel is the “medical brokerage”, “medical tourism facilitators” or a “medical travel agency”, intermediaries that have emerged to bridge the gap between clients and medical tourism providers. Traditional travel agents might also fulfill this role, while some researchers have suggested that medical tourism growth has been largely facilitated by the emergence of specialized internet websites. Others have documented the importance of employers and insurance companies in fuelling the growth in medical tourism. All these channels are represented in the model.

Missouri’s Hospital Association recently commissioned a study into domestic medical travel, suggesting that it created over 3,000 jobs and generated $124 million in non-medical travel expenditures in 2009. Finally, the right-hand side of the model depicts the supply side of medical tourism – a combination of hotels and resorts and the medical tourism facilities themselves, providing the three types of treatment as identified by Bookman and Bookman (2007) in their book on medical tourism – invasive, diagnostic and lifestyle treatments. The shaded area of the model is the “Hotels to Healthcare” (H2H) part of medical tourism, an overlap between hotels and resorts and the medical facilities themselves, often resulting in the provision of an integrated medical tourism facility. An increasing number of hospitals and health resorts that are geared towards medical tourism are building rooms that feel more like a hotel than a hospital room. This supply side will be influenced by destination externalities such as brand awareness, political stability, accreditation of facilities, and accessibility. An increasing number of governments, including India, Malaysia, Thailand, Singapore, the Philippines, South Africa, Cuba and Puerto Rica, are actively promoting medical tourism. Since quality

Figure 1. Medical Tourism: An Integrated Model

Demand Medical Tourists: Domestic and International Motivated By: Affordability Availability

Intermediaries Medical Brokers Travel Agents Online Agents Employers

Opportunity to vacation Privacy and anonymity Advanced technology

Insurance Companies

Better quality care Quicker access

Direct Channel

Source Market Externalities

Supply Hotels and Resorts H2H Medical Medical Facilities -Invasive -Diagnostic - Lifestyle

Destination Externalities

Economy

Destination brand

Health System

Political Stability

Political System

Accreditation Accessibility

is of critical importance in a patientâ&#x20AC;&#x2122;s choice of medical tourism destination, a priority for medical institutions in these countries is seeking accreditation to boost patient confidence to better compete in the medical tourism market. Although the model applies to both domestic and international medical tourism, domestic medical tourism, by definition, is subject to less uncertainty associated with/resulting from destination externalities. Hence, it is presumably a more feasible option in terms of matching medical tourism demand with supply.

The Potential for Inbound and Domestic Medical Tourism in the U.S. It is imperative therefore stakeholders in the medical and tourism industries in the U.S. explore the potential for domestic tourism in their region. We suggest a research agenda that could include the theory of planned behaviour, conjoint analysis and willingness-to-pay surveys to determine the consumer demand for medical tourism; economic models to determine the potential economic impact for a region should it attract medical tourists; and interviews with key players in both health and tourism sectors in order to identify areas of potential opportunities for specialization in medical tourism for a region. With domestic medical tourism likely to expand under U.S. healthcare reform, this research would be timely and have significant implications. If regions in the U.S. â&#x20AC;&#x201C; particularly depressed ones - can build a reputation for specialising in specific areas of treatment and surgery, the economic and social impacts could be significant. Medical tourism can generate

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diversified job opportunities for regions, not just in areas directly related to hospitality and catering, but also in terms of jobs for nurses, doctors and specialists which results in a much higher value added to the economy. If specialty clinics like the Mayo Clinic in Minnesota can draw patients from across the nation on the basis of their specialization, expertise, research, reputation and patient success, then there is no reason others cannot follow suit. n

About the Author Simon Hudson is the Center of Economic Excellence Endowed Chair in Tourism and Economic Development at the College of Hospitality, Retail and Sport Management, University of South Carolina, Columbia. He has held previous academic positions at universities in Canada and England, and has worked as a visiting professor in Austria, Switzerland, Spain, Fiji, New Zealand and Australia. Prior to working in academia, he spent several years working in the tourism industry in Europe. Simon has written five books; Snow Business, Sports and Adventure Tourism, Marketing for Tourism and Hospitality: A Canadian Perspective, Tourism and Hospitality Marketing: A Global Perspective, and Golf Tourism. The marketing of tourism is the focus of his research and in addition to the books he has published nearly 50 journal articles and 20 book chapters from his work. He is frequently invited to international conferences as a keynote speaker. Website address: www.tourismgurus.com

September / October 2011

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September / October 2011

M E DI C A L T OURIS M

Clinical Research Studies at Northwestern University Feinberg School of Medicine & Northwestern Memorial Healthcare ~

Revolutionizing

Medicine

Worldwide By Gabriella Vicuña

Consistently ranking among the nation’s top 20 medical schools, its medical specialties ranked amid the nation’s best, and six of those specialties ranked highest in Illinois by US News & World Report magazine, Northwestern University is an exemplary academic medical center. Encompassing over 3 million square feet of medical building space, approximately 2,000 clinical research studies or clinical trials took place at Northwestern in 2009.

Focus on Academic Excellence With a faculty of 3,173 and 2,500 medical and graduate students, residents and fellows, Northwestern University’s Feinberg School of Medicine is able to conduct medical and scientific research creating one of the most complete academically based Clinical Study centers throughout the U.S. and around the world. Below are three clinical research studies, currently taking place and changing lives.

Clinical Research Studies and Their Impact on Medicine According to ClinicalTrials.gov, clinical research studies are generally considered to be biomedical or health-related research studies in human beings that follow a pre-defined protocol. ClinicalTrials.gov includes both interventional and observational types of studies. Interventional studies are those in which the research subjects are assigned by the investigator to a treatment or other intervention, and their outcomes are measured. Observational studies are those in which individuals

are observed and their outcomes are measured by the investigators. The clinical trial process depends on the kind of trial being conducted. The clinical trial team includes doctors and nurses as well as social workers and other health care professionals. They check the health of the participant at the beginning of the trial, give specific instructions for participating in the trial, monitor the participant carefully during the trial, and stay in touch after the trial is completed.

What Are the Benefits and Risks of Participating in a Clinical Research Study? Benefits

Clinical trials that are well-designed and well-executed are the best approach for eligible participants to: • Play an active role in their own health care. • Gain access to new research treatments before they are widely available. • Obtain expert medical care at leading health care facilities during the trial. • Help others by contributing to medical research.

September / October 2011

M E DI C A L T OURIS M Risks

There are risks to clinical trials. • There may be unpleasant, serious or even life-threatening side effects to experimental treatment. • The experimental treatment may not be effective for the participant. • The protocol may require more of their time and attention than would a non-protocol treatment, including trips to the study site, more treatments, hospital stays or complex dosage requirements.

Clinical Research Study 1 Geron Trial ~ Human Embryonic Stem Cells Human embryonic stem cells (hESCs) are nature’s master stem cells. They are a self renewing source for the scalable manufacturing of functional replacement cells for every tissue and organ in the body. The hESCs with which Geron works were derived from surplus in vitro fertilized embryos originally created as part of an in vitro fertilization (IVF) procedure. The embryos, which would otherwise have been destroyed, were donated for research by the parental donors under informed consent. The hESC line that is used to produce GRNOPC1 is the H1 line. Studies using this line qualify for U.S. federal research funding, although no federal funding was received for the development of the product or to support the clinical trial.

The primary endpoint of the study is safety.

is also limited to subjects with subacute injuries – injuries that can be treated with GRNOPC1 within seven to 14 days after the injury. Animal studies have demonstrated that GRNOPC1 injections are ineffective if administered more than three months after the injury due to the scarring that occurs in the injured cord as part of the inflammatory response to spinal cord injury. “Injection of oligodendrocyte progenitor cells directly into the spinal cord lesion is a rational way to attempt to arrest or reverse the structural damage in the spinal cord caused by severe trauma,” Fessler said. “We are eager to begin evaluating the effects of these cells in subjects with severe spinal cord injuries.” The primary endpoint of the study is safety. Standardized physical examinations and neurological testing will be administered before and after the injection of GRNOPC1 at specified time points for one year after the injection to monitor safety parameters. The secondary endpoint of efficacy will use similar testing for evidence of any return of sensory function or lower extremity motor function for one year after injection of GRNOPC1. Subjects will be immune-suppressed from the time of injection with low-dose tacrolimus for 46 days, at which time the immune suppression will be tapered and withdrawn at 60 days. Subjects will be monitored for a total of 15 years after administration of GRNOPC1. “The first recipient receiving the injection of oligodendrocyte progenitor cells more than six months ago has not experienced any serious adverse events attributed to the stem cell transplant to date,” said Fessler. “It remains too early in the trial to determine improvement in neuromuscular control or sensation.”

“We are very pleased to be participating in the world’s first human embryonic stem cell clinical trial for spinal cord injury,” said lead national investigator Richard Fessler, M.D., professor of neurological surgery at Northwestern University Feinberg School of Medicine and a surgeon at Northwestern Memorial Hospital. hESCs have two characteristics that make them different from other naturally occurring stem cells. First, they are immortal – they express the enzyme telomerase that enables the cells to divide endlessly in tissue culture. This allows scalable manufacturing of therapeutic cells derived from a master cell bank. Second, hESCs have the ability to differentiate into any of the more than 200 functional, specialized cells that make up the tissues and organs of the human body. Geron scientists have learned how to grow undifferentiated hESCs under carefully defined conditions, enabling them to be numerically expanded to form large cell banks (hundreds of vials of frozen undifferentiated hESCs) that serve as uniform starting material for manufacturing procedures that convert the undifferentiated hESCs into functional therapeutic cells. The FDA-approved clinical study is a Phase I multi-center trial designed to assess the safety and tolerability of GRNOPC1 in patients with complete ASIA (American Spinal Injury Association) Impairment Scale grade A thoracic spinal cord injuries. Spinal cord injuries are graded in severity according to the ASIA Impairment Scale (AIS) – grade A being the most severe with complete loss of locomotor and sensory activity below the site of the injury. Most such patients do not recover function or respond significantly to physical therapy. The first subjects to receive GRNOPC1 under the clinical protocol will be AIS grade A injured patients with a thoracic injury resulting in a neurological level of T3 to T10. The therapeutic protocol

September / October 2011

Clinical Research Study 2 Tongue Piercing for Paralysis A new assistive neuro-technology (ANT), called the Tongue Drive System (TDS), enables individuals with severe disability access their environment with nothing but their tongue motion. The human tongue is inherently capable of sophisticated control and manipulation tasks with many degrees of freedom. It can move rapidly and accurately within the mouth such that the tip can touch every single tooth. The direct connection between the brain and the tongue generally allows it to escape damage even in severe spinal cord injuries (SCI). Unlike the brain, the tongue is accessible, and its location inside the mouth affords a degree of privacy. TDS consists of a magnetic tracer, the size of a lentil, attached to the tongue by gluing, implantation, or piercing. The

This device will enable them to have more independence and improved quality of life. tracer generates a magnetic field inside and around the mouth that is detected by an array of magnetic sensors mounted on a wireless headset. Tongue-movement-induced changes in the magnetic field are sent wirelessly to an ultra-mobile computer or smartphone, carried by the user, which processes and translates every tongue motion to a particular user-defined function. Once an individual with disability is “enabled” to access a computing device, he/she can nearly do everything that an able-bodied individual can do with that device. This includes communicating, education, training, entertainment, and controlling other devices such as powered wheelchairs (PWC), assistive robotic manipulators, and other home/office appliances on a local area network (LAN). Even the individual’s own natural or prosthetic limbs can be manipulated to move by functional electrical stimulation (FES). This trial is intended to evaluate the TDS by the ultimate intended users, individuals with severe disabilities, who are the best experts for indicating the benefits and possible shortcomings of any new ANT. The goal is to assess the acceptability and usability of the TDS for various tasks that are important in daily life such as computer access, wheeled mobility, and environmental control. Patient Martin Mireles, 37, was shot in the neck nearly two decades ago, leaving him with a severe spinal cord injury. Mr. Mireles is one of the participants of the Evaluation of a Tongue Operated Assistive Technology for Individuals With Severe Paralysis (TDS-1) clinical research study. Researchers at the Northwestern University School of Medicine are examining the technology aspect the study, being financed with almost $1 million in federal stimulus funds. To operate the system, the user wears a headset with sensors that pick up magnetic signals from the tongue ring. Moving the tongue to the mouth’s upper left corner, for instance, moves the wheelchair forward. (The researchers hope that in the future, touching each tooth could signal a different command, from turning on the television to answering the phone to opening a door.) Researchers decided to use the tongue because they wanted to take advantage of some of the functions a severely disabled

person still had. The tongue does not tire easily, they said, and it is not usually affected by a spinal cord injury because it is directly connected to the brain through a cranial nerve. Initially, they just glued the magnet to the user’s tongue, but it often fell off after a few hours. The idea for the piercing came from Dr. Anne Laumann, an associate professor of dermatology at Northwestern who had studied body art. Hopes are high that this evolution in medicine will give those that would have once lost all mobility, the ability to understand their condition and how this device will enable them to have more independence and improved quality of life.

Clinical Research Study 3 Breast Cancer ~ Tamoxifen Citrate as Possible Treatment The rationale behind the study is that estrogen can cause the growth of breast cancer cells. Hormone therapy using tamoxifen may fight breast cancer by blocking the use of estrogen by the tumor cells. It is not yet known whether topical tamoxifen causes less damage to normal tissue than systemic tamoxifen in treating patients with ductal carcinoma in situ. This study is being conducted to compare the effects of tamoxifen taken by mouth to the effects of a gel preparation 4-hydroxytamoxifen (4-OHT) which can be applied directly to the skin of the breast. The purpose of the study is to evaluate 4-hydroxytamoxifen to see how well it works compared with tamoxifen citrate in treating women with newly diagnosed ductal breast carcinoma in situ. Tamoxifen is an anti-estrogen pill, which is part of the usual treatment for duct carcinoma in situ (DCIS) of the breast. It is recommended to women with hormone sensitive DCIS after the surgical treatment. (Hormone sensitivity is present when the tumor cells make a protein called estrogen receptor or ER. This can be tested for in needle biopsy samples and your doctor will be able to tell you whether your DCIS is hormone sensitive or not) When tamoxifen is taken by mouth, it is broken down by the liver into its active form (4-hydroxytamoxifen or 4-OHT). Application of the 4-OHT gel directly to the skin may help women avoid some of the side effects of the tamoxifen pill. Unlike the pill, the gel is concentrated in the breasts and

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M E DI C A L T OURIS M therefore very little will be circulating throughout the blood stream and the body. Also, tamoxifen is not as effective in women whose enzymes do not convert tamoxifen into its active form and therefore their benefit from the tamoxifen pill may be less. It is possible that the use of the 4-OHT gel will be more effective than the tamoxifen pill in these women who have these enzymes. Participating in this study will require three (3) visits to the Lynn Sage Comprehensive Breast Center – a screening visit, the pre-surgical visit and a follow-up visit. During the screening and pre-surgical visits study participants will have a physical exam and blood work, and will be asked to complete a health questionnaire. In addition, nipple aspirate fluid (NAF) will be collected from the healthy breast. For this, the breast will be warmed with a hot pack, massaged briefly, and a small suction device will be applied, so that if any fluid is present in the ducts of the nipple, it will be drawn out (It is normal for most women have some fluid sitting in the ducts of the breast.) Any fluid that is produced will be collected for analysis, to see how much 4-OHT is accumulating in the breast tissue. Study participants found to be eligible for the study will be randomized to treatment with either oral tamoxifen (pill) or transdermal 4-OHT (gel). Randomization means that participants are put into a group by chance and neither participants nor the doctor will know which treatment she is receiving while in the study. Participants in the oral tamoxifen group will take one capsule containing tamoxifen and apply placebo gel to their breasts each day. Participants in the transdermal 4-OHT group will take one placebo capsule and apply 4-OHT gel each day to their breasts. In either case, participants will take one capsule and apply a gel each day to their breasts. All eligible participants will be on the study medication for 6-10 weeks before their standard surgical procedure for DCIS.

Human embryonic stem cells (hESCs) are nature’s master stem cells.

Northwestern Memorial Hospital Featured Site Visit ~ 4th Annual World Medical Tourism & Global Healthcare Congress

As a premier center of excellence, Northwestern Memorial Hospital has been selected as one of our featured site visits for registered attendees of our upcoming 4th Annual World Medical Tourism & Global Healthcare Congress. The tour and following reception are being sponsored by the Governor Pat Quinn of Illinois. For more information on registering to participate in the visit, please email info@MedicalTourismCongress.com. n References: www.feinberg.northwestern.edu www.clinicaltrials.gov www.geron.com/GRNOPC1Trial

Gabriella Vicuña serves as a Global Program Coordinator for Medical Tourism Association in areas which span events, membership, and publications. As an Associate Editor of the Medical Tourism Magazine and Health Tourism Magazine, Ms. Vicuña also provides editorial leadership for the MTA’s publications. Ms. Vicuña holds a degree in Business Administration and Tourism from the University of Florida. Prior to joining MTA, she was involved in patient services within an academic setting and in the private sector. Ms. Vicuña can be reached at Gaby@medicaltourismassociation.com

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Children’s Hospital of Pittsburgh of UPMC ~

Advancing Pediatric Medicine with Innovation and Family Centered Care

By Mariel C. Garcia, MBA

Clinical excellence in pediatric transplantation, cardiac care services, and neurosciences; exceptional, healing-friendly new facilities; concierge services that help patients and families feel at home until they return home: Children’s Hospital of Pittsburgh of UPMC welcomes you to the one place where these elements converge to set new standards in complex pediatric care.

e call this convergence PassportCareTM. It’s the reason why, across the United States and around the world, referring physicians and informed parents choose Children’s Hospital for complex clinical care. In more than 100 years of service, we’ve helped define excellence in pediatric care and research. The Leapfrog Group, a leading independent health care information organization, has recognized Children’s as one of the top pediatric hospitals in the United States for patient safety three years in a row.

Clinical Excellence

Our Heart Center unites some of the most highly respected pediatric cardiologists and cardiothoracic surgeons with highly specialized cardiac care services and some of the world’s most advanced pediatric heart disease technologies. According to data for 2008-2009 compiled by the Society for Thoracic Surgery, the Heart Center ranked as one of only two highvolume pediatric cardiovascular programs in the country with a surgical mortality rate of less than 1%. Nationally, the average mortality rate for high-volume pediatric cardiovascular programs was 3.4%. Our Pediatric Neurosciences program, with its leading pediatric neurologists and neurosurgeons, is recognized internationally for its outstanding care of infants, children, and

young adults with diseases of, or injuries to, the brain or spinal cord. The Hillman Center for Pediatric Transplantation, established in 1981 under renowned transplant pioneer Thomas E. Starzl, MD, PhD, as the nation’s first pediatric transplant center, has performed more transplants in infants or children than any other facility of its type. We specialize in heart, lung, heart and lung, liver, intestine, multivisceral, kidney, and blood and marrow transplants, and we achieve pediatric outcomes that rank among the best. At Children’s Hospital, a highly qualified team of physicians, researchers, and staff occupy an innovative new 10-acre campus designed to provide extraordinary family-centered care. And, during your stay with us, our Passport Care team will work closely with you, offering assistance with housing, transportation, administration, translation, and religious and cultural matters.

Telemedicine

Children’s Hospital is leading the way in the development of telemedicine services through “tele” clinical programs that bring pediatric specialists to other hospitals on a national and international basis through modern technology, including

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M E DI C A L T OURIS M high-definition teleconferencing and store-and-forward e-mail consultation. Children’s offers remote consultation of critical care units to hospitals around the world in need of pediatric intensivists. This effort is led by Ricardo Muñoz, MD, FAAP, FCCM, F.A.C.C., chief of Cardiac Intensive Care Unit and medical director for Global Business and Telemedicine for Children’s Hospital of Pittsburgh of UPMC. Children’s currently provides consultative services with pediatric cardiac critical care units in various cities in Colombia. In Palermo, Italy, telemedicine services are provided for post-operative management of pediatric liver transplant patients, led by George Mazariegos, MD, director of the Hillman Center for Pediatric Transplantation.

Passport Care Team Helps Families Feel at Home

When patients, families and visitors enter Children’s Hospital of Pittsburgh of UPMC through the Transformation Corridor, there’s a large sign welcoming them in 25 languages. The sign is just one of the many ways visitors are made to feel at home. Children’s Hospital created the Passport Care Program to help out-of-state and international visitors become accustomed to the hospital and the culture even before they arrive in Pittsburgh.

Through modern technology, Children’s Telemedicine Program enables pediatric specialists to practice medicine as they would in traditional outpatient and inpatient settings to help children all over the world.

Extending the Welcome Mat

The Passport Care team helps secure visas and navigate through the referral process. They also help patients and their families understand medical information and finances, and act as liaison between patients, physicians, and the clinical teams. The team helps families fill out forms and complete the registration and admission processes. They also help coordinate transportation, and lodging – all on a complimentary basis. Helping international families adapt to the local culture is also key function of the Passport Care team’s role.

Let’s Talk About Language

Every member of the Passport Care team is fluent in at least one language other than English. If a family speaks Arabic, Spanish, Portuguese, or French, staff members can interpret for them. If they speak one of the many other languages, the team can direct patients and staff to the many resources available such as the language line or in-person interpretation. The team helps families: • Communicate with Physicians and Hospital Staff • Navigate Through the Hospital and the Local Region • Understand Medical, Administrative, and Financial Documents n

George Mazariegos, MD, director, Hillman Center for Pediatric Transplantation, examines a transplant patient in the Pediatric Intensive Care Unit.

About the Authors

Mariel C. Garcia is the Director of International and Telemedicine Services for Children’s Hospital of Pittsburgh of UPMC. In this role, she oversees the operations of the Clinical Concierge service and the PassportCareTM Program to meet the needs of out-of-state and international patients and families. She is responsible for developing and implementing growth strategies for Children’s international business and has been instrumental in the program’s expansion through partnerships and cultivation of new markets; including the establishment of education and training agreements with key international hospitals and partnering with foreign insurance companies to make Children’s the hospital of preference. Ms. Garcia has over 9 years of Health Care and hospital management experience. She works closely with clinicians, administrators, and international customers in formulating strategic and operational plans. Ms. Garcia holds a Masters in Business Administration from the University of Pittsburgh and a bachelor’s degree in International Business from Universidad del Norte, Barranquilla-Colombia. Ms. Garcia can be contacted at mariel.garcia@chp.edu.

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Hospital stays are easier to manage when children and families have diversions, such as Children’s kid-friendly diagnostic suites.

Clinical excellence. Exceptional facilities. Family concierge. It’s PassportCare. TM

Clinical excellence in pediatric transplantation, cardiac care, and neurosciences; exceptional, healing-friendly new facilities; concierge services that help patients and families feel right at home until you return home. We call this service PassportCare. It’s the reason why referring physicians and informed parents across the United States and around the world choose us for complex pediatric care. To learn more, visit www.chp.edu/passportcare.

Affiliated with the University of Pittsburgh School of Medicine, and ranked among the nation’s best children’s hospitals by U.S. News & World Report. © Copyright September / October 2011 53 Medical Tourism Association

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US Health Insurance

Medical Tourism Market Update By Jonathan Edelheit

2012 will be a great year for US outbound Medical Tourism and there are big movements going on from Large Employers to Big Insurance Companies. While the MTA has spent a lot of effort in 2011 and will again in 2012 in building relationships in emerging markets such as Africa, Russia and CIS countries, the Middle East, GCC and China, we have always been the leader in educating US employers, insurance companies and health insurance agents interested in implementing medical tourism and sending their insured outside the US for medical care.

he industry had a lot of momentum in 2009 as many insurance companies moved forward with their plans, but was derailed when Obama brought Healthcare Reform into the picture which caused insurance companies to stop all new programs/initiatives and to focus on fighting for survival. Many employers are still sitting on the bench on the sidelines watching the fight between insurance companies and the US government unfolds under healthcare reform, waiting to see what the final result was and how it really affected them.

unsustainable. It will become extremely unsustainable starting in 2014 when sick people pay the same costs as healthy people and insurance companies are forced to accept sick people at any time and cover all their conditions immediately at the same costs as a healthy person. This is when insurance really no longer is insurance, meaning you calculate from the risk what the costs will be.

A Year Later

Now that employers and health insurers are comfortable with healthcare reform and realize costs are going to continue to rise, many are turning back in the direction of medical tourism anew. It is very exciting to see all of the activity going in Medical Tourism in the US with both private sector companies and public sector companies implementing medical tourism. Those in the industry who pay close attention will have seen the news over the past 6 months popping up on

Over a year after Healthcare Reform became law, finally US employers and insurance companies are comfortable with healthcare reform. What that means is that they aren’t necessarily completely happy with it, but they finally understand how it affects them and how they need to comply with it. The reality of it for employers it that the majority of them understand, Healthcare Reform isn’t going to lower costs. Some smaller employers are already seeing the effects and are being hit with health insurance rate increases of 40% or higher. With health insurance rates already too high, constant increases to the cost of health insurance just make the market

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Rochester’s Doing It

Several of the biggest US health insurance companies have already implemented medical tourism. © Copyright Medical Tourism Association

Google alerts of US Self Funded Employers and Third Party Administrators implementing Medical Tourism, as well as Governmental Entities like the City of Rochester, New York. The reasons why they are implementing it is either the cost savings or because of ethnic employees. The Mayor of Rochester and the Rochester Chamber of Commerce will present at our annual event in Chicago about the entire city plan surrounding this initiative. As more and more US employers become open to the idea of medical tourism, a much larger trend will develop and movement that will pick up steam and energy in 2012. Several of the biggest US health insurance companies have already implemented medical tourism or are announcing their plans shortly, quietly going through the request for proposal (RFP) process and not raising any flags.

Domino Effect Dental Clinics around the world should be very excited because it looks like two of the largest dental insurance companies in the United States will soon be allowing their insured to take their dental benefit overseas. Everyone has been waiting for dental tourism to take off with the US insurance companies, and the time has come. Several smaller health insurers in the US with under a million lives are also in their Request for Proposal (RFP) Process and once it is concluded will be implementing their medical tourism programs. What’s really exciting about it all this isn’t just that several of the biggest carriers and employers are now back on track and moving forward again with implementing medical tourism after the delay from healthcare reform, it’s what will happen once they implement it. When they do, it is going to cause a chain reaction domino effect. When one dental insurance company allows their American insured to travel overseas and use their dental benefit, all the competing dental insurance companies in the US will have to implement it also, or they will no longer be competitive and they will lose their edge.

Others to Follow The same holds true for US health insurance companies, once these companies or a big employer goes public with their new medical tourism plans, their competitors know they have to invest and move forward in this space. An example is if Insurance Company “A” implements medical tourism and

Insurance Company ”B” doesn’t, any employers who are interested in medical tourism for their employees because of the cost savings, or any employers who have high ethnic populations who want to travel back home for healthcare, they will have to switch from Carrier B, to Carrier A who covers medical tourism. Insurance companies don’t want to lose their employer groups or the profits that come with it. Employers from around the country are going to closely follow the first large employers implementing medical tourism and once they see that first employee travel and the costs savings, it is going to create a revolution with US health insurance benefits. This year at the MTA’s conference in Chicago a private luncheon for US employers will be held for an open forum for collaboration on how the MTA can support employers through education and other initiatives and how it can help US employers increase awareness amongst their employees of medical tourism and to help increase utilization and engagement of the medical tourism benefit by employees. The MTA will be focusing on its initiative of consumer awareness, by helping employers understand obstacles employees must overcome in order to travel for healthcare and helping them provide the employee education on the quality of healthcare that is missing from many existing medical tourism programs in place in the US. n

Jonathan Edelheit is CEO of the Medical Tourism Association and assistant editor of the Medical Tourism Magazine. With a long history in the US health insurance industry, including running a national healthcare administrator, Mr. Edelheit was the first person in the US to implement medical tourism into health insurance plans. Mr. Edelheit is also editor of several leading US health insurance magazines and organizes one of the largest US healthcare conferences in the US for employers and health insurance companies, the Employer Healthcare Congress. Mr. Edelheit is the co-author of “Medical Tourism~ An International Healthcare Guide For Insurers, Employers and Governments.” Mr. Edelheit can be reached at: Jon@MedicalTourismAssociation.com

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U.S. Inbound

Medical Tourism Competitiveness By Rosanna Gomez Moreno, J.D.

uring my tenure at the Texas Medical Center, I found that the U.S. continues to serve as a beacon for specialty care and a destination for medical travelers looking for the best medical procedures and treatment due to the unavailability or accessibility of treatment or procedures at home. Realistically, however, medical travel has become quite competitive over the past decade and certainly, in the past five years due to the availability of web-based information, the creation of international organizations dedicated to the medical travel industry and research conducted on the global industry as a whole. While there are established inbound international patient/medical tourist/medical travel (these terms are used interchangeably and for purposes of this article medical travel will be used) programs at many leading healthcare institutions throughout the U.S., any facility or institution contemplating the creation of a program should consider what the Texas Medical Center and member institutions have done quite successfully over six decades and what challenges exist today.

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A Case Study: Texas Medical Center The Texas Medical Center in Houston is the largest medical center in the world and is comprised of 49 member institutions. As Houston grew, so did the Texas Medical Center. The Texas Medical Center Corporation (TMC) oversees the development of the medical center and provides the infrastructure similar to a municipal government. In addition, member institutions sit on the governing committees. Over the years, many member institutions have gained global stature for the first-class

The Texas Medical Center in Houston is the largest medical center in the world and is comprised of 49 member institutions. ÂŠ Copyright Medical Tourism Association

specialty healthcare and state-of-the-art procedures provided such as The University of Texas M.D. Anderson Cancer Center, the Methodist Hospital/Methodist International, Texas Heart Institute at St. Luke’s Episcopal Hospital and one of the largest pediatric hospitals in the U.S., Texas Children’s Hospital. In order to compete globally, these institutions created strategic plans with the following key points: • The Creation of In-House Concierge Programs for Medical Travelers from Abroad • Collaborative Relationships with Internationally Recognized Staff Physicians for Receiving Patients and Referring Physicians from Abroad • Strong Academic and Raining Programs with Local Medical Schools • Budgets to Support Their Strategic Global Efforts • Affiliation agreements with foreign institutions for academic exchange and operational support, including support with the international accreditation process, collaborative research programs with protocols to U.S. standards and additional training for medical students, residents and physicians at the U.S. affiliate facilities. • Foreign Representative Offices Opened in Strategic Countries for Market Positioning and Referral of Patients

… medical travel volume increased by 20% from 2009 to 2010 with a 16% increase in revenue during the same period. In support of member institutions strategic plans and to facilitate the entry of medical travelers arriving from abroad, the TMC negotiated an agreement in 2005 with the Houston Airport System and the Houston Greater Convention and Visitor’s Bureau. An airport liaison program was established at Bush Intercontinental Airport providing the public infrastructure support necessary with financial support for the program from the participating TMC member institutions. The multilingual airport liaisons welcome and facilitate the entry of a medical traveler and accompanying family members to the U.S. The medical traveler is greeted upon arrival at the gate of the plane, navigated through immigration and customs with a medical visitor center outside customs for weary medical travelers and their guests to relax until transportation arrives. This program serves as a model of how public and private institutions can work together providing the infrastructure for strong medical travel programs. The TMC has had its share of challenges, however, due to events outside its control. Prior to 9/11, the TMC received more than 40,000 medical travelers annually. Although some of the member institutions international programs continue to grow due to their strategic efforts, the overall number of medical travelers to the TMC has declined. In 2009, the number rose to 18,000, but in 2010, the number declined to a little over 15,000. According to Suzanne Suarez with Marketing and External Affairs at the TMC, there was a decline of 12% in 2010. In a recent article in the Houston Business Journal (May 6, 2011), Cathy Easter, president and CEO of Methodist International at The Methodist Hospital in Houston, stated that medical travel volume had increased by 20% from 2009 to 2010 with a 16% increase in revenue during the same period. According to Easter, Methodist International relies on collaborative relationships with their physicians, a diverse

multilingual and international staff with an office in Dubai for patient referrals with a strategic focus in the Middle East. The programs with the strongest strategic plans continue to grow due to their concerted efforts in global outreach and affiliations regardless of the overall decline in patient volume at the TMC. Some countries are elevating their national hospital certification program to U.S. standards such as Mexico adopting U.S. hospital standards in 2007 and the first in the world to do so. Should other countries follow the Mexico model of adopting U.S. hospital standards with Joint Commission for national hospital certification, the individual hospital international accreditation process will be much stronger elevating the competitiveness of the medical travel programs within those countries and in direct competition with U.S. facilities. In addition, U.S. Department of State requirements for obtaining visas for travel to the U.S. for pleasure, business or medical reasons are stringent post 9/11 requiring for the presumption of the intent to stay in the U.S. to be overcome. With the difficulty in obtaining a visa for entry into the U.S., many countries have created a specific visa for medical travelers in order to facilitate their entry for medical treatment. Korea created a medical visa due to the number of medical travelers arriving daily. The post 9/11 difficulty entering the U.S. spurred countries, such as Singapore, Malaysia, Thailand and Korea to fill in the gap with accredited hospitals and the creation of medical travel programs. In light of the global competition, the competitive advantage U.S. institutions have had, should not be squandered.

Informed Patients The world has changed and an important factor in the global medical travel industry lies with the informed patient. An informed medical traveler traveling to the U.S. or another country for medical treatment expects the following: • Accessibility to Medical Procedures Not Available in the Country Where They Reside • Availability of Medical Procedures Thereby Circumventing the Wait Times in Their Country of Origin • Affordability and Value for Quality Care

Accessibility and Availability Access to medical procedures requires priority for the medical traveler in light of their limited time in the U.S. Hospitals planning to enter the medical travel program business must

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M E DI C A L T OURIS M plan strategically with a diverse multilingual staff and internal administrative support to provide the necessary concierge services the medical traveler expects upon arrival. The services required to attract the medical traveler must make accessibility to those procedures in a timely manner, including but not limited to access to the attending physician and their staff, a dialogue with the physician in country and the physician in the U.S. for follow-up care, assisting the medical traveler with their family, lodging, and other needs they may require for their stay. The decision to enter the medical travel industry requires longterm strategy and budget to provide the services necessary for the medical traveler and their families. In addition, a strong medical travel program can prove quite lucrative and profitable to any institution with strategic global outreach.

Affordability and Price Differentials With the internet, medical travelers are savvier with regard to cost of procedures; physician’s certifications and licensing; hospital ranking; and if part of an academic center or academic setting, the state-of-the-art medical breakthroughs and procedures provided. In today’s global economy, pricing is important and the cost savings is considerable in other countries where similar procedures or treatment could be provided at a fraction of the cost with savings of 60-80% outside the U.S. While visiting several facilities in Mexico City last year, the programs provided in neurosurgery, cardiovascular surgery and oncology were at least 60% less than the U.S. Two of the facilities were JCI accredited and part of the same hospital system with a long-term affiliation agreement with a healthcare institution in Houston. Other facilities visited were in the process of obtaining their JCI accreditation, conducting clinical trials under the supervision of U.S. institutions with Mexican physicians and with a large percentage of their medical staff residency and/or fellowship trained in the U.S., Canada or Europe. Affordability of quality care comes into question when the cost of that care is double or triple the cost in the U.S. It must be acknowledged that advances in medicine are being reached every day in other parts of the world at an affordable cost to the medical traveler. If we are to remain competitive and retain our global strategic position in specialty healthcare not just for Americans but also for the medical traveler, affordability will be a decision-making factor in years to come. Today’s medical traveler is informed whether they rely on information from the internet and social media, a friend, a recommendation from their family physician, health insurance plan, employer or direct contact with the facility where treatment is received. The issue of transparency with regard to pricing and availability of medical packages is essential for a medical traveler to make an informed decision. In the Deloitte 2009 Medical Tourism Report, the U.S. will receive a slight increase to 561,000 by 2017. With cost savings abroad for treatment, inbound medical tourism programs must become more competitive and not expect to fill costly empty beds with medical travelers. In order to make up for a shortfall in reimbursement, it has been common practice to charge a premium for procedures provided to medical travelers with little or no discount for gross charges. Today’s medical traveler knows U.S. institutions discount charges thus the medical traveler expects a discount for services provided or treatment; if not, they will go elsewhere where they will receive similar medical treatment at an affordable cost.

Suggestions for U.S. Inbound Programs U.S. hospitals must be competitive in pricing due to the significant cost savings to the medical traveler in other countries and the information disseminated globally today. Medical travel programs and global outreach programs should be focused on specialties, centers of excellence and medical breakthroughs. In

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addition, the global outreach programs should include strategic representative referral offices, affiliate and operational support agreements and with budgets to support those programs. The strongest advertising campaign is usually through word of mouth from a satisfied medical traveler and their families. Strategic positioning is important and what market is natural to the healthcare institution. TMC member institutions have strategically positioned themselves in Latin America due to Houston’s geographic position and in the Middle East due to Houston’s oil and gas industry position in that part of the world. The most important suggestion, I believe, begins with the hospital’s administrative decision to enter the medical travel industry. The focus for a global outreach program should be long-term not short-term with an emphasis in quality and accessible care at an affordable cost. Any program established under these guidelines should prove to be quite lucrative for the hospital’s bottom line, while providing the best-of-the-best medical care to the global community. n

About the Author Rosanna Gomez Moreno is a Texas licensed attorney and CEO of RGM Global, L.L.C., a consulting company advising local and state governments, hospitals and clinics. Ms. Moreno’s educational presentations provide an indepth view of successful medical tourism programs for hospitals and clinics, global marketing and positioning, the travel and insurance industries impact on medical tourism and in-depth case studies of existing health care clusters globally. As a partner in Global3, she and her partners provide consulting, project development and logistical services to companies, developers and governments focused on the Latin American market. In addition, Ms. Moreno is a partner in Blue Marble Healthcare, a healthcare cluster consulting and design company. Ms. Moreno participates in global healthcare and medical tourism conferences around the world. Most recently, Ms. Moreno participated as a plenary speaker at the April 2011 Texas Public Health Association Annual Conference in Houston. In November 2010, Ms. Moreno was a speaker on global health clusters at the University of Incarnate Word’s Center for Medical Tourism and Research in San Antonio. In October 2010, Ms. Moreno was a featured speaker and faculty member of the “Advanced Medical Tourism Executive Course” in Cairo, Egypt. In addition, Ms. Moreno presented an overview of medical tourism before the Whitehall Club of Houston. Ms. Moreno was a speaker at the International Tourism Fair of the Americas in Mexico City in September 2010. Ms. Moreno presented at the first “Seminar on Health Tourism in Mexico City” and was featured as an expert on medical tourism with a discussion on the medical tourism industry in Houston on the New York-based Peter Greenberg Travel Talk Show broadcast live from Houston in August. In April 2010, Ms. Moreno participated as a featured speaker at the “Global Healthcare and Medical Tourism Conference” in Seoul, Korea. In October 2009, she participated as a speaker in the second “World Medical Tourism and Global Health Congress” in Los Angeles. Ms. Moreno attended the University of Texas at San Antonio earning her B.A. in 1983 and earned an M.A. in International Relations from St. Mary’s University in 1994. In 1996, Ms. Moreno attended South Texas College of Law in Houston receiving her Juris Doctorate in 1999.

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Health or Lifestyle:

Medical Tourism

Allows Both By Dr. Michael Sigler

Salomon Shamah, Administrator of the Panama Tourism Authority coined the phrase “Panama, we bring the world together,” and was quoted stating, “The new Cold War is the war for tourists. It’s a friendly war, but still, it’s a war.”

The Frustration of Rising Health Care Costs Imagine yourself in your country just after you have left your doctor’s office. His Secretary handed you a bill. Let’s say, for example, that it was a bill of $4,000 for an 8 hour antiaging evaluation and, post evaluation, you’ll receive another automatic billing payment of $1,200 to $2,400.00 per month. This alone is a very de-motivating factor when you return home, even if you are managing to thrive in the current economy. Like most savvy consumers today, you begin searching Google for “anti aging therapies” and call around to this place and that place only to find that the medical procedure is roughly the same in your area. That’s a huge disappointment, right? Well, that’s where medical tourism can make a huge change in not only the quality of people’s lives, but also their pocket books. During your search for quality healthcare, did you ever consider Googling the cost of your procedure in another country? The thought likely never crossed your mind; however, this is precisely how an ever growing percentage of Americans are saving a fortune on healthcare. Medical tourism has not grown exponentially in the past decade because of failure. Instead, it has flourished because people are happy with the results and the savings. With more people realizing that they

can receive procedures overseas at a fraction of the U.S. price for the same quality care, the numbers continue to grow.

Is Health in Medical Tourism the Solution? Now imagine yourself on a plane looking through that inflight magazine, your ears begin to pop as the plane descends and the captain says, “This is Captain Vargas calling from the cock pit. It’s a beautiful sunshiny day in Panama City, Panama. The temperature is 82 degrees Fahrenheit with a slight breeze out of the north. Those on the left side of the plane will see the Pearl Islands. Those of you on the right will see The Amador Causeway. Flight attendants prepare for landing.” Many countries, both inbound and outbound, provide VIP services where a representative greets you at the gate and escorts you through the herds of people waiting to step into these “unknown” paradises around the world. You casually stream by them and, minutes later, your bags are being loaded into your private limo. You are whisked away to private suite, waiting with Wi-Fi and Perrier water. You look at your husband or wife and kiss them, thanking them for bringing you. If you think this description is overrated, it’s not. You will likely be pleasantly astonished at the high quality of service that medical tourists are provided. You see, the countries

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M E DI C A L T OURIS M participating in medical tourism realize that you can receive the same care in your own country, but by providing the same level of care at a huge discount and combining that care with service that is absolutely unbeatable; it is difficult not to take advantage of.

Cutting Pharmaceutical Costs in Half Countless Americans have to determine whether to spend their money on much needed pharmaceuticals or keep the electric on in their home. With social security cuts constantly being discussed in the U.S. political agenda, it is hard to predict what tomorrow will bring for those that depend on social security to pay for medical care. However, for those who have managed to save for retirement or set aside funds to pay for healthcare, medical tourism is a viable alternative. Countries like Panama, El Salvador, Columbia, Ecuador and Costa Rica can provide the same quality of care and medications at half the price – and in most cases, more than 70% less. When attempting to determine the cost of medical care, you must first determine what you are charged by physicians, hospital or rehabilitation facilities, diagnostic facilities and pharmacies. Years ago, the bulk of the costs of medical care were created by the fees associated with Physicians, diagnostics and hospitals. In fact, it represented nearly 90% of the cost of health care. As pharmaceutical companies grew and medical breakthroughs were realized, pharmaceuticals began being prescribed for nearly everything under the sun. Patients saw a shift in the expense paradigm, with pharmaceuticals representing a larger percentage of the overall cost of health care. Today, with the majority of geriatric patients taking an average of five different types of medication daily, it is not at all uncommon for patients to feel stress simply due to the fact that prescription costs are depleting their savings. Many retirees have a looming fear that, should a surgical procedure become necessary, their savings can be wiped out entirely. The difference that can be made by utilizing medical tourism is significant simply because the majority of the countries participating in medical tourism are home to fabulous compounding pharmacies. These pharmacies and the medications that they produce go through a rigorous testing process to ensure that the medication is always of top quality, but because the pharmaceuticals are made in-house, the price is drastically reduced. This results in patients being able to save amazing amounts of money on prescriptions. Let’s use Europe and the U.S. as an example. In Europe, the cost of hormone treatments might run the average patient $2400 each month. In the U.S., the cost would be around $1860. However, in Costa Rica, the costs for the same prescriptions would be about $440. As you can clearly see, the possible savings are remarkable. This is precisely why many patients are choosing to participate in medical tourism. You might be surprised, but the savings doesn’t end with prescriptions. These countries can also provide extremely deep discounts on supplies, lab fees and professional fees. For medical tourists coming from Europe or the U.S., the savings in just one visit can be well worth the trip. However, the savings possible over multiple trips can be the difference between feast and famine for your retirement savings. For instance, a woman interested in breast augmentation might see an average cost of $8000 in the United States. However, if she chose to travel to Ecuador, the total cost of the trip and the procedure could be as little as $4000. The same is true for a wide variety of procedures, giving patients a true

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choice when it comes to how they choose to spend their money on medical care.

What Types of Medical Services Are Available with Medical Tourism? The types of medical services available to medical tourists are the very same services that are available here in the states, which range from a variety of elective procedures to more complex, specialized surgeries. However, with the cost of the procedure, anesthesia, accommodations, airfare, meals and land transportation included, medical tourism is becoming more attractive to the American patient. Complicated heart surgeries can be costly, often in upwards of $100,000 in the United States; however, in countries like Panama or El Salvador, the same procedure can be combined with the costs of rehabilitation and travel and still equal less than 40% of that U.S. bill. The same is true for elective procedures like breast reductions or implants, liposuction, facelifts and more.

Medical Tourism Is Not Just for Patients Not surprisingly, medical tourism is an interest of doctors in the U.S. as well. In fact, countless U.S. based doctors schedule travel to foreign countries each year to take part in comprehensive continuing medical education programs. These programs allow them to expand their knowledge in their area of expertise, while also enjoying the benefits of an exotic, vacation-like environment. The irony? Doctors are also paying less to continue their education in foreign countries, yet the implementation of this knowledge comes at a hefty charge to the U.S. patient. U.S. doctors can currently take advantage of continuing medical education courses in Age Management Medicine, Cardio/Pulmonary, Clinical Endocrinology, Dermatology, Geriatric Medicine, Internal Medicine, Women’s Health and Neurology, as well as a wide array of specialty conferences. The conferences themselves are held at amazing resorts in several exotic locations, like Hawaii, Nassau, Costa Rica, Aruba and the Virgin Islands. Of course, other locations such as London, Las Vegas, New Orleans, Napa and Niagara Falls also hold conferences as well. These conferences are generally three days in length, with only four to five hours of the day being dedicated to the conference. However, longer conferences do exist. In fact, some of these CME courses actually require a fair amount of time via online lessons, conference time and hands on clinical evaluation.

Do Insurance Companies Pay for Medical Tourism? Even insurance companies are jumping aboard the medical tourism ship, which could play a primary role in the healthcare costs in the U.S. over time. It makes sense. Why would an insurance company want to reimburse a hospital thousands of dollars for a covered procedure when the patient can go to a country like Panama and have the same procedure performed at less than half the cost with travel and accommodations included? Unfortunately, not all insurance companies are on board with medical tourism just yet. Individuals that currently have insurance policies should first consult with their insurance provider before scheduling to have any procedures performed outside of their country. This simple phone call can alleviate any misconceptions about coverage and enlighten patients to the true amount of their financial responsibility if the choice is made to participate in medical tourism.

Is Medical Tourism the Right Choice for Your Health and Lifestyle? Medical tourism is not right for everyone. Those who do not enjoy traveling or being far away from family and friends might rather continue their healthcare regimen at home. Likewise, those who are unable to travel due to severe health issues will obviously not be good candidates for medical tourism. Individuals interested in participating in medical tourism should take great care to ensure that the lines of communication are open and flowing with information. Patients should be aware that accreditation and other standards do vary worldwide. Certain destinations may pose a higher risk for medical tourists than other locations, making it extremely important

ÂŠ Copyright Medical Tourism Association

for patients and family members to do their homework before selecting a destination for medical care. Reviewing crime rates, safety of tourists and medical standards should always be of the utmost concern. The top priority of any great clinic should always be to reduce the patientâ&#x20AC;&#x2122;s stress. In the medical tourism world, patients will find countless clinics that excel in this area. With such a wide array of clinics readily equipped with highly skilled teams that consistently go above and beyond for their patients, most individuals will find that medical tourism is not just a necessary cost saving measure for health, but an enjoyable one as well. n About the Author Michael O. Sigler, M.D., is Executive Director of Age Management Panama, a Virtual Preventive Medicine Clinic that provides consulting services based entirely on the Internet with specialized Health Insurance Portability and Accountability Act (HIPAA) approved, 21st Century, medical based software technology. This preventive medicine virtual clinic provides secure messaging for patients between visits, personalized video-based plans and health literacy information, as well as monitoring of preventive medicine activities to improve patient participation and optimization. In addition to Age Management Panama, Dr. Sigler also serves as the Executive Director of Live Well Pharmaceuticals Inc., a Good Manufacturing Practice (GMP) pharmaceutical company headquartered in Panama, and its Hong Kong subsidiary Live Well Pharmaceuticals HK. Dr. Sigler focuses on biotechnology proteins and peptides (rHGH Somatropin, Long Acting rHGH) and generic pharmaceuticals.

September / October 2011

M E DI C A L T OURIS M

Due Diligence

in Facilitation By Medical Tourism Magazine

The Medical Tourism Industry has some great players in it. With amazing hospitals and clinics, a growing number of medical tourism facilitators using best practices and consultants leading the path, more and more players are in the news. But, who is doing their due diligence?

hen it comes to making decisions about medical tourism providers and facilitators, it would seem essential that best practices, certifications and accreditation take an important role in ensuring patient safety and good patient outcomes. Typically, the accreditation of the facility and credentials of the surgeon are at the forefront of the patient’s decision making process. With the growing interest from the employer market in establishing medical tourism programs, the use of a medical tourism facilitator may create an ease in matching patients with providers and effectuating a continuum of care. How does one choose a facilitator and what is the importance of due diligence in this selection process? A recent story that made headlines in the US brings this issue to light. The Hartford Courant reported on September 13th of this year that the City of Hartford cancelled its contract with Satori World Medical, a Medical Tourism Facilitator based in San Diego, California. On its website, Satori World Medical boasts itself as the “world’s first global healthcare network and service company specifically designed to deliver high quality healthcare services, share the tremendous cost savings with plan sponsors and their employees and coordinate all medical and travel services for individuals who need care.” According to a press release issued by Satori on June 30, 2011, Satori had gone through a competitive bidding process and was selected as the facilitator to provide the employees of the City of Hartford access to their international networks of physicians to save the City from 40-80% per procedure. The

September / October 2011

City of Hartford Benefits Administrator Richard Pokorski stated, “We employ a large Hispanic workforce and having access to some of the best doctors and hospitals in Puerto Rico through Satori’s Global Network may be a very attractive option for their medical care.” Pokorski anticipated a 66% savings in healthcare costs as a result of the program. Until now. Kevin Rennie columnist of The Hartford Courant broke the story in August, pointing out that “Satori’s founder, president and chief executive officer Steven Lash was convicted of wire fraud and mail fraud in federal court and sentenced in 2004 to 51 months in prison. Lash, who also was ordered to pay $36.4 million in restitution, had been the chief financial officer of FPA Medical Management, a San Diego company that reported record earnings before filing for bankruptcy in 1998, leaving patients, doctors and lenders in the lurch.”

When Satori World Medical Inc. was confronted about Steven Lash’s prior convictions, the City of Hartford was not satisfied with the answers it received. In a follow up story this month, columnist Vanessa De La Torree stated that the City sent a termination letter which effectively terminated services immediately, ending their contract officially on December 7, 2011. “The city decided to cancel the contract because of fraudulent behavior that was brought to light in Kevin Rennie’s opinion column,” city spokeswoman Sarah Barr said. “When Satori World Medical

Inc. was confronted about Steven Lash’s prior convictions, the city was not satisfied with the answers it received and the contract was terminated.” (http://articles.courant.com/201109-13/community/hc-hartford-satori-0913-20110912_1_ medical-tourism-health-care-costs-contract) A simple background check of Satori’s management could very well have prevented this type of event from occurring, which causes embarrassment to the City, detriment to the reputation of the industry and most importantly, a loss in opportunity for the City’s employees. Companies responsible for the handling of patients’ healthcare should be required to be transparent in their business dealings. The Medical Tourism AssociationTM has been an advocate of Facilitator transparency from its inception. The established best practices of its certification program require corporate transparency and background review, as the lives of patients are at stake. Without the proper processes and protocols in place to determine reputable companies from less reputable, anyone can put up a fancy website and seem legitimate. It is not uncommon for claims to be brought against a company or individual which may or may not be legitimate. However, it is important for the managers of patient benefits to take due diligence steps to protect the interests of their employees when offering healthcare benefits packages. Employers, Insurance Companies and even hospitals expose themselves to significant and potentially absolute liability by working with unlicensed and unregulated medical tourism facilitators. An employer failing to perform due diligence on a company which holds a fiduciary duty to its employees could be catastrophic. What are the implications to this news? Satori has been reportedly quite successful at promoting its services under the slogan of offering due diligence in its medical networks and expanding its medical directory boards. Most recently in July, 2011, The Public Employee Benefits Alliance (PEBA) selected Satori to implement medical tourism into their member employees programs. In August 2011, Satori partnered with HealthEZ, a family-owned Minnesota-based health plan offering innovative services for companies with self-funded health plans. It also partners that same month with HealthFirst TPA, a Texas based Third Party Administrator to offer its clients and thousands of their employees access to its networks. HealthFirst TPA claims itself to be one of the most advanced TPA’s in the US.

• Lack of appropriate protocols • Inappropriate patient-physician matching protocols • Lack of aftercare protocols What about the quality of medical networks? In a press release which appears to be in response to the recent negative publicity, Satori discussed the quality of its medical networks. Specifically, Satori stated in this release, “Satori’s CMO conducted on-site due diligence visits to all of Satori’s global network hospitals, which includes reviewing Joint Commission International (JCI) accreditation reports, hospital performance measures and physician credentials and outcomes.” Interestingly, in reaching out to several of the hospitals in Satori’s networks, we were informed that it is not part of their practice to show any party outside of hospital management the results of the JCI accreditation reports and that there are no exceptions to this protocol. (http://www.pr.com/press-release/355249) Medical Tourism Facilitator Certification is critical to the survival of medical tourism facilitators and also important for the credibility of the industry. Facilitators need to be pro-active in establishing and maintaining best practices. One story like this may destroy all the hard work and credibility of not just quality hospitals and facilitators, but the industry as a whole, particularly for the future of the employer and insurance based medical tourism market. The Medical Tourism Association encourages its members to hold themselves to higher standards with the need to recognize and understand who the quality and long term players are. The moral of the story….know your partners and manage your risk for the sustainable long term. n

Sherry Laboratories in Indiana tied up with Satori in January 2011 for its employees also citing the reduction of costs as its motive. Imperial County Schools Voluntary Employees Benefits Association (ICSVEBA), a federally qualified employee benefits trust representing twelve school districts linked with Satori in November 2010. The list goes on. As more and more political subdivisions see the value in medical tourism, the effect of this news may be inhibitive to the industry’s growth. It should not matter how many news articles facilitators have been mentioned in, how many patients they say they have or who they say their clients are. At the end of the day, when something goes wrong, someone will be held accountable. Other pertinent issues that continually emerge in the industry pertaining to facilitation are: • Lack of corporate transparency • Misrepresentation of Officers/Advisors • Misrepresentation of office locations • Misrepresentation of patient experience and/or volume • Insufficient liability insurance

September / October 2011

M E DI C A L T OURIS M

The Wisdom

in Considering a Great Vacation in Combination with Your Dental Work

By Rafael E. Lorenzana, DDS Your dental work does not have to be an unpleasant experience. No matter how painless the procedure is or how good a surgeon´s hands are, a trip to the dentist causes anxiety, stress and discomfort.

hese feelings make some people postpone important procedures, only worsening the problem. Turning your next appointment into time to relax and explore a new destination can put your mind at ease and make your trip to the dentist stress free. Wouldn’t it be great if you could look forward of your next trip to the dentist and feel excited about it? Dental tourism in El Salvador has increased in recent years, and many people are considering different types of procedures performed in this country, one of the most requested treatments is the removal of wisdom teeth.

Wisdom Teeth Wisdom teeth (also known as the third molars), are the last teeth to erupt in your mouth and are the teeth least needed for good oral health. Most people have four wisdom

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teeth that usually erupt through the gums in their late teens or early twenties. Sometimes wisdom teeth remain trapped in the jawbone under the gums because there is insufficient room for them to erupt. As such, the wisdom teeth often become impacted poorly positioned and may lead to a host of potential problems, including gum disease. Young adults who keep their wisdom teeth often quickly develop gum disease, which appears to increase the risk during pregnancy and possibly other health problems. Gum disease occurs when bacteria grows in the tissue supporting teeth, which can damage the tissue and cause spaces

Your dental work does not have to be an unpleasant experience. © Copyright Medical Tourism Association

known as pockets to form around the roots. As it worsens, the infection can loosen and damage the teeth, eventually requiring them to be pulled. Wisdom teeth are particularly vulnerable because they are difficult to reach and keep clean. Once the bacteria get established in the mouth, the risk they will spread and damage other teeth increases significantly. Pain and swelling are the most common symptoms. Whether you have obvious symptoms or not, it is important to diagnose existing or potential problems caused by your wisdom teeth. Their removal is a fairly standard oral surgery that requires some post-operative care to reduce the chance of infection or other complications.

The cost of these types of procedures in El Salvador is just a fraction of the cost in the United States. After the teeth are extracted, the patient may need stitches; luckily many stitches melt over time and a few may need to be removed after a couple of days. A folded cotton gauze pad placed above the wound help stop the bleeding. Pain medication is prescribed to reduce the amount of discomfort experienced after the local anesthetic wears off. As with any oral surgery, refrain from drinking through a straw as doing so creates suction and may disrupt the sutures. Wisdom tooth extraction recovery takes approximately five to seven days, with the gum area being fully healed in approximately three to four weeks.

Why Seek Dental Treatment in El Salvador? It is no secret that one of the top reason patients will be inclined to travel abroad seeking dental treatment is that they are in search of a value in cost. This certainly does not equate to the patient sacrificing quality in the process. El Salvador is among the best places in the world to consider this type of procedure. We at Lorenzana Dental Center provide decades of academically supported experience, the latest technology using bio-security standards as required in The United States, providing you the best service and quality available worldwide. The country also has many well trained anesthesiologists with countless years of experience, another reason to rely on any type of treatment or procedure you are

searching for. We pride ourselves in offering comparable service to that which you may receive at home, in a paradise, only few hours away. The cost of these types of procedures in El Salvador is just a fraction of the cost in the United States, giving you the opportunity to pay for the treatment, lodging and the chance to get to know all the beautiful places that this country has to offer.

Discover El Salvador A beautiful tropical country in Central America with amazing beaches and a rich Mayan background, El Salvador offers its visitors a wonderful travel experience along with the finest quality dental care at an affordable price. World renowned as an ultimate surfing destination, you may consider scheduling your treatment or procedure accordingly to perhaps experience the adrenaline rush of the world-class breaks prior to your appointment. The two surf areas on El Salvadorâ&#x20AC;&#x2122;s Pacific coast, La Libertad and the Wild East feature abundant quality breaks. This in turn allows the patient to enjoy an all-around great experience and walk away with much more than just dental work. n

About the Author

Dr. Rafael Lorenzana feels Medical Tourism is the cutting edge of the future and is working closely with local identities to help make El Salvador the most sought out destination for high quality medical, cosmetic, and dental procedures. With more than 30 years experience in private practice and teaching in both El Salvador and the United States, he has dual citizenship in both countries, a graduate of Baylor College of Dentistry, and certified in Prosthondontics from the University of South Carolina. Rafael is also the only dentist in Latin America board certified from the American College of Prosthodontics. An American citizen but born in El Salvador, Dr. Lorenzana was a Health Vice Minister from El Salvador after his studies in the States. This distinctive double-cultural background has allowed Lorenzana to identify the expectations from different cultures. Doctor Lorenzana pioneered Medical Tourism in El Salvador and his experience with Medical Tourism has become an aggressive service that has helped position Lorenzana Dental Center very successfully in Germany, Ireland, Mexico, the United States and parts of Central America.

World renowned as an ultimate surfing destination, you may consider scheduling your treatment or procedure accordingly.

ÂŠ Copyright Medical Tourism Association

September / October 2011

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OF MEDICAL TOURISM 2011 EDITION Don’t miss out in being featured in the main directory of Industry Leaders - Let future business contacts find you easily! Printed and Distributed at the 2011 World Medical Tourism & Global Healthcare Congress in Chicago Featured Year Long on the Medical Tourism Magazine Website Emailed to over 20,000 Healthcare Leaders INCLUDING Insurance Companies • Employers • Hospitals • Medical Tourism Facilitators • Governments • Healthcare Providers • Healthcare Leaders • Consultants and More

September / October 2011

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September / October 2011

M E DI C A L T OURIS M

The Global Healthcare Provider Shortage and Medical Tourism ~

Impact and Solutions By James Woomer, MSN, CRNA

Introduction to a Global Problem The issue is not only quantitative; it is also qualitative, meaning that existing providers may not be functioning to the level necessary to meet the needs of the population. These concerns are not unique to the developing world alone. What is becoming an issue for some countries is the potential impact that the medical tourism industry will have on their existing healthcare infrastructures, with some arguing that the provider shortage will only be worsened due to diversion of human resources and funding away from public healthcare and into the private sector. Itâ&#x20AC;&#x2122;s important to understand the dynamics at play and also of the possible solutions to the shortages that we face in the years ahead.

Increased Demand and Increasing Costs Economic and population growth in the next decade will be centered in the Asia-Pacific region, India, and Africa. This

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growth will result in literally billions of people with newfound wealth and resources to spend on healthcare related services. They will seek information that currently may not be readily accessible to them, in part due to the tremendous healthcare provider shortage worldwide. Consumers and professionals will need to utilize unique methodologies in order to meet this demand for healthcare and health information. As the developing world continues to feel the benefits of economic growth, the demand for healthcare information and services will drastically increase as areas of the world that

This growth will result in literally billions of people with newfound wealth and resources to spend on healthcare related services. ÂŠ Copyright Medical Tourism Association

could not afford to use precious resources on healthcare will now have the ability to focus on their health. The global ‘baby boomer’ phenomenon is a major factor in the increased demand for healthcare services around the world, with over 70 million baby boomers in the United States alone. This year, the first baby boomers began reaching retirement age. Along with the acute diseases commonly found in the developing world, the aging global population will face chronic health conditions such as cancer, cardiovascular disease, and diabetes. These three diseases alone account for a staggering amount of the healthcare dollars spent each year. It’s no secret that the cost of providing healthcare is increasing precipitously around the world. OECD data from 2010 shows that healthcare expenditures account for: • 16% of U.S. GDP • 9% of GDP for OECD Countries • USD $4.2 Trillion Spent Per Year Globally In addition, the OECD reported that healthcare spending as a proportion of GDP grew rapidly from 2000 to 2008 in many OECD countries, with annual growth rates of: • 11% in Slovakia • 4.6% in the U.K. • 4.3 % in the Netherlands • 3.4% in the United States It’s quite evident that these rising healthcare costs coupled with an increasing demand for healthcare services pose a very serious threat to the stability of the global healthcare system.

Limited Provider Supply What happens when rising costs and increased demands meet a decreased supply of providers? Consider some of these statistics: • In 2010, the American Medical Association predicted a shortage of 91,500 physicians in the United States by 2020. • Health Affairs (July/August 2009) published a report projecting a nursing shortage of 260,000 RNs just in the U.S. by 2025. • In 2006, WHO estimated a global shortage 2.3 million nurses, physicians, and midwives • A 2010 WHO report estimated a shortage of 2.4 million nurses in India alone. • China has a current nursing deficit of 5 million nurses (Nursing Outlook, 2010).

of nursing faculty, the migration of skilled providers, an aging population of providers, and unsatisfactory job conditions. A significant cause of this shortage is the aging nursing and physician population: • By 2012, the Average Age of RNs in the U.S. will be 44.5 Years Old • 55% of currently working nurses will retire between 2011 and 2020 (Nursing Management Aging Workforce Study, 2006). • Predicted shortage of nearly 100,000 physicians in the U.S. alone over the next decade, with one-third of American physicians retiring in that time frame. What does this global shortage mean for those in the medical tourism industry?

Impact on Medical Tourism

Worse yet, if the goal of healthcare communities around the world is to have a similar nurse to population ratio as in the most developed nations of the world (1:100), it is possible that there could be a shortage of 50 million nurses globally.

As ever-increasing numbers of healthcare consumers seek more cost-effective solutions to their healthcare needs abroad, the issue of provider shortages is not left behind in their home countries.

Admittedly, these statistics can vary widely. However, most industry experts concede that we are facing a significant shortage of providers, particularly nurses, while at the same time witnessing a dramatic increase in the demand for healthcare around the world.

Many nations around the world see the medical tourism industry as a tremendous opportunity for economic growth. For example, the medical tourism industry in Thailand is responsible for 0.4% of their GDP. However, regardless of the potential for economic gain, concern is being voiced from Southeast Asia that the growth of the medical tourism industry in countries such as Thailand, Malaysia, Singapore, Indonesia, the Philippines, and Vietnam may be creating some problems.

There are numerous factors to consider when examining the cause of the global provider shortage, including a shortage

September / October 2011

M E DI C A L T OURIS M

A 2010 WHO report estimated a shortage of 2.4 million nurses in India alone.

Specifically, the concern is that this growth may exacerbate any shortage of healthcare providers currently being experienced in the region and may actually increase the cost of healthcare in these areas due to the imbalance of provider supply with consumer demand. The concept is that this imbalance will further limit access to care for local patient populations. In addition, there is a concern that the growth of the medical tourism industry may be creating an unsustainable increase in the availability of expensive, highly technical healthcare services. The issue is complex and controversial, and it is unlikely to disappear from the debate. How is care to be delivered efficiently to a growing world population in the face of provider shortages, increased demands, and skyrocketing costs? These realities will drive consumers to seek less conventional options for seeking health information and healthcare services and will also force them to take more responsibility for their own healthcare.

Expanding the Role of Nurses In October of 2010, The Institute of Medicine released a landmark report titled The Future of Nursing, which called for fundamental changes in the role of nurses in the American healthcare system, including: • The Ability of Nurses to Practice to the Full Extent of Their Training and Education • Viewing Nurses as Full Partners with Physicians and Members of Other Healthcare Professions in the “Redesigning” of Healthcare in the U.S. The recommendations in this report could be adopted internationally in order to implement needed changes to the way we deliver healthcare. Of significant importance is the ability for healthcare providers of all professions to offer their services in the global marketplace without artificial constraints placed on them by government bodies or competing professions.

Predicted shortage of nearly 100,000 physicians in the U.S. alone over the next decade, with one-third of American physicians retiring in that time frame. Advanced Practice Nurses (APNs) can play an important role in the global healthcare system by increasing access to healthcare services and improving the overall quality of care. Nurse Anesthetists, Nurse Practitioners, Nurse Midwives, and Clinical Nurse Specialists are highly educated nurses who can provide the intensely specialized care that patients with complex illnesses require and do so very cost-effectively. One example of the value of APNs to the global healthcare system is the use of Nurse Anesthetists. Nurse Anesthetists are APNs who receive special education, often at the graduate level, in the administration of anesthesia. They are used throughout the world in over 100 countries in various capacities, including the United States, Europe, Asia, and Africa. In the United States, Certified Registered Nurse Anesthetists (CRNAs) administer anesthesia to patients of every age and for every surgical procedure, from neonates to the elderly, and from cataract surgery to organ transplants. Their value to the healthcare system in the United States is undeniable.

September / October 2011

Nearly 45,000 CRNAs in the U.S. administer over 30 million anesthetics per year in all 50 states and in the U.S. military, working with surgeons, anesthesiologists, or independently. The rapid increase in the demand for healthcare services around the world is quickly surpassing the number of qualified providers. The expansion of the role of nurses and APNs around the world can assist in meeting these demands.

Using Technology to Train, Educate, and Communicate The ability to leverage existing technologies and to incorporate future technologies into our healthcare system may provide some solutions to the problems created by the global healthcare provider shortage. What was once only possible in the realm of science fiction has now become a daily reality. Information and Communication Technologies (ICT) are being utilized across the globe both to manage and educate patients and to train healthcare providers who are thousands of miles apart. These include methods such as the use of: • Telemedicine and Telenursing • Telehealth • Mobile Health • Human Simulation • Social Networking Technologies Hospitals have utilized video-conferencing systems to facilitate communication between healthcare providers and distant experts, and between patients and their physicians. Tele-ICU programs have been implemented in hundreds of ICUs around the United States and their use is spreading internationally. Healthcare professionals are managing patients across town and across the world, providing expert clinical care chronically ill patients through such mechanisms as virtual blood pressure and blood glucose monitoring. The proliferation of mobile devices, even in the poorest nations, now permits outreach to patients in remote areas of the world, enabling them to receive basic healthcare services and information that will improve their lives. When combined with distance education, these strategies have shown real promise in the battle to deliver care efficiently and cost-effectively, especially in the area of chronic disease monitoring and management. This can result in decreased hospital visits and an increase in patient compliance. It has also been suggested that utilizing this technology may permit the transmission of new information much faster than traditional methods, enabling state-of-the-science standards to be implemented and make their impact early. The use of human simulation technology in the education and training of nurses may play a critical role in finding a solution to the international provider shortage. Simulation education can be used to target specific areas of need to: • Improve Basic Clinical Skills • Teach Crisis Management Skills • Assess Clinical Competence • Develop Critical Thinking and Psychomotor Skills • Improve Patient Outcomes and Patient Safety Health 2.0 and the role of social media technologies are also rapidly growing in healthcare. For example, on February 9th 2009, surgeons at the Henry Ford Hospital in Detroit

became the first people in the world to Twitter a surgery live as it happened. During robotic surgery to perform a partial nephrectomy for renal cancer, itself an incredible use of technology in healthcare, the surgeons updated the family and the world on the progress of the case. Is this use of technology to communicate with patients and professional colleagues a passing fad? Unlikely.

Final Analysis In the coming years, healthcare systems around the world will be faced with the challenge of delivering healthcare to a global population that has an increasing hunger for services and information. The global burden of disease, especially chronic disease, will place a tremendous strain on the ability to meet these demands. Reliance on outdated care models will do nothing to solve these challenges and will serve only to exacerbate them. Fortunately, rapidly evolving technologies now allow multiple solutions to be implemented that can assist in the cost-effective and efficient delivery of healthcare. Nurses and Advanced Practice Nurses are uniquely positioned to alleviate this crisis, enabling people of all socioeconomic ranks to have access to safe and affordable healthcare anywhere in the world. n About the Author James Woomer, MSN, CRNA is the President and CEO of Advanced Practice Nurse International (APNI), a global healthcare consulting firm located in Washington, D.C. APNI’s team of internationally known nursing experts assists national governments and healthcare organizations to increase access to patient care, decrease the cost of healthcare delivery, and improve nursing staff efficiency and patient safety. APNI can guide organizations through the process of introducing Advanced Practice Nurses into their healthcare systems, develop academic APN programs, design and implement patient safety initiatives, and improve the clinical skills of nursing staff using competency-based training and human simulation technology. He is also a member of several professional societies, including the International Society for Quality in Health Care, International Health Economics Association, American College of Healthcare Executives, American Organization of Nurse Executives, American Association of Nurse Anesthetists, and the Society of Ambulatory Anesthesia. He has nearly two decades of clinical, academic, and business experience in the healthcare industry. He is a graduate of the Pennsylvania State University and the University of Pittsburgh Nurse Anesthesia Program, where he received the Agatha Hodgins Award for Outstanding Clinical and Didactic Achievement in December of 2000. He is a past Vice-President of the Pennsylvania Association of Nurse Anesthetists and has been an active Adjunct Instructor at the University of Pittsburgh’s Nurse Anesthesia Program since 2003. He is a past recipient of the Pennsylvania Association of Nurse Anesthetists Didactic Instructor of the Year Award. James maintains an active clinical anesthesia practice and is the Vice-President and Chief Operating Officer of RemCare Anesthesia Solutions, LLC, an anesthesia-staffing firm located in Pennsylvania. James can be reached for comments or questions at +1-202351-6835 or jwoomer@apnurseinternational.com. www. apnurseinternational.com

September / October 2011

M E DI C A L T OURIS M

The Impact of Applying International Standards to Quality Services Jordan’s Private Hospital Setting

By Dr. Hashem Abu Sneineh

Experience Treating International Patients

A Win-Win Scenario ~ Focusing on the Patient

In 2007 the value of the private healthcare sector was one billion dollars. The Jordanian private medical sector became a very important exporting sector; it is competing globally to receive patients from all different parts of the world. The Oxford Business Report published in 2009 that Jordan treated 45,000 Iraqis, 25,000 Palestinians, 20,000 Yemenis, 19,000 Sudanese, 10,000 Syrians, 10,000 Libyans, in addition to 1,800 Americans, 1200 British, and 400 Canadian patients, making Jordan the first country in the region in terms of medical tourism and gave the private hospitals a motivation to enhance the quality of services provided to patients in every available way. One of these world-wide known methods is International Accreditation, and for the purpose of this article, I will be focusing on JCI accreditation.

We understand that international patients seek some sort of international standard set in place through accreditation, so we have made it a priority to ensure that facilities seeking to embrace the medical tourism industry and treat international patients invest in international accreditation. It has become a win-win situation for us, as our local patient population also benefits from the high quality standards being put into place. The main benefits include having access to advanced medical

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institutions which have a pool of policies and procedures mastering the work processes and guarantee a safer delivery for the medical services from the providers to the patients.

International Accreditation ~ Quality Standards in Jordan One of the greatest concerns of traveling patients, if not the greatest concern, is identifying the criteria to use when choosing the hospital that provides the best perceived quality care for patients. Patients need assurance that the medical treatment and the healthcare services they will receive, are delivered under the best international standards available. We consider JCI Certification to be one of the best assurance tools within the medical tourism industry; therefore our hospitals utilize it to solidify their commitment to their number one priority, patient safety. By applying such international accreditation standards, the hospital staff will also be immersed in a number of policies which will guide them to a best practices model, and they will have the opportunity to receive intensive training programs to help them perform in a more effective and safe way. What we jokingly refer to as the “JCI fever” began in 2006. Leading private hospitals invested in this international accreditation and JCI certificates became a staple on the walls of the most coveted hospitals in Jordan. By 2010, Universities Hospitals followed suit. Currently, the total number of accredited hospitals in Jordan is 8, of which 6 are within the private sector. JCI accreditation is now one of the most important factors in attracting patients to hospitals in Jordan for treatment. It encourages patients, particularly those from developed countries, who do their research before opting to travel for treatment to consider Jordan.

The Effects of International Accreditation on Medical Providers The result of a study conducted in 2010 to measure the improvement on service’s quality in four JCI accredited private hospitals in Amman, reflected an improvement in the quality in terms of physician & nurses performance, documentation, medication errors, and infection prevention. This improvement was a result of applying JCI standards as the statistic of these hospitals shows. The average decrease of the infection control percentage in three of the four studied hospitals was 0.18% after the accreditation; the documentation percentage has improved as well. The documentation was the most improved aspect because of the JCI standards; the table below shows the exponential jump of commitment to documentation, the numbers in the table below shows the percentage of the perfectly completed medical records before and after the application of the JCI standards: Post-Accreditation

Pre-Accreditation

Hospital 1

98%

75%

Hospital 2

91%

71%

Hospital 3

88%

71%

Medication errors were also improved following JCI implementation. The average percentage decrease of the medication errors was 0.19% due to the better training of staff along with the increased number of policies regarding this issue. In order to understand how the application of the JCI standards affected the way they provide services to patients, 362

healthcare providers were surveyed as well. They responded to the study and gave the following rank for the effect of JCI standards on the quality aspects; number one rank was given to the most affected aspect by the JCI accreditation: 1. Medication Use System 2. Infection Control System 3. Documentation System 4. Doctors Performance 5. Nurses Performance In terms of the quality of doctors’ performance, 68% of the healthcare providers reported that after the application of the JCI standards, there was an evident focus and improvement in doctors in training, credentialing and privileges process. Nurses are the “engine” of any hospital and with that being said, the JCI standards provided significant attention to nurses’ performance. A reported 89% of the participants improved after they followed the JCI standards, encompassing documentation, medication use, infection prevention, communication, and safety. Infection prevention is among the most important issues in healthcare and one in which healthcare providers found that the establishment of JCI standards impacted the most. The majority of the studied sample reported that they are now armed with the tools of international standards, which in turn lead to an all around minimization of the infection rate by abiding by the policies and procedures regarding the infection rates and prevention. Documentation is taking the lead among any other areas of improvement; patients’ medical records are the very most important communication tool among healthcare providers in terms of patients’ health and medical case and history. Of the sample of medical staff included in the study, 66% assured that the JCI standards helped them understand the documentation methods and as a result to better handle patient records.

The Importance of the Study Results The surveyed sample consisted of doctors and nurses and urged the private hospitals’ management to provide a significant focus on accreditation certificates and in specific to the JCI accreditation; they recommended to apply these accreditation standards as a set of best practices that would

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M E DI C A L T OURIS M enable them to work in an efficient, effective, safe and patient oriented environment, in turn increasing job satisfaction and creating a better atmosphere where they can work safely. The health practitioners also encouraged the heads of the accredited hospitals to cooperate with non-accredited hospitals to spread the culture of accreditation all through the country, as they stressed that accreditation is not only a marketing tool, but more importantly it is a tool to improve and enhance the level of services quality provided to patients, whether these patients are local or medical tourists. It is very important to mention, that in order to create a better understanding of the accreditation system and how it serves the patients, the accredited hospitals have embarked in a mission to disseminate information and education in the form of lectures, creating awareness for the public as well. This piece of advice was given to the hospitals by members of the study sample, doctors and nurses in the accredited hospitals. They create awareness campaigns about the benefits of accreditation during the process of treating patients. This is done by talking to patients about their rights and responsibilities, by practicing medicine safely, and by providing the highest possible quality. Several studies in numerous countries around the world were performed about the impact of JCI accreditation on the quality of services rendered, mainly showing a noteworthy improvement throughout all level of services. Moreover, several lectures were given by JCI executives, supporting that JCI standards helped hospitals considerably improve their performance. This study is one of the very first, if not the only one, to test the impact of the accreditation standards on the quality in the Jordanian private hospitals from the standpoint

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of their very core; the providers of healthcare. The results are in compliance with the previous studies, and reiterate that when accredited by an international accrediting body such as JCI, hospitals donâ&#x20AC;&#x2122;t simply purchase a marketing tool to polish their public image. This is an investment to improve existing methodology, raise their level of performance and apply best practices in order to offer all patients the best possible quality of care. n About the Author Dr. Hashem Abu Sneineh serves as the International Marketing Coordinator in for world-renowned Specialty Hospital in Amman, Jordan. Dr. Abu Sneineh received his PhD in Business Administration with a focus on Quality in 2010. Forming an integral part of the Specialty Hospital since 2003, he has experience in areas including Human Resources Management, Patientsâ&#x20AC;&#x2122; Affairs Management, providing the background for his current position. In addition to his work at Specialty Hospital, Dr. Abu Sneineh is a member of the Volunteer Team of the Private Hospital Association, where he generates strategies to internationally market the Jordanian hospitals and the country of Jordan as a viable destination for medical tourism. Through his career, Dr. Abu Sneineh has gained vast experience in the quality field and in implementing quality standards from several accreditation bodies such as the Joint Commission International (JCI) and the Health Care Accreditation Council (HCAC), as well as receiving accolades including the King Abdullah Award for Excellence.

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M E DI C A L T OURIS M

Spain ~ The Heart of

Transplant Surgery

By Olivia Goodwin

Valencia, the third largest city in Spain has reinvented itself as an up and coming destination for tourism and lately, limb transplants. Beyond the Beauty Surrounded by the Mediterranean Sea this city brings in visitors from all over the world to experience the historic beauty. While in Valencia tourists can visit the Serranos Towers which is considered to be the largest Gothic city gateway in all of Europe, the towers were constructed at the end of the 14th century and were used as prison cells, or they can walk around the Plaza de la Virgen which sits on the site that once was the forum of Roman Valencia. These are some activities that those who didnâ&#x20AC;&#x2122;t travel to Spain for a transplant might want to partake in. While tourism is now booming, the transplant industry has been well established for years and even more so lately.

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Spain has become a world leader in organ donation since it set up a network of transplant coordinators in 1989 at all hospitals to closely monitor emergency wards and identify potential donors within intensive care units, this coordination network is on a national, regional and hospital level. Transplant coordinating teams were founded and put in charge of all steps of transplant procurement including; locating donors to the organ grafting or tissue banking. This program has proven to

Spain is the only country with a sustained increase of organ donation during the last 17 years. September / October 2011

M E DI C A L T OURIS M be successful; waiting times and lists in Spain have decreased. For example, heart transplant waiting lists fell from 116 patients in 2004 to 85 patients in 2005.1 Dr. Rafael Matesanz, MD, director of the Organización Nacional de Trasplantes in Spain said, “Spain is the only country with a sustained increase of organ donation during the last 17 years.” There has been a rise from 550 to 1546 annual donors, for all organs.2

Progressive Medicine Valencia has also been home to some of the first body part transplants in Spain and in the world. Dr. Pedro Cavadas and his team at La Fe Hospital have been responsible for performing Spain’s first partial face transplant, double hand transplant and now the world’s first double leg transplant.

Valencia has also been home to some of the first body part transplants in Spain and in the world. Dr. Pedro Cavadas and his team at La Fe Hospital have been responsible for performing Spain’s first partial face transplant, double hand transplant and now the world’s first double leg transplant. Dr. Cavadas originally from Valencia, received his Doctorate in Medicine from the University of Valencia and completed his residency with La Fe Hospital in 1995, where he specialized in Plastic and Reconstructive Surgery. Dr. Cavadas decided to do more with his talent; after spending periods of time in Kenya he founded the Pedro Cavadas Foundation, a nonprofit organization that’s dedicated to reconstructive surgery in Africa.3

The Transplant Leader Dr. Cavadas performed Spain’s first bilateral hand transplant which was also the first woman in the world to have had this performed and only the seventh person worldwide to have this procedure. In December 2006, the 47 year old patient who lost both her hands 28 years ago in a chemistry experiment underwent the 10 hour reconstructive surgery at La Fe Hospital in Valencia. The majority of hand transplants worldwide have been successful except in the cases where patients stop taking proper medications according to the doctor’s orders.4 Just a few short years later in August 2009, Dr. Cavadas successfully performed the first partial face transplant in Spain and the eighth ever performed worldwide it was also the first transplant to include both tongue and jaw. The surgery took more than 30 people to facilitate, but after 15 hours the 43 year old man received his new face.5 One year later in March 2010, Dr. Joan Pere Barrett from the Vall d’Hebron University Hospital in Catalonia performed a full face transplant that included the entire face, including the nose, lips, jaw, teeth, muscle tissue, skin and cheek bones, thereby making Barcelona home of the first full facial transplant. After successfully completing various types of transplants Dr. Cavadas, along with his team of 50 at La Fe Hospital pioneered the world’s first double leg transplant in July 2011. Generally, prosthetic legs are the best option for leg amputees, but in this case the amputation was very high on the thigh, leaving too little tissue to attach a prosthetic limb.6 Cavadas said in an article in the Huffington Post that the key to the long period of rehabilitation will be how the patient’s nerves regenerate and join up with structures like muscles, joints and skin. He expects that if everything goes well the patient will be walking with crutches in six or seven months.7

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With all these advancements, Spain is emerging as an international front runner in the medical industry. Its historic beauty might have been the country’s initial intrigue but its transplant innovations are giving Spain the esteem it deserves. n _____________________

1 http://www.ont.es/publicaciones/Documents/Articulos/2007/Circulation_Matesanz.pdf 2 http://www.ont.es/publicaciones/Documents/Articulos/2007/Circulation_Matesanz.pdf 3 http://www.gabarron.org/files/Awards/2011_Science_Research_Award_Winner_CV.pdf 4 http://www.typicallyspanish.com/news/publish/article_7857.shtml#ixzz1VVpn9EXu 5 http://www.typicallyspanish.com/news/publish/article_22762.shtml#ixzz1VVqCtwb4 6 http://www.newscientist.com/article/dn20681-worlds-first-double-leg-transplant-

performed-in-spain.htm

7 http://www.huffingtonpost.com/2011/07/12/double-leg-transplant-first_n_896442.html

About the Author Olivia Goodwin serves as Communications Coordinator and Assistant Editor for the Medical Tourism Association and Magazine. She travels around networking and developing ideas for the Magazine and the Association. Olivia holds a degree in Multimedia Journalism from Florida Atlantic University. She may be reached at Olivia@MedicalTourismAssociation.com

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September / October 2011

M E DI C A L T OURIS M

A Sweet Toothed Fat~

Free Life to Obesity By Sonia Jones

Changing to a Healthier Lifestyle ~ Reaps Lifelong Benefits Most people know deep down that their lifestyle has contributed to their high cholesterol or high blood pressure or low energy levels or constipation or weight gain, aches and pains and more. So many conditions are related to poor nutrition, lifestyle and being overweight; all very fixable. The evidence of going “on a diet” and the inevitable coming “off a diet” doesn’t work. Actually, losing the weight is the relatively easy bit compared to keeping that weight off over the longer term? The evidence has shown over and over again that 90 to 95% of people who have lost weight will gain the weight back on within 2 to 5 years and for some it doesn’t take very long.

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Battling the Food Manufactures Many times, the “food industry spoon” feeds the public confusing information. It’s in their interest to do so. To have people hooked on certain foods and drinks is good news for the food manufacturers. Hooked being the operative word, if this was not the case it would all be so easy to eat healthily and maintain a sensible weight. Most people get their information from advertising the food manufactures bombard the public with. The supermarket shelves are full of temping foods where their packaging often costs more than the food they contain. A huge amount of money goes into the research and development of the presentation, so you will buy, consume and get hooked. Even in your own home you can’t get away from it, if you

watch TV there are advertisements are constantly temping you and making you think that this latest product is your “quick fix” answer to your weight and health problems. Over the decades consumption of various sweet substances has steadily been rising to such an extent that people are consuming massive amounts. Partly, as the food industry has added higher amounts of sugar (or other sweet ingredients) and because there are even more products on the shelves that contain some sort of sweet ingredients, the public has truly become hooked. On the subject of sweet things here is a list of sweet substances you need to look out for when you read the ingredients of the products you consume: dextrose, maltose, HFCS (high fructose corn syrup, which many experts are claiming is much worse than sugar), fructose (not to be confused with fresh fruit), lactose, glucose, sucrose (another word for sugar), levulose, galactose, mannitol, sorbitol, xylitol, corn syrup, concentrated cane juice, dextrins, dextrans, and malto-dextrins. Secondly, by managing to gradually add more sweetness, people are left wanting more, so consumers are left constantly craving to satisfy their need for a sweet taste. You have to start with being aware of the amount of hidden sugar or recognizing sweet ingredients in its many guises and begin to re-educate your taste buds. This is a very important step!

Consuming Chemicals That Taste Sweet is Not the Answer Some people think they can get around this by maintaining their need for sweet things while reducing their calorie consumption. They turn to unhealthy foods that are sweetened with chemicals. There is an irony about this, in both animal and human trials these chemical sweeteners have shown to increase most people’s craving for sweet and fatty foods! It is not unusual for some people to experience increased fluid retention, even weight gain and digestive problems. As you look on the supermarket shelves there are more and more products appearing that contain chemical sweeteners of one type or another. The problem with this tactic is that it does nothing to re-educate your taste buds. One must also keep in mind, adding chemicals to your diet is not a way to a long-term healthier life. Other issues that need to be discussed or highlighted are that people eagerly jump on the band wagon to devour the latest “quick fix” solutions, fluids, lotions, potions, pills, drinks, diet bars, and weird routines such as taking massive amounts of laxatives, consuming medications that speed up their system, vomiting, drinking gallons and gallons of water and a whole lot more unhealthy practices. A lot of people want to lose their weight very fast. Here lies a problem. This approach does absolutely nothing to address any underlining problems and 99% of quick fix gimmicks either cost your pocket or cost your health and are not sustainable in the long run.

Does Calorie Counting Work? The idea that one-size weight-loss diet fits all also doesn’t work. Each person has different health issues and often different reasons why they have weight issues. Each person has a set of symptoms and clues that add up to creating an individual picture. A plan of action should encompass a doable short term, medium and very importantly, a healthy long-term plan that eventually becomes second nature or simply part of one’s good habits. People who count calories still make some very poor food choices and are obsessed with weighing or measuring food, and calculating numbers. Here is a typical example of what happens over and over again to so many people to some degree. In an article written by Dr. Allen King called “Obesity and Health”, a case study is presented which demonstrates how he put 500 of his patients on a 1000 calorie a day diet. Six months later, the average patient lost 50lbs! Wow, success you would think or say. Sounds good doesn’t it?

However, three years later these same patients have now gained an average of 60lbs - that is very depressing! For some it didn’t take as long as 3 years. Now the dieters are 10lbs heavier than before they started the diet!

What Farmers Know You Should Know Farmers have known for a long time and it very much applies to humans also that animals fed on raw food are leaner and slimmer going to market compared to animals fed the same foods and the same amount of food but cooked (being the only difference) making these animals fatter. So why is this? Raw foods are bursting with ‘live enzymes’ and many vital nutrients are left intact, all encouraging health-gain and weight-loss. Something else farmers do, they restrict the amount of food their animals are given for a few days and then for a few days the animals are allowed to eat as they did before. These animals also go to market heavier than those who have been fed constantly so more profit without extra cost! This is what most people do; restrict their food for a while (go “on a diet”) for a few days then go back to their normal eating habits (come “off the diet”) and they repeat the process.

Keeping your blood sugar levels stable is vital in reducing the body’s need to produce as much insulin. We have a built-in survival mechanism. If you think how many situations in history have humans been faced with a famine. It makes sense that the body hangs on to as much as possible. The very action of restriction greatly increases the activity of this potent fat-storing enzyme. Then there is insulin which stimulates the quantity and activity of lipoprotein lipases. If insulin levels are high then the lipases are more active however if insulin is low the lipases are far less active. This is another very important aspect to the whole health/weight scenario. Keeping your blood sugar levels stable is vital in reducing the body’s need to produce as much insulin. So again it’s not so much about counting calories it’s about what you eat and how it affects your blood sugar levels. And this brings me to the other point about raw and cooked food mentioned earlier. A raw carrot has a very different affect on your blood sugar levels than when it’s cooked and the more it’s cooked the greater the affect. Feast and famine (going on and coming off a diet) can induce changes in the action of an enzyme that burns fat, which seems to be lower in dieters. So dieting may well be increasing your fat-storing enzymes while lowering your fatburning enzymes. This doesn’t mean all your food should be raw? It does mean you need to incorporate more raw foods that are rich in enzymes and nutrients into your new long term

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M E DI C A L T OURIS M lifestyle plan. This is another reason why sugar and other sweet ingredients need to be eliminated, as they greatly affect your insulin levels regardless of calories consumed.

Your Fat Phobia May Be Hindering Your Success In the last few decades fat was deemed the big energy to weight-loss and health, people turned to processed products the food industry convinced the public they needed, products like “lite” or “fat-reduced” or “fat-free”. The industry cleverly got people to change their habits and a massive industry was born producing highly processed oils and fats like margarine which contained “trans fatty acids” that turned out to be lethal to health. It took a big effort by many health authorities to get products with “trans fatty acids” removed from the supermarket shelves. Essential fatty acids EFAs, as the name would indicate are essential to health and a stable weight. It has been estimated that most people only get about one tenth of the “essential fatty acids” they need. EFAs are needed for the metabolism, fluid balance, anti-aging, circulation and so much more. If you want to lose weight, extend your life, reduce inflammation, prevent chronic disease you need to eat the correct types of fats and oils. If you are one of those people who is “fat phobic” do not panic! Remember if your “fat phobia” had worked you wouldn’t be reading this now. It is also important to realize the presence of fat in the stomach delays the emptying of the stomach, contributing to the feeling of satiety (the feeling of fullness) for longer. We need some fats to ensure the absorption of fat soluble vitamins like Vitamin E, Vitamin A and Vitamin D. Avoid the processed fats found in mayonnaise, ice-cream, margarine, chips (crisps), the average oil on the supermarket shelf, you get the idea. Essential fatty acids are found in foods like cold pressed or extra virgin oils, in unroasted nut and seeds, fresh produce like avocados, and oily fish.

The more processed your food is the more you are moving away from enzyme rich foods that keep humans and animals healthier and slimmer.

In a Nutshell As you go for the next “quick fix” solution be aware you are moving further away from long term success. The more processed your food is the more you are moving away from enzyme rich foods that keep humans and animals healthier and slimmer. Relying on the food and diet industry to provide you with answers like artificial sweeteners so you can maintain your sweet taste will sabotage your health and long term weight loss. A great place to start is to gain an understanding of good nutrition so you can make informed choices about your diet. Check the ingredients of every product in your store cupboard and bin everything that is going to sabotage your new long term health-gain and weight-loss. Kick start this by having only fresh fruit and vegetable for just a short few days. This gives the body a break with old habits and gives you a chance to begin re-educating your taste buds. n About the Author Sonia Jones is a published author from England, trained in England with renowned Dr. L Plasket at The Plaskett International College, becoming a Nutritional Therapist. Then Sonia joined well known Beryl Crane at The Crane School of Reflexology in England, receiving a diploma in Reflexology. Moving to Australia for 4 years to study Naturopathy at The Australian Institute of Applied Sciences, she received an Advanced Diploma of Naturopathy. Sonia now lives in Boquete, Panama and is the co-owner of The Haven Spa, Health Clinic, Fitness Center and Hotel. She is a published author of three books so far, fourth one out shortly. In 2009, she saw the launch of their brand of natural organic, toxic-chemical-free personal skin care products. These products are the first of their kind in Panama and after much red tape are registered in Panama.

September / October 2011

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September / October 2011

CHICAGO, ILLINOIS USA

OCTOBER 25TH - 28TH 2011 Marriott Renaissance Schaumburg Convention Center Hotel

World Medical Tourism & Global Healthcare Congress

Learn About The Latest Trends In Medical Tourism And Network With Industry Professionals

Up To 20,000 Pre-Scheduled Networking Meetings 100+ Speakers • 140+ Exhibitors • 400+ Buyers Up To 1,500 Attendees From Over 85 Countries “+” = UP TO

FIVE LEADING HEALTHCARE CONFERENCES

ONE LOCATION

ONE EXHIBIT HALL 5X THE TRAFFIC HEALTH &WELLNESS I N T E R N AT I O N A L

AN INTERNATIONAL HEALTHCARE DEVELOPMENT CONFERENCE

P A R T O F W O R L D M E D I C A L T O U R I S M & G L O B A L H E A LT H C A R E C O N G R E S S

Medical Tourism & Buyers of Healthcare Converge in ChicagoLand! The 4th Annual World Medical Tourism and Global Healthcare Congress is gaining momentum with registration already up by 200% at this time compared to last year’s Congress. After hearing about the success of last year’s conference, the next one more than five months away has already drawn a crowd of industry professionals wanting to be among the first to register, ensuring a spot at this year’s congress. The focus for this year is “Year of the Patient in Emerging Markets,” featuring some of the upcoming largest growth areas of Medical Tourism in Russia, CIS Countries, China and the Middle East and GCC region. The congress will have a heavy focus on attracting buyers of healthcare and a specific track on these emerging regions.

THIS YEAR’S TRACKS INCLUDE: 1 Emerging Patient Markets in Russia, CIS, China, Middle East and GCC Regions 2 US, Canadian and Caribbean Markets 3 Expatriate Healthcare and Global Health Insurance/Global Benefits 4 Inbound Medical Tourism to the US and US Domestic Medical Tourism 5 International Wellness 6 Healthcare and Hospital Development New to this year’s conference, will be a chance to network with participants from the Employer Healthcare Congress, one of the US’s largest employer and insurance healthcare conferences, which will have integration for certain networking functions.

SOME OF THE PRELIMINARY FEATURED AND EXPERT SPEAKERS SO FAR ARE: • Bill Rancic - Entrepreneur and winner of The Apprentice • Dr. Robert Rey - as featured on Dr. 90210 • Hon. Prof. Peter Anyang’ Nyong - Minister for Medical Services Ministry of Medical Services, Kenya • Mouhanad Hammami, MD-President, National Arab American Medical Association • Yakov Elgudin, MD, PhD, FACS - President, Russian American Medical Association • Vladimir Budiansky - Medical Director, Moscow Doctor • Jacqueline Madrigal - Human Resource / Benefits Manager, American Apparel • Jack Norton - Human Resources Manager, Blue Lake Casino & Hotel • Muna Almuallem - Manager of International Benefits, Mary Kay Inc. • Chris Russo - President and Chairman of the Board American Society of Travel Agents (ASTA) • Renee-Marie Stephano, Esq. - President, Medical Tourism Association

• David Jaimovich - President and Founder, Quality Resources Intl. • Dr. Hisham Diwani - General Manager, Health Insurance, Ministry of Health –Syria • J. Edson Pontes M.D - Senior VP International Medicine, Detroit Medical Center • Stacy Dreyfus - Founder, Orchid Resorts & Escapes • Samer Ellahham, MD,FACP,FACC,FAHA,FCCP - President, International Association of Healthcare Quality • Karen H. Timmons - Former President and Chief Executive Officer, Joint Commission International and Joint Commission Resources • Dr. Terry Stevens - Managing Director, Stevens & Associates • Bill Ruschhaupt - Chair, Global Patient Services, Cleveland Clinic • Rosanna Gomez Moreno - CEO, RGM Global • Colin Rohlfing - Assoc. AIA, LEED AP BD+C - Sustainable Design Leader, Hellmuth, Obata & Kassabaum Inc.

M E DI C A L T OURIS M

Minimally-Invasive Solutions for Sinus and Allergy Sufferers ~ An Opportunity to Indulge in Palm Beach Living By David C. Brodner, M.D.

It is estimated that more than 37 million Americans suffer from sinus infection (sinusitis) every year, making it one of the most common health conditions in the country. Sinusitis simply means your sinuses are inflamed - red and swollen - because of an infection or another problem. This disease accounts for one in every five antibiotics prescribed and results in an average of four lost workdays for every patient.

hese numbers may be significantly higher, since the symptoms of sinusitis often mimic those of allergies and cold and many afflicted never see a doctor for a proper diagnosis and treatment plan. Sinusitis is typically treated first with medication. In at least 20 percent of patients, though, medication alone is not enough and surgery is required.

Causes of Sinus Infection Acute sinusitis usually follows a viral infection in the upper respiratory tract, but allergens (allergy-causing substances) or pollutants may also trigger acute sinusitis. A viral infection causes damage to the cells of the sinus lining. This damage leads to inflammation. The lining thickens with fluid that obstructs the nasal passage. This passage connects to the sinuses. The obstruction disrupts the process that removes bacteria normally present in the nasal passages, and the bacteria begin to multiply

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and invade the lining of the sinus. This causes sinus infection symptoms. Allergens and pollutants produce a similar effect.

What Are the Symptoms of Sinusitis? One of the most common symptoms of any type of sinusitis is pain, and the location depends on which sinus is affected. Most people with sinusitis have pain or tenderness in several places and their symptoms usually do not clearly indicate which sinuses are inflamed. In addition to the pain, people who have sinusitis often have thick nasal secretions that can be white, yellowish, greenish, or blood-tinged. Sometimes these secretions drain in the back of the throat and are difficult to clear. This is referred to as “post-nasal drip.” Cases of sinusitis are also usually accompanied by a stuffy nose and a general feeling of fullness over the entire face.

Less common symptoms of sinusitis (acute or chronic) can include the following: • Tiredness • Decreased Sense of Smell • Cough That May be Worse at Night • Sore Throat • Bad Breath • Fever Because the nose can get stuffy or congested when a person has a condition like the common cold, they may confuse simple nasal congestion with sinusitis. A cold usually lasts about 7 to 14 days and goes away without treatment. Acute sinusitis often lasts longer and typically causes more symptoms than a cold.

Treatment Options Chronic sinus disease is troublesome and frustrating to patients. Today, available technology is faster, gentler, and more thorough than past options. Patients can expect quicker recovery, shorter operating time, and lower overall costs. Traditionally, those who suffer from sinusitis have two routes to relief—antibiotic medical therapy or sinus surgery.

Medical Therapy Sinusitis is typically treated first with medication. Treatment with antibiotics or topical nasal steroid sprays is often successful in reducing mucosal swelling, fighting infection, and relieving obstructions of the sinus opening. Inhaling steam or use of saline nasal sprays or drops can also help relieve sinus discomfort. However, at least 20% of patients do not respond adequately to medications.

Conventional Sinus Surgery The goals of sinus surgery are to clear blocked sinuses restoring normal sinus drainage and to preserve normal anatomy and mucosal tissue. Conventional sinus surgery required bone and tissue to be removed to open blocked sinus passageways - leading to post-operative pain and bleeding that required uncomfortable nasal packing to control.

Balloon Sinus Dilation Technology When medications don’t work and sinus surgery is not a desirable option, what is a patient to do? I now offer a new sinus treatment as an option - a minimally invasive technology that utilizes a small, flexible, sinus balloon catheter that is placed into the nose to reach the sinuses. The sinus balloon catheter is gradually inflated to gently restructure the previously blocked nasal passage, maintaining the integrity of the sinus lining, and restoring normal sinus drainage and function. There is minimal bleeding and many patients have been able to return to normal activities within 24 hours. Clinical research has indicated that the Balloon Sinus Dilation technique is a safe and effective tool in dilating blocked sinuses.

The balloon sinus surgery procedure can be performed in my office under local anesthesia. It’s quicker than a dental procedure and there is virtually no pain due to the minimally invasive technology. Balloon Sinus Dilation is a true advance in sinus care because in many cases, the procedure can be done without removing any tissue or bone. That means quick recovery times and less post-procedure discomfort. Similar to cardiac angioplasty, a procedure in which a balloon is used to dilate obstructed blood vessels, balloon sinuplasty expands constricted openings to the sinuses. While watching a live endoscopic image on a video monitor, I guide a tiny, narrow balloon into the blocked sinus opening. Once the balloon is in place, it is inflated by using a syringe connected to the end of a tube outside the body. This technology is an endoscopic tool and may be used with other medical therapies or sinus surgery techniques. It does not limit future treatment options if you have progressive disease.

The Benefits of Balloon Sinus Surgery (Sinuplasty) • Safe and Effective • Minimally Invasive • Reduced Bleeding • Improved Recovery Time

Education and Communication is Key Balloon sinus surgery doesn’t entirely eliminate the need for conventional sinus surgery. The balloon will not fit all passageways and may not work for patients with large cysts, severe bone disease, or previous sinus surgery. Patients are thoroughly educated on the procedure, expectations and provided a customized protocol to ensure the best possible outcome. Understanding the need of my patients for a solution such as this one empowered me to continue my education and as an expert in the field, I travel around the country lecturing and teaching other sinus surgeons how to perform this cuttingedge, minimally-invasive technique. Consequently, patients too are inclined to travel to my office in Palm Beach County in search of this innovative procedure.

Minimally-Invasive Solutions ~ Opportunity to Indulge & Explore Palm Beach It’s important for patients and their companions to understand all factors that encompass a decision to travel

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M E DI C A L T OURIS M for healthcare. Proper communication between the home or “referring physician” and the treating physician in the destination of choice is imperative. Following the established protocol may also ensure a best outcome scenario and planning accordingly is essential. Traveling for treatment, in this case, for a non-invasive procedure, to destination such as Palm Beach can certainly present the opportunity to also enjoy a great vacation. The caveat is to ensure clear communication between all medical providers; home and destination as well as making sure one’s companion(s) have a clear expectation of the experience. With all factors taken into account, it can prove to be a win/win situation for all involved!

Traditionally, those who suffer from sinusitis have two routes to relief—antibiotic medical therapy or sinus surgery.

Rich in culture and history, and known as Florida’s Cultural Capital due to its exquisite museums, performing art venues, festivals and upscale shopping, Palm Beach offers visitors and locals alike the opportunity to indulge in its sultry ambiance. Relaxing while playing on Florida’s first 18-hole course, or scope out the best in the world; the PGA Tour’s Honda Classic. Alternatively, there are over 40 public courses to choose from throughout Palm Beach. A lavish tropical paradise featuring beaches offering a year-round alluring climate and in the winter, perhaps one can enjoy world-class equestrian polo, steeplechase, and dressage facilities. A Sunday Brunch can be served field side for an equestrian and polo experience or perhaps at one of the resort restaurants and cafes of the island of Palm Beach, which have catered to world-famous celebrities and royalty for decades! The hospitality industry in Palm Beach features some of the best in the world. With real estate gurus such as Donald Trump lending his famous Mar-a-Lago, the breathtaking Boca Raton Resort & Club and a plethora of gastronomic options throughout the city, Palm Beach is sure to exceed the most seasoned traveler’s expectations. The medical tourism industry in Palm Beach is positioned to grow exponentially within the coming years. As more and more providers embrace it and key players of the tourism and hospitality industry understand the needs of traveling patients and their companion(s) as well as how to best deliver their services to them, Palm Beach will soar as a top destination for medical tourism. n Resources: www.BrodnerMD.com www.pbcms.org www.palmbeachfl.com Note: The National Institute of Allergy and Infectious Diseases and the American Rhinologic Society contributed information to this article.

About the Author Dr. Brodner has been caring for the patients of Palm Beach County since 2001 and is proficient in managing all ailments of the Adult Ears, Nose and Throat. He has created The Center for Sinus, Allergy, and Sleep Wellness to concentrate his practice in aiding patients suffering from sleep disorders such as snoring, obstructive sleep apnea, and insomnia; allergy issues requiring testing and treatment; and all complaints of the nose and sinuses. He is the only specialist in Palm Beach County double Board-Certified in both Sleep Medicine and Head and Neck Surgery. For more information visit www.BrodnerMD.com.

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ÂŠ Copyright Medical Tourism Association

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M E DI C A L T OURIS M

Marketing Wellness Tourism in Las Vegas:

AquaStretch

A New Wellness & Spa Service for the World By George Eversaul, A.P. Staff at the University of Nevada, Las Vegas (UNLV) Wellness Center has developed an exceptional new wellness program and spa service that creates a remarkable opportunity for both health and medical tourism around the world. And with that opportunity comes the challenge of marketing this breakthrough technology, both to increase wellness and medical tourism to Las Vegas and to disseminate its existence internationally.

quaStretch represents an outstanding opportunity for Las Vegas because it may benefit hundreds of thousands of tourists that already visit Las Vegas resort spas, who may then decide to come back to Las Vegas in part because they would like to experience another AquaStretch session that is probably not yet available in their home town. In a December 2010 email to a former lieutenant governor of Nevada, the CEO of Nevada’s largest bio-technology consortium said AquaStretch “could really be the cornerstone of health and wellness tourism to Las Vegas.” The purpose of this article is to describe AquaStretch and its potential wellness and medical applications and to describe AquaStretch’s current marketing plans using relatively low cost strategies. Our objective is to provide practical ideas about how to improve the marketing of wellness and medical tourism no matter what the location or service.

AquaStretch: The Opportunity AquaStretch is a significant new wellness program and spa service that immediately and dramatically reduces chronic

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aches and pains, including many idiopathic pain problems not resolved by other modalities. A/S is often much more effective than massage and other forms of bodywork and may last three to four times longer. AquaStretch also helps restore flexibility, relieves pain due to sports injuries and may help enhance recreational sports performance. For example, golfers may drive balls 20 to 30 yards further, and runners may improve their half-marathon times by five minutes. A/S also helps reduce muscle soreness from over-training, both the intensity of that soreness and its speed of recovery, i.e. from 48 hours to 12 hours. This may result in the ability to compress training and in a significant quality of life improvement for serious athletes. The medical tourism value of AquaStretch was summarized in a letter to UNLV’s Vice-President for Student Wellness by the Medical Director of the Nevada Clinic, whose physicians and advanced practitioners have referred over 600 patients to the UNLV AquaStretch Wellness program since it began in January of 2008. Dr. Fuller Royal, also the President of Nevada’s Board

of Homeopathic Medical Examiners for over 25 years, said AquaStretch is a “breakthrough in pain management and preventive medicine.” Royal also said, “The vast majority of these patients have reported immediate and dramatic pain relief, profound relaxation, and/or improvements in sleep and physical functionality.” AquaStretch’s medical tourism potential is also being recognized by physical therapists, after the UNLV Wellness Center staff trained three doctors of physical therapy. Jessica Huss, DPT, recently presented data suggesting A/S was twice as effective (10 degrees per day versus five degrees per day) as land based p.t. procedures to increase flexion in total knee replacement (TKR) patients. Huss’s TKR data also found A/S was subjectively 80 percent less painful. Her further affirmed replicating the significant benefits of AquaStretch for patients with fibromyalgia, scoliosis pain and lower back pain (purportedly due to MRI confirmed disk degeneration) reported by patients at the UNLV Wellness Center. Huss, who has been doing aquatic therapy since 2003, says she now uses AquaStretch 80 percent of the time, and all the traditional aquatic therapy she learned about 20 percent of the time. She is now developing pre-surgical AquaStretch applications that may reduce post surgical pain, improve postsurgical sleep and decrease total rehabilitation time.

What is AquaStretch? AquaStretch is like being stretched by an athletic trainer and is similar to Thai massage, only with movement in three to four feet of water preferably >88° F, and with 2- to 15-pound weights attached to your body. A/S theoretically works by resolving excessive calcifications in your connective tissue (fascial adhesions) that form from improper healing. For example, if you injure your ankle and it needs four weeks to heal properly, many people excessively use that ankle after only a week or two, which results in improper healing, causing a loss of flexibility and/or pain on movement. One of the most important ways in how AquaStretch is unique is that A/S creates significant pain relief and restoration of flexibility immediately. Most clients get 60 percent to 100 percent relief in their first session. In general, if you answer yes to either of the following questions, it is worthwhile for you to try AquaStretch once: 1. Do you have chronic pain more than three months after an injury or surgery? 2. Do pain drugs, chiropractic adjustments, or massage only provide short term relief? The basic AquaStretch Wellness service can be learned in about 12 hours, of which 10 hours is in the pool developing A/S skills, followed by 20 to 30 hours of real client practice. AquaStretch is primarily being taught to massage therapists, athletic trainers, physical therapists and their assistants and aquatic therapists who have “good” hands. The UNLV’s Wellness Center’s “AquaStretch Basics” course has been approved for continuing education credit by the National Certification Board since November of 2008. Similar courses are now being taught by several nationally recognized aquatic therapy instructors who trained at UNLV.

AquaStretch Marketing Summary: We live in a world where everything is advertised or described as the “best” to the point where superlative claims are often ignored even when they may be true. And the AquaStretch process of being stretched in the water does not look or logically sound like it could produce results significantly better than other alternatives. AquaStretch must usually be

experienced for this phenomenal modality to be understood. Therefore, our marketing focus has been to get key people to try AquaStretch once so those people will tell others, using a “First Session Free,” or “First Session Free - Unless it Works” strategy. Word-of-Mouth Marketing: In Las Vegas, many hotel/casino resorts offer extensive concierge services and/or have casino VIP hosts who routinely refer guests to community resources. Until those resorts build their own indoor AquaStretch pools, they may refer people, and even provide limo service, to the non-competing university facility offering A/S. Accordingly, concierge staff and VIP hosts are offered A/S First Session Free. Also in Las Vegas, casino floor personnel, casino dealers, cocktail waitresses, bartenders and limo drivers have frequent guest interactions in which AquaStretch would be exciting to speak about and suggest. And many of these employees have occupationally aggravated back, neck, shoulder and foot pain problems relieved by AquaStretch. These workers are offered A/S First Session Free – Unless it Works. In Las Vegas and other tourist communities, hotel front desk staff and hair stylists who work on tourists and constantly talk to their clients should be considered for First Session Free for their referral potentials. For all these word-of-mouth referrers, it is important to provide a “rack card” or a flyer with the AquaStretch Wellness program information. Online Marketing: Many people decide to take action on an idea after they do online research. Therefore, it is important to have information about the program or service online for them to review, with links to that base information in many other websites. In our case, the AquaStretch Wellness program is described on the UNLV website in the Aquatics section of the UNLV Wellness Center. AquaStretch will also be listed in the Medical Tourism Destination Guide sponsored by the Las Vegas Convention & Visitors Authority. At minimum, we hope to establish links with the State of Nevada Commission on Tourism and the non-profit Southern Nevada Medical Industry Coalition. We’ve also had success in online marketing with MeetUp. com groups because they seem to be attended by people who are highly motivated. We attend or offer free A/S session “meet-ups” to people interested in alternative medicine, fibromyalgia, chronic pain, etc, while focusing on massage therapy meet-up groups. Because of the economic downturn, and because of professional burnout, massage therapists see

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M E DI C A L T OURIS M AquaStretch as a way to supplement their income with their “good hands,” using a modality that is less taxing and equally profitable and is often more effective than table massage work. Massage therapists have also proven to be an excellent source of referrals to AquaStretch. Referrals by massage therapists have resulted in two exceptional opportunities to market AquaStretch. First, two massage therapists working at the Bellagio Hotel who learned of A/S suggested to their Director of Spa Operations that the Bellagio Spa should offer A/S. This recommendation led to our training of 14 Bellagio massage therapists, including both lead massage therapists, and the Bellagio Spa offering AquaStretch as a “World Therapy” in October 2008. A/S training is now done in-house by lead massage therapist Julie Bevel whose A/S spa service focuses on the profound relaxation and meditative qualities of A/S rather than its wellness, fitness or chronic pain reduction properties. Second, another massage therapist we trained working at the J.W. Marriott Las Vegas resort referred its then general manager, Jim Rose, to AquaStretch for a sports injury he sustained as a serious amateur marathon runner. After Rose’s A/S session, he reported complete resolution of his pain and the ability to “run effortlessly.” Rose has since been promoted to be the general manager of the prestigious Marriot Camelback Inn in Phoenix and recently offered to fly us to Arizona and stay at his property so we could demonstrate AquaStretch to a Marriott regional vice-president. Governmental Marketing: In December 2010, former Lt. Gov. Lorraine Hunt (R-NV) formed an ad hoc committee that is now called the SNMIC Nevada Health & Wellness Tourism Task Force. This group met monthly and created an excellent opportunity for many different parties involved in Nevada wellness and medical tourism to interact and become aware of their mutual interests and diverse backgrounds. These meetings included physicians and office managers, physical therapists, program administrators, university staff, hospital marketing heads, governmental agencies and entrepreneurs. One of the most interesting observations of these meetings was how almost completely unaware these parties were of other medical tourism activities. Almost none of them were knowledgeable about the UNLV Wellness Center, let alone its remarkable AquaStretch Wellness program. And we were not aware of the Cleveland Clinic’s Ruvo Brain Center or the internationally known Sher Institute for Reproductive Medicine that already attracts many of its patients from outside Las Vegas. Nor were we aware of outstanding physicians in Las Vegas who actively participate in medical tourism marketing. For example, Ken Osgood, MD, MPH is President of Medical Scientific Resources, an organization that has been providing health screening services at Las Vegas conventions for years. As another example, Mike Crovetti, D.O. created the Coronado Surgical Suites for non-hospital total knee replacement surgery, an environment that, based on data to July, 2011, has not yet had post-surgical infections. Nor were we aware of a facilitator who routinely brings groups of Russian executives to Las Vegas for executive physicals and medical procedures. This person agreed to try AquaStretch after a recommendation to include A/S in his medical services offerings by a Las Vegas CEO he knows, who is a member of the NV Health Tourism committee. The Nevada Health Tourism committee meetings were also attended by directors or senior staff members from several state of Nevada agencies involved in medical tourism. This included

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people from Governor Sandoval’s office, the Director of Operations and Workforce Initiatives for Diversify Nevada and the Nevada Commission on Tourism. The State of Nevada’s interest in health and wellness tourism was not only because of its impact on tourism, but also because the creation of health care jobs is a state priority. For example, it has been estimated that AquaStretch may create over 1,000 high paying jobs. Some of the Health Tourism committee meetings were also attended by a Vice-President of the Las Vegas Convention & Visitors Authority. This individual was instrumental in establishing the LVCVA’s relationship with the Medical Tourism Association and with the publication of the Medical Tourism Destination Guide for Las Vegas. In its efforts to support wellness and medical tourism, we are encouraging the LVCVA to test market the viability of promoting AquaStretch to its conventioneers. The LVCVA may also consider creating promotional literature on Las Vegas wellness and medical services to distribute to conventioneers, as well as having booth space available at some Las Vegas conventions for Las Vegas wellness and medical tourism providers. We are also asking the LVCVA to provide and/or allow a shuttle bus service between the Convention Center and the UNLV Wellness Center located only two miles away, so conventioneers may be able to come for AquaStretch sessions and to take advantage of the Wellness Center’s extensive, state of the art fitness facilities.

AquaStretch is often much more effective than massage and other forms of bodywork and may last three to four times longer. In November 2010, shortly after the elections, the Nevada State Chamber of Commerce, in conjunction with the University of Nevada, Las Vegas, sponsored a “meet the state legislators” conference, in part to present new technology developed at UNLV that was ready for commercial development. At this meeting, AquaStretch was explained one-on-one to over a dozen state assemblymen and several state senators for about five minutes each. After describing A/S’s potential to create over 1,000 new jobs and to stimulate medical tourism to Nevada, each legislator was offered a free A/S session for themselves or anyone on their staff or their loved ones who suffered from chronic pain. We hope that knowledge by governmental agencies and state legislators of AquaStretch and its potential to generate tourism and create health care jobs will lead to support for the inclusion of an AquaStretch Research & Training Center at whatever new sports stadium complex is selected to be built in Las Vegas. The A/S Center would use the stadium’s parking facilities and would create a unique architectural photo opportunity because of the A/S Center’s use of solar power. The A/S Research & Training Center would potentially become the model for an international AquaStretch franchise system. Local Marketing: Many people who live in Las Vegas know people who work in the tourism industry and/or have friends who visit them with problems that may be resolved by AquaStretch. Therefore, we also market AquaStretch locally to three target groups: the university community, local health care providers and the general public. AquaStretch is promoted at the UNLV Wellness Center itself with 8.5-by-11 posters located in several locations, with

one 2’-by-3’ poster adjacent to where A/S is provided and where tour groups are brought to view the pool and in listings of the RebelX flyer that describes exercise, yoga and other fitness classes at the Center. Both the RebelX offerings and AquaStretch Wellness program information are also posted online on the UNLV website.

Most clients get 60 percent to 100 percent relief in their first session.

Easily visible at the Center’s front desk are copies of an AquaStretch Information & Instructions handout available in racks. These handouts are also given out by physicians and advanced practitioners in Student Health Center, also located in the Wellness Center building, to students referred to the AquaStretch Wellness program. UNLV students are given free A/S sessions but may be treated by A/S facilitators in training. In the spring semester of 2011, a campus-wide email campaign was sent in two emails describing the wellness benefits of AquaStretch and offering their first A/S session free to all faculty and staff with a very poor response. Word-ofmouth has proven to be the best method to make the university community aware of AquaStretch, so we assertively ask administrators, staff, faculty, and students who experience A/S to “spread the word” and to encourage their friends and loved ones with pain to “try AquaStretch once.” Based on word-of-mouth referrals, knowledge of AquaStretch spread quickly to the UNLV dance department, where students frequently injure themselves and compulsively continue to rehearse, audition and perform prematurely, causing the fascial adhesions that result from improper healing. This led to a local choreographer, who also taught yoga classes at the Wellness Center, to train as a Wellness Center AquaStretch facilitator. A/S’s reputation spread to the dance professors, who have invited that choreographer and A/S’s creator to speak about AquaStretch for dance injuries at several dance classes. A/S’s reputation in the dance community was further enhanced when a physical therapist from one of the Cirque du Soleil shows in Las Vegas, Luc Fecteau, started bringing eight to 10 Cirque performers to UNLV weekly as part of his A/S training. Luc became aware of AquaStretch after a Wellness Center lifeguard observed his Cirque acrobat wife, Lynn, swimming awkwardly because of a loss in shoulder functionality due to several surgeries. Despite over eight months of extensive physical therapy by Fecteau and others in the Cirque Performance Medicine department, Lynn still had about a 60 percent loss of shoulder mobility. After three AquaStretch sessions, she had only a 10 percent loss remaining, and a month later, she had less than a 2 percent loss. This motivated him to learn A/S, and he has been promoted to Director of Performance Medicine for the new Cirque show in Los Angeles. Over a dozen local physicians (M.D. and D.O.), numerous advanced practitioners (APN, APH - Nursing or Homeopathy, and other health care providers refer patients to the UNLV AquaStretch Wellness program, including staff from the Student Health Center. The first physician to evaluate AquaStretch for its health and wellness potentials was Fuller Royal, M.D, Medical Director of the Nevada Clinic since 1982. Royal was chosen because of his reputation in the state of Nevada as an open-minded, objective physician actively involved in alternative medicine both in his practice and as the President of the Nevada’s Board of Homeopathic Medical Examiners for over 25 years. In August 2007, he watched an AquaStretch session. A few weeks after that demonstration, he accepted our invitation to personally try AquaStretch.

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M E DI C A L T OURIS M Shortly thereafter, Royal suggested AquaStretch to another M.D. in his clinic for his back pains, who did so with great, immediate success. Because of their personal experiences, these two doctors immediately started referring to the AquaStretch Wellness program when it was first offered at the UNLV Wellness Center in January 2008. As a result, the clinic’s nursing and front desk staff and its advanced practitioners were knowledgeable about AquaStretch and were highly motivated to encourage patients to also try AquaStretch, while being able to explain why A/S might benefit those patients from their personal knowledge and experience. The Nevada Clinic continues to refer its patients to the UNLV AquaStretch Wellness program enthusiastically. Royal’s assistance also led to passage by the State of Nevada’s Legislative Council Bureau changes to the Nevada Administrative Code (N.A.C. 630A.014) specifically defining that AquaStretch exercising may also be used as a form of aquatic therapy, legalizing A/S for insurance purposes on December 16, 2008. During Christmas break of 2008, we met for the first time with Sal Biazzo, D.O., the chief physician for the UNLV Student Health Center. After Biazzo personally experienced an A/S session, he routinely started to refer student health center patients in February 2009. Because the Student Health service limits the number of osteopathic manipulative therapy (OMT) sessions a student may receive each year, Biazzo was impressed how A/S served as a soft tissue preparation tool that consistently allowed his OMT to be gentler and yet be more effective and longer lasting.

It has been estimated that AquaStretch may create over 1,000 high paying jobs. A year later in February 2009, Biazzo invited us to speak about AquaStretch to the entire Student Health staff including all their APN. Student Health continues to refer patients for AquaStretch Wellness, especially by those physicians and APN who had A/S. However, the majority of physicians and advanced practitioners who refer patients for AquaStretch Wellness did so because one of their patients told them about A/S. If the doctor, P.A., APN, or APH expressed interest in learning more about the A/S program, we would contact them and offer to meet with them at their office, unless they wanted to experience a “free” AquaStretch session as a professional courtesy. Without exception, those healthcare providers who personally experienced A/S have referred the most patients and patients who more likely had fascial adhesion problems A/S helps relieve. Because the Wellness Center and its pools were closed for construction repairs in the summer of 2011, we had the opportunity to establish an AquaStretch Wellness program at Sun City Anthem, a 7,000 home planned community in Henderson, Nevada. To create word of mouth referrals, we offered free A/S sessions to Anthem residents, Anthem monitors (i.e. the people who work at the front desks of Anthem’s 3 recreational centers), and Anthem fitness staff, as part of their AquaStretch training program. Anthem itself marketed its new AquaStretch service by producing an excellent five-minute television report that

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appeared on the July 11, 2011 edition of their Anthem Alive show that was broadcast repeatedly on their public access cable station. Anthem also announced the availability of AquaStretch and its wellness benefits in the July and August 2011 monthly editions of Anthem’s Spirit Magazine. In the fall of 2011 and spring of 2012, we plan to do more local public marketing after the UNLV Wellness Center reopens. We intend to invite local TV and newspaper health reporters to come experience AquaStretch, so they may write about AquaStretch from personal experience. We also intend to ask writers and editors for What’s On and other magazines published for Las Vegas tourists to try AquaStretch and to recommend the UNLV Wellness Center and AquaStretch as something worthwhile to do in Vegas. We may also investigate the cost and test market 4-by-8.5 rack cards and consider training A/S facilitators to work on cruise ships. Also, after the Wellness Center reopens, we plan to ask individuals involved met via the Health Tourism committee to try AquaStretch.

Insurance Marketing: AquaStretch’s Cost Savings Potential In June 2011, Jonathan Edelheit, President of the Medical Tourism Association, made an excellent presentation to the SNMIC Health and Wellness Tourism Task Force at the Las Vegas Convention Center. One of the most important understandings we acquired from his well-organized program was that some U.S. health insurance companies are legally encouraging and economically supporting their insured patients to use medical tourism as a way to cut health care costs. Medical tourism may allow both the total cost to the insurance company and the insured co-pay to be less – Win/Win. This situation may create an exceptional opportunity to market AquaStretch because of the significant healthcare cost savings routinely reported after A/S. To summarize, postAquaStretch people often report needing fewer office visits, needing fewer prescription drugs, less physical therapy, less osteopathic manipulative therapy (OMT) or chiropractic care and massage less frequently. In Las Vegas, we plan to ask self-insured companies and corporations with existing wellness programs to document and do research on the cost savings generated by an AquaStretch Wellness program. With that data, we may be able to approach insurance companies already supporting health tourism to recommend some of their insured travel to Las Vegas for AquaStretch services, knowing the benefit of this extra-ordinary modality is almost always experienced in the first A/S session. n

About the Author George Eversaul is the creator and developer of the AquaStretch Wellness program at the University of Nevada, Las Vegas Wellness Center, considered a major breakthrough in preventive medicine and fitness training. AquaStretch is an aquatic form of myo-fascial release that is usually more effective than massage and lasts much longer. George teaches “AquaStretch Basics” to massage therapists, approved by the National Certification Board, and “AquaStretch for Fitness Trainers”, approved by the American Council on Exercise, in part because AquaStretch may also improve recreational sports performance.

M E DI C A L T OURIS M

The Medical Tourism

Sandwich ~

Satisfying Patient and Health Provider Demands

By Adrian Myram Medical Tourism is a fast moving and incredibly challenging market place. There are many organizations wishing to jump on the bandwagon and there are many too who are falling off very quickly! Success requires a thorough understanding of ever changing patient demands.

his is no easy ride but a nail biting rollercoaster that even the most experienced and seasoned professionals in our industry struggle with. It is about listening to what the market is saying, reading the trends and then reacting and adjusting your strategy to survive. People entering the business need to be brave and smart. This market has been compared to the Gold Rush. There are lots of people falling over themselves to take a piece of the action with very high and arguably misguided expectations. But beware the fools’ gold! This is still a very immature emerging market and has to be treated with respect and patience.

Medical Tourism Comfort Zones Medical Tourism is a term many use to describe the flow of patients across international borders. Our definition though

is not so simple and black and white. As an organization committed to matching patients to healthcare providers around the world, we have our own insights into the market and what it represents. We believe Medical Tourism is a concept of patients travelling outside their neighborhood but fundamentally within their “Comfort Zone”.

Understanding these ever changing Comfort Zones is critical to keeping up with the market and delivering an effective service for patients and healthcare providers.

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M E DI C A L T OURIS M Understanding these ever changing Comfort Zones is critical to keeping up with the market and delivering an effective service for patients and healthcare providers. We recognize that the comfort zones vary for every single patient. What works for one patient may not for another. Some patients are frequent travelers and will think nothing of jumping on a plane and travelling across the world for surgery. Others will feel completely out of their depth but would be comfortable travelling within their own country. Comfort Zones are like ripples. They are stronger near the source and get weaker and weaker. The further away you travel from your home, the less likely it is you will be prepared to have surgery there. Healthcare providers are all pitching for a piece of the market and if you are trying to reach people on the furthest ripple you need to recognize that the target market is significantly smaller. There are often easier pickings nearer to home and there is still a massive market to explore for Medical Tourism within countries but these can be busy markets forcing people to push the boundaries along the ripples. This is a dangerous game and every provider has to decide which part of the market they want to operate in whilst recognizing that the market changes and it can change very quickly! These Medical Tourism Comfort Zones continually shift and understanding these shifts and reading what influences them is important. Take the US market for instance. In recent years we have seen a general trend that the Comfort Zone for US patients has shifted. There are still plenty of patients prepared to travel across continents but it is fair to say that there is a trend in US patients staying closer to home and travelling only as far as Latin America or staying within US borders. There are many reasons for this – more competitive pricing in the US, improved quality in Latin America hospitals, political unrest elsewhere in the world or general economic instability to name a few.

The accessibility of new cutting edge treatments around the world is also an important part in defining the market. But rather than thinking the end is nigh for Medical Tourism it is simply a case of reading the opportunities. Some markets may shift in one direction, whether on a temporary basis or otherwise, but it is likely that opportunities will arise to compensate. Overall Medical Tourism is undoubtedly a growth market as a whole but you need to understand each individual market. The Comfort Zone for some US patients may have shrunk but Comfort Zones for other patients around the world are expanding for different reasons. Patients from Africa for instance are actively seeking to travel for treatment, as the opportunities may not be available in their own countries. We have adjusted our marketing not just to target familiar US and UK patient markets but also to seek out other patient markets around the world that may be less familiar but are craving to have access to Medical resources around the world.

Healthcare Provider Evolution As an organization working with patients from all over the world and dealing with healthcare providers in over 40 countries we have an enviable position to evaluate the market place. Healthcare providers have to be very targeted in their approach and we have seen many multinational facilitators take radical and necessary steps to change their strategies to react to the market place. Some have decided to move away from traditional procedures such as cosmetic surgery and focus in

September / October 2011

specialist areas such as stem cell therapies. Others have moved away from servicing certain geographic regions and grown their networks closer to home. Others still have moved away from patients groups recognizing that certain patients are more difficult to convert than others! As a lead generator servicing these providers we have worked with healthcare providers to understand the market place and even in our relatively short 3-year history we have evolved significantly and will continue to do so. Reacting to the market place is not just about understanding where patients are travelling to. It is equally about what they are prepared to travel for and why. Healthcare providers need to consider patient behavior as well as competitor behavior. It is a hugely complex world for those involved in Medical Tourism. Prices are changing around the world and it is clear more competitive pricing in the US and UK is having an impact on patients travelling further afield. It is not changing the fact that there is a growing Medical Tourism market but it is changing where patients are travelling to. Quality is also changing around the world and the improvement in quality and the work of accreditation and other bodies to promote this is opening up new markets. The accessibility of new cutting edge treatments around the world is also an important part in defining the market. There will always be centers of excellence whether in the USA or China for example and these will dictate where patients will be prepared to travel to. Healthcare providers are finding innovative ways to keep up with the pace and obtain a competitive advantage. In some cases doctors themselves are travelling to overseas clinics and hospitals and operating there to reduce costs for patients. Many providers are offering consultations for patients in their home countries to give patients assurances before the travel. It is also refreshing to experience that the objectives are not always about making money but also about making affordable healthcare more accessible around the world. This truly is a caring profession and Medical Tourism is now even evolving to doctors travelling to “outreach centers” in Developing Countries to treat groups of people locally that otherwise would not have access to their services.

Finding the Balance We are caught in the sandwich between patients and providers and simply offer a dating service to match the two.

Success for a lead generation company is about finding that balance between what patients want and what healthcare providers want. People want information, they are curious about the Medical Tourism market and they crave information. However, this does not mean they are ready to travel and commit to surgery overseas. Healthcare providers on the other hand want quality patients who are ready to travel. There is large area in the middle full of window shoppers! We act as a filter to separate the wheat from the chaff. We seek to satisfy the patients’ demand for information and ultimately, when they are ready we will introduce them to the most appropriate Healthcare providers that can satisfy their treatment needs. We are evolving away from patients making comparisons based purely on price towards providing information to allow patients to research and make informed decisions about their medical journey. We recognize that this is a difficult and oftencomplex decision for patients and it is not just about price. Price is just one factor and patients need information about quality, waiting times, new treatments and techniques etc. Patients will only be in a position to make a decision when they have fully understood all aspects. Travelling abroad for treatment involves risk and to keep them within their Comfort Zones they need information to help them manage this risk and provide the necessary assurances. Only then will they make a commitment to travel. Understanding patients and their Comfort Zones is one thing. This is just the starting point. Attracting the right patients and giving the healthcare providers the best chances of converting patients is all part of the challenge... n

About the Author Adrian Myram is Chief Operating Officer of AllMedicalTourisem.com and qualified as a Chartered Accountant with KPMG. He has extensive commercial experience across many industries including Medical Tourism. AllMedicalTourism.com is run by a group of Internet marketing experts. After a resounding success in the online travel industry they have brought the same web marketing knowhow to the Medical Tourism industry to help healthcare providers, from hospitals to facilitators, to find the patients they seek. AllMedicalTourism.com was founded on a very simple concept: matching patients seeking care with healthcare providers offering the very services these patients are seeking. It’s simple, and it’s effective. It has grown into a truly international operation with an impressive portfolio of healthcare providers covering a wide range of procedures in over 40 countries and attracting patients from all over the wide. They use highly targeted marketing techniques and a range of marketing channels to locate patients who use the internet to research their healthcare options for specific procedures. These patients are then matched to appropriate healthcare providers who can satisfy their needs on a real time basis. To find out more please visit their website at www. allmedicaltourism.com or join their patient community by searching for AllMedicalTourism on facebook.

We are caught in the sandwich between patients and providers and simply offer a dating service to match the two.

September / October 2011

P R E SS R E L E A S E

MedicalTourism.com Launches New Language Translations in Spanish and Arabic for International Patients West Palm Beach, Florida: September 20, 2011. MedicalTourism. com is the leading internet site rated by Google for Medical Tourism information. The Medical Tourism Association™ has the opportunity to launch a fresh look to the site with more information and user-friendly access for MTA members. The Medical Tourism Association™ has re-launched www. MedicalTourism.com with a whole new look and feel, making it more user friendly with more content and information. Additionally, the website has been translated into both Spanish and Arabic. Renée-Marie Stephano, President of the Medical Tourism Association™ stated, “Many patients from the Middle East and GCC spend billions of dollars every year traveling for healthcare so it was important for us to make sure our patient website was translated into Arabic. Also a large portion of people who speak Spanish also travel for healthcare, so for the MTA these were the two most important languages for us to have working and live on MedicalTourism.com. We are excited to shortly release in the next few weeks the website being launched in Russian, Chinese and then additional languages,” Ms. Stephano added. This will prove to be a game changer for the Medical Tourism Association™ and the industry as a whole, allowing patients who speak certain languages to literally have the healthcare of countries from around the world at their fingertips and to be one of the most extensive international healthcare websites in the world. MedicalTourism.com is a comprehensive internet portal and informational website established for medical tourism; an educational web portal, which includes not only the education of patients, but insurance companies and employers in the Medical Tourism Industry as well. Lisbeth Stein, Membership Coordinator for the Association reports, “MTA members will be receiving a huge benefit with the new launch, and will get exclusive free listings and profiles under country and procedure pages on the website where patients can learn about their hospital or organization and contact them directly. This is a big part of the MTA’s initiative to educate patients and consumers from around the world and to help brand and raise awareness of Medical Tourism Association™ members.”

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Medical Tourism.com allows patients to: • Plan for an international medical procedure • Evaluate the various locations, facilities and specialists who are available for their type of procedure • Learn more about specific countries and facilities • Compare pricing - both for procedures and for the entire travel packages available • Connect hospitals, providers and Medical Tourism Facilitator companies to find the best fit The Medical Tourism Association™ also referred to as Medical Travel Association, is the first membership based international non-profit trade association for the medical tourism and global healthcare industry made up of the top international hospitals, healthcare providers, medical travel facilitators, insurance companies, and other affiliated companies and members with the common goal of promoting the highest level of quality of healthcare to patients in a global environment. Our Association promotes the interests of its healthcare provider and medical tourism facilitator members. The Medical Tourism Association™ has three tenets: Transparency in Quality and Pricing, Communication and Education. n For more information on MedicalTourism.com please go to http://www.MedicalTourism.com or email info@MedicalTourism.com For more information on the Medical Tourism Association™ please go to http://www.MedicalTourismAssociation.com Contact Lisbeth Stein Membership Coordinator US 001.561.791.2000 Lisbeth@MedicalTourismAssociation.com

ÂŠ Copyright Medical Tourism Association

September / October 2011

M T A M E MB E R HOSPITALS Almater Hospital SA de CV Fco. I Madero No 1060 Mexicali, BC Mexico 2110 City: Mexicali, BC Country: Mexico Phone: 686-523-8000 Fax: 686-553-5235 Website: www.almater.com American Hospital Dubai P.O. Box 5566 Dubai - UAE Dubai UAE Phone: 971-4-336 7777 Fax: 971-4-309 6325 Website: www.ahdubai.com Assaf Harofeh Medical Center PO Beer Ya’akov Zerifin 70300 Israel Telephone: 972-8-9779589 Fax: 972-8-9779526 Website: www.assafh.org Bangkok Hospital Medical Center 2 Soi Soonvijai 7, New Petchburi Road Bangkok 10310 City: Bangkok Country: Thailand Phone: (+662) 310 3455 Fax: (+662) 310 3115 Website: http://www.bangkokhospital.com Baptist Hospital South Florida 8940 N. Kendall Drive Suite 601E Miami Florida 33176 City: Florida Country: United States Phone: 7865964643 Fax: 7865963648 Website: www.baptisthealth.net

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Email: international@fvhospital.com International Guide: http://international. fvhospital.com G.M.C Hospital and Research Centre P.O. Box 4184 Ajman, United Arab Emirates City: Ajman Country: United Arab Emirates Phone: 97167463333 Fax: 9716746444 Website: www.gmchospital.com

City: Mexico City Country: Mexico Phone: 52 55 5424 6896 Website: http://www. medicaltourismmexico.com.mx Moolchand Healthcare Group Lajpat Nagar III New Delhi, 110024 India Telephone: 911142000000 Website: www.moolchandhealthcare.com

HCA East Florida Division 450 Las Olas Blvd. Fort Lauderdale, FL 33301 City: Fort Lauderdale Country: United States Phone: 954-767-5722 Fax: 954-767-5793 Website: www.saludinternacional.com

Narayana Hrudayalaya NO 258/A Bommasandra Industrial Area, Anekal Taluk Bangalore, Karnataka 560099 India Telephone: 080-27835000 Fax: 080-27835207 Website: www.narayanahospitals.com

Hospital Alemao Oswaldo Cruz Rua Jooo Juliao, 331 Paraiso Sao Paulo, 01323 903 Brazil Telephone: 5511 3549 1000 Fax: 5511 3287 8177 Website: www.hospitalalemao.org.br

Prince Court Medical Centre Sdn. Bhd 39, Jalan Kia Peng Kuala Lumpur 50450 Malaysia Telephone: +603 21600000 Fax: +603 21600110 Website: www.princecourt.com

Hospital Clinica Biblica Calle Central y Primera Avenidas 14y16 San Jose, Costa Rica 1037-1000 Toll Free: 1-800-503-5358 Telephone: 506-522-1414 Fax: 506-257-7307 Website: www.hcbinternational.com

Seoul Wooridul Spine Hospital 47-4 Chungdam-dong, Gangnam-gu Seoul 135-100 Korea Telephone: +82-2-513-8157 / 8385 Fax: +82-2-513-8386 / 8454 Website: www.wooridul.com

Hospital Punta Pacifica Boulevard Pacifica and Via Punta Darien, Panama City 0831-01593, Panama Telephone: (507) 204-8024 Fax: (507) 204-8010 Website: www.hospitalpuntapacifica.com

SevenHills Hospital Marol Maroshi Road Andheri East Mumbai Maharashtra 400059 City: Mumbai Country: India Phone: 00912267676767 Fax: 00912229250043 Website: www.sevenhillshospital.com

Beijing United Hospitals & Clinics #2 Jiang Tai Road, Chaoyang District Beijing, 100015 PRC Beijing, China Phone: 59277085 Fax: 59277200 Website: www.ufh.com.cn

Istishari Hospital 44 Alkindi Street Amman, 11190 City: Amman Country: Jordan Phone: 96265001000 Website: http://istisharihospital.com/

Severence Hospital Yonsei University Health System 250 Seongsanno, Seodaemun-gu Seoul, Republic of Korea 120-752 Telephone: +82-2-2228-1482 Fax: +82-2-363-0396 Website: www.yuhs.or.kr/en/

Conclina C.A. Hospital Metropolitano Avenida Mariana De Jesus S/N y Nicolas Arteta Quito Pichincha Ecuador City: Quito Country: Ecuador Phone: 593 2 3998000 Fax: 593 2 2269247 Website: www.hospitalmetropolitano.org

Jackson Memorial Hospital International 1500 NW 12th Avenue Suite 829 Miami, Florida 33136 City: Miami Country: United States Phone: 305-355-5544 Fax: 305-355-5545 Website: http://www.jmhi.org

Shuang Ho Hospital 291 Jhongjheng Rd. Jhonghe City, Taipei County 235 Taiwan City: Jhonghe City Country: Taiwan Phone: 886-2-2249-0088 X8807 Fax: 886-2-2248-0900 Website: http://shh.tmu.edu.tw/

Jordan Hospital Queen Noor Street Amman 11190 Jordan Telephone: +962 6560 8080 Fax: +962 6560 7575 Website: www.jordan-hospital.com

Taipei Medical University Hospital 252 Wuxing Street, Taipei 11031, Taiwan Tel: +886-2-2737-2181 ext. 3336 Fax: +886-2-2737-4257 Email: ipc@tmuh.org.tw Website: www.tmuh.org.tw

Doctors Hospital #1 Collins Avenue P.O. Box N-3018 Nassau, Bahamas Telephone: 242-302-4600 Fax: 242-323-4801 Website: www.doctorshosp.com FV Hospital - Far East Medical Vietnam Limited 6 Nguyen Luong Bang, Saigon South (Phu My Hung) District 7, Ho Chi Minh City VIETNAM Telephone: (84-8) 411-3333 Fax: (84-8) 411-3334 Website: www.fvhospital.com International Patient Services Telephone: (84-8) 411-3420

Medanta- The Medicity Sector 38 Gurgaon, Haryana 122001 India Telephone: 911244141414 Fax: 911244834111 Website: www.medanta.org

Taipei Medical University Wan Fang Hospital 111 Section 3, Hsing-Long Rd., Taipei 116, Taiwan Tel: +886-2-2930-7930 ext. 7766 Fax: +886-2-8662-1135 Email: ims@wanfang.gov.tw Website: www.taiwanhealthcare.com

Medica Sur S.A.B. de C.V Puente de Piedra #150 Col. Toriello Guerra Del Tlalpan Mexico City, Mexico 14050

Taipei Medical University Shuang Ho Hospital 291 Jhongjheng Rd., Jhonghe City, Taipei County 235, Taiwan

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Tel: +886-2-2249-0088 ext. 8807 Fax: +886-2-2248-0900 Email: tmushh@shh.org.tw Website: http://eng.shh.org.tw The Nairobi Hospital P.O. Box 30026 Nairobi, 00100 Kenya Telephone: 254 020 2846001 Fax: 254 020 2728003 Website: www.nairobihospital.org The Specialty Hospital P.O. Box 930186 Amman, 11193 Jordan City: Amman Country: Jordan Phone: 00962-6-5001111 Fax: 00962-6-5697425 Website: www.specialty-hospital.com SPECIALTY, COSMETIC, & DENTAL CLINICS Aestheticup Clinica Robles/ Aestheticup Dental House Virrey del Pino 2530 Ciudad Autonoma de Buenos Aires Buenos Aires, Argentina Phone: 1-866-816-9971 Fax: 541147860560 Website: www.aestheticup.com Barbados Fertility Centre Inc. Seaston House, Hastings Christ Church Barbados Telephone: 246-435-7467 Fax: 246-436-7467 Website: www.barbadosivf.org Cancun Cosmetic Dentistry Las Americas Shopping Mall, Store 215 Cancun 77500 Quintana Roo, Mexico Telephone: 998 106 8106 Website: www.cancuncosmeticdentistry.com Clinica Jose A. Rivas S.A. Avenida Carrera 19 #100-88 Bogota, Colombia Telephone: (571)616-3077 Fax: (571)257-8304 Website: www.clinicarivas.com Dental Polyclinic Dr. Hodzic & Center for Regenerative Medicine “MEDENT” 18, Istria Street Rovinj, 52210 Croatia Telephone: +385 52 842 500 Fax: +385 52 842 501 Website: www.poliklinika-dr-hodzic.com Regenerative Medicine Institute, Mexico Av Paseo De Los Heroes, # 10999-501 Tijuana, BC Mexico 22010 City: Tijuana Country: Mexico Phone: (619) 421-0700 Fax: 888-557-2797 Website: www.regenerativemedicine.mx Instituto Bariatrico Dr. Betances C/Rafael A. Sanchez, Ed. Medicalnet Suite 405, Ens. Piantini Santo Domingo, Dominican Republic City: Santo Domingo Country: Dominican Republic Phone: 8097329400 Fax: 8095407070 Website: www.bariatrica.com

Integra Medical Center Juarez 239 Nuo Progreso, Tamqulipas 88810 Mexico Telephone: 899-937-0260 Website: www.integramedicalcenter.com International Orthopedic Group Badia Hand to Shoulder Center 3650 N.W. 82nd Avenue, Suite 103 Doral, Florida 33166 United States Phone: 3052274263 Fax: 3055377222 Website: www.drbadia.com Lorenzana Dental Center Pasaje Sagrado Corazon 826 San Salvador, San Salvador El Salvador Telephone: (503) 2263-4572 Facsimile: (503) 2263-4575 Website: www.doctorlorenzana.com Prudent Hungary Dental Clinic 16 Lucsony Street Mosonmagyarouar , 9200 Hungary Phone: 36202199457 Website: www.prudenthungary.com Rehab in Mexico Ave. Alfonso Reyes 143 Norte, Colonia Regina Monterrey, Nuevo Leon Mexico Telephone: 52 81 8331 0911 Fax: 52 81 8331 0911 ext 1004 Website: www.rehabinmexico.com San Patricio MRI & CT Center 280 Marginal Kennedy Guaynabo, Puerto Rico 00968 Phone: 787-620-5757 Fax: 787-620-5761 Website: www.sanpatriciomrict.com The Catholic University of Korea Yeson Voice Center The Institute of Performing Art Medicine Hyung-Tae Kim, MD, PhD 638-13 Ssanbong Build. 2nd Fl. Shinsadong, Gangnamgu Seoul, 135-896, South Korea Telephone:82-2-3444-0550 Fax: 82-2-3443-2621 Website: www.yesonvc.com Wintergreen Center for Rehabilitation AB Kyrkovage 13 Nykroppa 680 90 Sweden Telephone: 004659041888 Fax: 004659041889 Website: www.wintergreen.se MEDICAL TOURISM FACILITATORS Ageless Wonders Panama / Panama Medical Tourism Your Premium Health & Wellness Specialists 73rd street San Francisco, Palma Real Bldg., No. 12A Panama City, Republic of Panama US (224) 353-7701 Tel (507) 396-1640 support@panamamedicaltourism.com edeycaza@panamamedicaltourism.com http://www.agelesswonders-pma.com/

Angels Global Healthcare 10-799 O’Brien Drive Peterborough Ontario K9J 6X7 City: Ontario Country: Canada Phone: 7057435433 Fax: 7057415147 Website: www.angelsglobalhealthcare.com BYZAlliance Medical Travel & Medical Consulting Hakkiyeten Caddesi. Unimed Center No: 8/10 34349 Fulya - Istanbul Turkey Telephone: 90 212 240 82 99 Fax: 90 212 231 39 56 Website: www.byzalliance.com Cambria Healthcare Inc. 18101 Point Dookout Dr. Suite 139 Houston, 77058 United States Telephone:1-469-323-6119 Facsimile: 1-972-841-4856 Website:: www.CambriaHealthcare.com Catalunya Turisme Passeig de Gracia 105-3a-08008 Barcelona, Spain City: Barcelona Country: Spain Phone: 34934849900 Fax: 34934849888 Website: www.catalunyaturisme.com China Health Today 3551 19th Avenue SW Naples, Florida 34117 City: Naples Country: USA Phone: 866-768-1631 Fax: 239-244-8375 Website: www.chinahealthtoday.com Debson Medical Tourism 1200 McGill College Avenue Suite 1100 Montreal QC H3B 4G7 Telephone:1-877-900-DEBS(3327) Website: www.debsonmedicaltourism.com Diversified Surgical Management, LP 1015 North Carroll, #2000 Dallas, Texas 75204 City: Dallas Country: USA Phone: 214-843-0830 Fax: 214-853-4644 Website: http://www.dsmglobal.com/ Global Health Israel (GHI) 32 Shaham St., P.O. Box 7790 Petah-Tikva Israel Telephone: 972 3 9232202 Fax: 972 3 9229750 Website: www.globalhealthisrael.com Global Health Travel Cassandra Italia 80A O’Shannassy Street Sunbury, VIC 3429 Australia Telephone: +613-9744-5872 Fax: +613-9740-4243 Website: www.globalhealthtravel.com.au Green4Care 24 Rue Louis Blanc Paris, France 75010 City: Paris Country: France Fax: 01.55.26.94.95 Website: www.mymedicaltreatmentabroad.com

Health Travel Guides 600 Townsend Street, Suite 120e San Francisco, CA 94103 City: California Country: United States Phone: 415-412-4811 Website: www.healthtravelguides.com KONGRESIST Travel Inc. Cumhuriyet Cad. No. 179 D. 15, Harbiye Istanbul, 34373 City: Istanbul Country: Turkey Phone: 902122312772 Website: www.kongresist.com Max Global Consulting Services House # 220, Street Charay Hesa Doham-eKartiparwan Kabul Afghanistan Telephone: +93 706 272 491 Med2Heal OHG Warschauer Strube 5 Frankfurt, Hesse Germany 60327 City: Frankfurt Country: Germany Phone: 49.69677.01438 Fax: 49.69207.36469 Website: www.med2heal.com Medical Retreat Abroad, LLC 6146 Whiskey Creek Drive Suite 723 Fort Myers, FL 33919 City: Fort Myers Country: United States Phone: 800-460-4166 Website: www.medicalretreatabroad.com Medical Services of Costa Rica Hacienda Los Reyes, casa 241 primera etapa, La Guacima, Alajuela Costa Rica Telephone: 00506 22203596 Fax: 00506 22203596 Website: www.medicalservicesofcostarica.com Medical Tour Experts, Inc. 8379 W. Sunset Road Suite 105 Las Vegas, NV 89113-2204 City: Las Vegas Country: United States Phone: 1-702-650-0011 Fax: 702-650-2292 Website: www.mte101.com MedicalTour International Co. Ltd. 2-3-9 Sawamura Matsumoto, Nagano 390-0877 Japan Telephone: 81263882810 Fax: 81263882322 Website: www.medical-tour.jp Medical Tourism Co, LLC 7000 Independence Parkway, Suite 160, PMN 149 Plano, Texas 75025-5741 USA Telephone: 972-814-1614 Fax: 1-800-661-2126 Website: http://www.medicaltourismco.com Medical Travel Riga Maza Nometnu Street 10-1 Riga LV1002 Latvia Phone: 37128652969 Website: www.medicaltravelriga.com Medical Treatments Management 340 South Lemon Avenue #7012 Los Angeles, Ca. 91789 City: Los Angeles, Ca

Country: USA Phone: 1-800-870-6059 Website: mtmweb.biz Med Tour Pal - Astute Management Consultancy Private Ltd. A-204, Raj Darshan, Dada Patil Wadi, Naupada, Thane (West), Mumbai, Maharashtra India 400602 City: Mumbai Country: India Phone: 02225420304 Website: http://medtourpal.com/ Mediline Ahi Evren Cad.,Ata Penter, No 1, Kat G2 Maslak, Istanbul 34398 Turkey Phone: 905304035251 Website: www.medilineus.com Medpro Bavaria GmbH Falkenbach 75 Freyung 94078 City: Freyung Country: Germany Phone: 498551913528 Fax: 498551913456 Website: www.medprobavaria.com Med Tours Latinamerica 9a Avenue Sur + 12 C.Ote. 22A Colonia Utila Santa Tecla, La Libertad El Salvador, Central America City: Santa Tecla, La Libertad Country: El Salvador Central America Phone: 503-2229-3000 Website: www.labcofasa.com Medtral New Zealand Mercy Specialist Center 100 Mountain Road Epsom Auckland 1149 City: Auckland Country: New Zealand Phone: 64 9 623 6588 Fax: 64 9 623 6587 Website: http://www.medtral.com MedTravel Ecuador Av. de los Shyris 2811 e Isla Floreana Quito, Ecuador City: Quito Country: Ecuador Phone: 593-2 2433307 Fax: 593-2 2445364 Website: www.medtravelecuador.com MedVoy Inc. 1917 King Street Denver Colorado 80204 USA Telephone:720-771-6760 Facsimile: +1-866-254-0108 Website: www.medvoy.com Nirmal Hospitalities Siddanth Villa, Plot No 54157, Rsc 13, Goral II 480092 Mumbai,Maharastr India City: Mumbai Country: India Phone: 91 098 333 70334 Fax: 91 22 28693823 Website: www.nirmalhospitalities.com Pan American Dental Tours 30 Raymond Road North Salem, NY 10560 United States of America Telephone: 914-485-1026 Fax: 206-984-1889 www.panamdentaltours.com

September / October 2011

M T A M E MB E R Spain Medical Services c/ Menorca, 2 bl. 6-1A Las Rozas, Madrid 28230 City: Madrid Country: Spain Phone: 34693902182 Website: www.spainmedicalservices.com SPA-MED-HOLIDAY Cecile Billiet Edificio Reforma Obelisco, St. 1106 Av Reforma 15-54, Z9 Guatemala City 01009 Guatemala Telephone: 00 502 2332 4648 / 00 502 593 79 438 Skype: spa.med.holiday Website: www.spa-med-holiday.com Surgical Trip, LLC Thomas O’Hara 7491 North Federal Highway, Suite C-5, #293 Boca Raton, FL 33487 Telephone: (800)513-8996 Website: www.SurgicalTrip.com Transmed Tourism LLC 7629 Wynndel Way Elk Grove, 95758 Country: United States Phone: 916-752-5539 Fax: 916-647-4876 Website: http://www.transmedtourism.com URUHEALTH (Health and Tourism in Uruguay) Dr. Marcelo Rodriguez Av. Ricaldoni 2452 Montevideo 11600 Uruguay Telephone: (+598) 27114444 Fax: (+598) 27114444 Website: http://www.uruhealth.com Veiovis 93 S. Jackson St. #28310 Seattle, WA 98104-2818 USA Telephone: (671) 646-6012 Wbsite: www.veiovis.com Veiovis Country: Philippines Website: www.veiovis.com Veiovis Country: Guam Website: www.veiovis.com Vung Tau Tourist Sanatorium Medicoast Nguyen Thi Mai 165 Thuy Van St. Thang Tam Ward Vung Tau City, Viet Nam Telephone: 84.64.853857 or 64.510756 Fax: 84.64.852395 Website: www.medicoast.com.au

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Las Vegas Convention & Visitors Authority 3150 Paradise Road Las Vegas, NV USA 89109 City: Las Vegas Country: USA Phone: 702 892 0711 Website: www.lvcva.com Travel World International, Ltd. Plot 3 Kimathi Avenue Uganda Pan Africa Hse PO Box 37017 Kampala, Uganda City: Kampala Country: Uganda Phone: 256312261990 Website: wwwtravelugandasafaris.com Well-Being Travel Anne Marie Moebes 71 Audrey Avenue Oyster Bay, NY 11771 United States of America Telephone: (516) 624-0500 X2312 Fax: (516) 624-6024 Website: www.travelsavers.com GOVERNMENT/ HEALTHCARE CLUSTER Cluster Servicios de Medicina y Odontologia - Medical and Dental Services Cluster Calle 41 No. 55-80 Plaza Mayor- Entrada Norte-Piso 3 City: Medellin Country: Colombia Phone: 57 4 261 36 00, ext. 112 Fax: 57 4 513 77 57 Website: www.medellinhealthcity.com

Programa Disfruta Salud Peru Avda. Republica de Panama San Isidro, Lima 3647 Peru Telephone: 511 222 1222 Website: www.peruhealth.org Sugery Facilities Resources PO Box 9500 Gurnee, IL 60031 Country: United States Phone: 847-775-1970 Fax: 847-775-1985 Website: http://www. surgeryfacilitiesresources.com Taiwan External Trade Development Council 10th Floor 333 Keelung Rd. Sec 1 Taipei, Taiwan 11012 City: Taipei Country: Taiwan Phone: 886 2 2725 5200 X 1934 Fax: 886 2 2757 7261 Website: http://www.taitra.org.tw INDUSTRY ASSOCIATIONS & CHAMBERS AAAHC International - Accreditation Association for Ambulatory Healthcare 5250 Old Orchard Road Suite 200 Skokie, IL 60077 USA Telephone: 8478536089 Fax: 8478539028 Website: www.aaahc.org CORPORATE MEMBERS CORPORATE GOLD MEMBERS

Health & Wellness Tourism Commission, Agexport 15 Ave. 14-72, zona 13 Guatemala City 01013 Guatemala Telephone: 00 502 2422-3400 ext 3418 Fax: 00 502 2422-3400 Websites: www.healthwellnessguatemala.com www.export.com.gt

Cardiac Care Europe a program by Clinical Liaison Sourcing AG 16 Oberallmendstrasse, CH-6203 Zug, Switzerland City: Zug Country: Switzerland Phone: 41417660320 Website: www.cardiaccareeurope.com

Korea International Medical Association 57-1 Noryangjin-dong, Dongjak-gu Seoul 156-800 Republic of Korea Telephone: +82-2-2194-7250 Fax: +82-2-2194-7380 Website: www.healthtour.co.kr

Doctors Hospital #1 Collins Avenue P.O. Box N-3018 Nassau, Bahamas Telephone: 242-302-4600 Fax: 242-323-4801 Website: www.doctorshosp.com

Medellín Cluster Servicios de Medicina y Odontología Medical and Dental Services Cluster 41 N 55-80 Plaza Mayor - Entrada Norte -- Piso 3 Medellin, Colombia 0000 Telephone: 57 4 261 3600 ext. 112 Fax: 57 4 513 77 57 Website: www.medellinhealthcity.com

Equals3 Limited The Custom House EX 31 IEU Barnstaple, Devon United Kingdom Telephone: 44 845 056 8432 Fax: 44 845 056 8432 Website: www.equals3.co.uk

Asic Travel 08 Ramo Buildings, Elhay Elmotamaiez, 06th of October, Egypt Phone: 20238379858 Fax: 20238379857 Website: www.asictravel.com

Plataforma Turistica de Madrid Plaza de la Independencia,6, Planta 3 Madrid 28001 Spain Telephone: +34912767235 Fax: +34912767223 Website: www.madridnetwork.org/turismo

“Golden Health” Health Care Services Company “Golden Health” Health Care Services Company P.O. Box No. 5351 Abu Dhabi UAE City: Abu Dhabi Country: United Arab Emirates Website: www.goldenhealth.ae

Celebrity Transportation Services, Inc. 220 SW 9th Avenue #204 Hallandale, Fl 33009 City: Hallandale, Florida Country: USA Phone: 954-328-6653 Website: www.ctsmiamilimo.com

Porto Alegre Healthcare Cluster Travessa do Carmo St. 84 Rio Grande do Sul (RS) Porto Alegre 90050-210 Brazil Phone: 555132896717 Website: www.portoalegrehealthcare.org

Konesens Research 389 Palm Coast Parkway SW, Ste. 4 Palm Coast, FL 32137 USA Telephone:1-866-533-9808 Fax: 1-888-533-4883 Website: www.konesens.com

TRAVEL AGENCIES & HOSPITALITY

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Narayana Hrudayalaya NO 258/A Bommasandra Industrial Area, Anekal Taluk Bangalore, Karnataka 560099 India Telephone: 080-27835000 Fax: 080-27835207 Website: www.narayanahospitals.com SurgeryOverseas.com London United Kingdom Telephone: +44 845 056 8432 Website: surgeryoverseas.com The Nairobi Hospital P.O. Box 30026 Nairobi, 00100 Kenya Telephone: 254 020 2846001 Fax: 254 020 2728003 Website: www.nairobihospital.org CORPORATE MEMBERS AB Complete Medi-Tour LLC 1060 S. Japlin Way Aurora, CO 80017 USA Telephone: 720-529-8474 Fax: 720-748-1047 Advanced Practice Nurse International 1455 Pennslyvania Avenue NW, Suite 400 Washington DC, 20004 United States Phone: 202-351-6835 Website: www.APNurseInternational.com Advatech Healthcare PVT. Ltd. 302 Mayfair Swarnadeep, 323 Purbalok Kolkata, West Bengal India 20099 City: Kolkata, West Bengal Country: India Phone: +9193397668653 Website: http://www.advatechhealth.com AllMedicalTourism.com 70A, Club Street, 069 443 Singapore Telephone: +44 (0) 845 057 4039 Fax: +44 (0) 845 057 4039 Website: www.AllMedicalTourism.com Altera Health, Inc. 4 Coachman Court East Brunswick, New Jersey 08816 USA Telephone: 917-699-6300 AIMIS Spine (American Institute of Minimal Invasive Spine Surgery) Kolonakiou Ave 25, Zavos Kolonakiou Center, Block A, Suite 201 Limassol, Cyprus City: Limmassol Country: Cyprus Phone: 00357 25 873 387 Fax: 00357 25 320 370 Website: www.aimisspine.com ASISER (Asisa Servicios Integrales De Salud, S.A.U) Av. Manoteras 24, 2nd Floor Madrid 28050 Spain Telephone: 34917329666 Fax: 34917329769 Website: www.asiser.es

Cape Health Destination PO BOX 29, By-Den Weg Vlottenburg, 7604 Western Cape, South Africa Telephone: 0027-21-8813603 Website: www.capehealth.co.za

Cosmas Health, LLC 3619 South Avenue Springfield, MO 65807 USA Telephone: 417-894-3359 Website: www.cosmashealth.com

Cardiac Care Europe a program by Clinical Liaison Sourcing AG 16 Oberallmendstrasse, CH-6203 Zug, Switzerland Phone: 41417660320 Website: www.cardiaccareeurope.com

Costamed Clinics Calle Primera Sur No 101 Cozumel, Mexico 77600 Telephone: (987)872-9400 Fax: (987)872-9400 Website: www.costamed.com.mx

Caribbean Health Travel Magazine c/ natail a sanchez No. 45 Santo Domingo, Republica Domnicana Phone: 8097329400 Website: www.chtmagazine.com Carpatia Group Pm 2 Burebista, BID14, SC 3, 4th Fl, Apt. 79-80 Bucharest 031108 Romania Telephone: +40213228308 Fax: +40213228459 Website: www.carpatiagroup.com Catalunya Turisme Passeig de Gracia, 105-3a Barcelona, 08008 Spain Telephone: 34 934 849 900 Fax: 34 934 849 888 Website: www.catalunyaturisme.com China Health Today. 3551 19th Avenue SW Naples, Florida 34117 City: Naples Country: USA Phone: 866-768-1631 Fax: 239-244-8375 Website: www.chinahealthtoday.com Circana Health Passport 8400 NW 33rd St Suite 300 Miami, Florida 33122 City: Miami Country: USA Phone: 866-512-2583 Fax: 305-437-7406 Website: http://www.circana.com Clements International 1 Thomas Circle NW, 8th Floor, Washington, DC 20005 USA Telephone: 202-872-0060 Fax: 202-466-9064 Website: www.clements.com CMN 150 Commerce Valley Drive West, 9th Floor Thornhill, ON L3T 7Z3 Canada Telephone: 905-669-4333 Fax: 905-669-2221 Website: www.cmn-global.com Commission of Graduates of Foreign Nursing Schools International 3600 Market St., Suite 400 Philadelphia, PA 19104-2651 USA Telephone: 215-222-8454 Fax: 215-495-0277 Website: www.cgfns.org

Costa Rica Medical Tourism Inc 7013 South Tamiami Trail Suite A Sarasota, Fl 34231 City: Sarasota, Florida Country: USA Phone: 941-388-7552 Fax: 941-388-7523 Website: http://www.costaricamts.com Debson-ITS 466 Strathrona Westmount Quebec H342x1 Canada Telephone: 1-888-933-2ITS(487) Website: www.debsonits.com

Florida Med-Retreat 1303 N. Tamiami Trail Sarasota, Florida 34236 City: Florida Country: United States of America Phone: 9419536949 Fax: 9419536867 Website: www.floridamedretreat.com Free Health, LLC. Telephone: 561-792-4418 Fax: 561-792-4428 Website: www.freehealth.com Gallup 111 South Wacker Suite 4850 Chicago IL 60603 USA Telephone: 312-288-2432 Fax: 312-357-0856 Website: www.gallup.com Global Benefit Options 10 Park Avenue, PO Box 25 Caldwell, NJ 07006 USA Telephone: 201-433-2222 Fax: 973-226-7774 Website: www.globalbenefitoptions.com

DentalCareBudapest.com 190. Szabadsag Street 2040 Budaors Hungary Telephone: 36 30 333 8888 Website: www.dentalcarebudapest.com

Global Care Medical, Ltd. Zabotinsky 53 Ramat Gan, Israel City: Ramat Gan Country: Israel Phone: 00972-73-7888050 Website: www.gcmed.com

Dentalight LLC 711 Bald Hills Road North Round Top, New York 12473 USA Telephone: 518-250-2550 Fax: 208-955-6187 Website: www.dentalightimplants.com

Global Healthcare Alliance 617 North Magnolia Ave Orlando, FL 32801 USA Telephone: 407-330-2515 Fax: 775-269-6424

Diversified Surgical Management, LP 1015 North Carroll, #2000 Dallas, Texas 75204 USA Telephone: 214-843-0830 Fax: 214-853-4644

Global Healthcare Concierge LTD PO Box 2277 Sag Harbor, NY 11963 USA Phone: 631-532-1868 Fax: 631-204-6667 Website: www.globalhealthcareconcierge.com

El Salvador Medical Vipsal 1224 PO Box 025364 Miami FL 33102 City: El Salvador Country: El Salvador Phone: 503 226 34572 e-Medsol Pvt Ltd 34/1121 A, 129 BMRA Balakrishna Menon Road Cochin 682025 India Telephone: 091-484-3250706, 9846170036 Website: www.emedsol.biz Executive Education Programs UCLA 10960 Wilshire Boulevard, Suite 1550 Los Angeles, California 90024 USA Telephone: 310 267 5600 Fax: 310 312 1711 Website: http://emph.ucla.edu Fairmont Specialty 5 Christopher Way Eatontown 07724 USA Telephone: 732-676-9886 Fax: 732-542-4082

ÂŠ Copyright Medical Tourism Association

Global Health, Inc. 3214 Charles B. Root Wynd, Suite 213 Raleigh, North Carolina 27612 USA Telephone: 919-251-8605 Fax: 919-781-8782 Website: www.globalhealthinc.org Global Health Solutions, LLC 358 West Lake Drive Edwardsville, IL 62025 USA Telephone: 618-444-1552 Global Surgery Providers, Inc. 284 South Main Street Suite 1000 Alpharetta, Georgia 30188 USA Telephone: 877-866-8558 Website: www.globalsurgerynetwork.com Green4Care 24 Rue Louis Blanc Paris, France 75010 City: Paris Country: France Fax: 01.55.26.94.95 Website: http://www.green4care.org

Goodness Company - Medical Tourism Marketing 820 Baker Street Wisconsin Rapids, WI 54494 City: Wisconsin Rapids Country: USA Phone: 715-254-0711 Website: www.goodnesscompany.com Hayes, Inc. 157 S. Broad Street Lansdale, PA 19446 USA Telephone: 215-855-0615 Fax: 215-855-5218 Website: www.hayesinc.com Healthcare in Flight 2218 Minsky Place Lilily, oshawa, Ontario Canada City: Ontario Country: Canada Phone: 855-879-4325 Health Links International 11435 Drummond Court Dallas, TX 75228 USA Telephone: 214-564-7341 U.S. Fax: 888-235-0208 International Fax: 425-974-7902 Website: www.healthlinksintl.com Health Travel Guides 600 Townsend Street, Suite 120e San Francisco, CA 94103 City: California Country: United States Phone: 415-412-4811 Website: http://www.healthtravelguides.com HLV Health N Heal Pvt. Ltd. K-13 A Green Park Extn India 110016 City: New Delhi Country: India Phone: 911126180125 Fax: 911126180129 Website: www.healthnheal.com HOK 60 East Van Buren 14th Floor Chicago IL 60605 City: Chicago Country: United States Phone: 3144212000 Fax: 3127826727 Website: www.hok.com Homewatch CareGivers 7100E. Belleview Ave., Suite 303 Greenwood Village, CO 80111 USA Telephone: 303-758-5111 Fax: 303-758-1724 Website: www.homewatchcaregivers.com Hospital Scout Betenstr, 13-15 Dortmund 44137 Dortmund, Germany Phone: 492319144880 Fax: 4923191448888 Website: www.hospitalscout.com International Board of Medicine and Surgery P.O. Box 6009 Palm Harbor, FL 34684 USA Telephone: 813-966-1431 Fax: 813-925-1932

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M T A M E MB E R International Healthcare by Design 40 Annesley Ave Toronto, Ontario M462T7 Canada Telephone: 416-696-0000 Fax: 416-696-0011 Invest Barbados Trident Financial Center Hastings, Christ Church Barbados, BB15156 Telephone: 246-626-2000 Fax: 246-626-2097 Website: www.investbarbados.org Istishari Hospital 44 Alkindi Street Amman, 11184 City: Amman Country: Jordan Phone: 96265001000 Fax: 96265698833 Website: http://www.istisharihospital.com/ Kahler Grand Hotel 20 SW Second Ave Rochester, Minnesota 55906 USA Telephone: 507-280-6200 Fax: 507-285-2586 Website: www.kahler.com Medi Czech Lazarska 13/8 Prague Czech Republic 12000 City: Prague Country: Czech Republic Phone: 420 222 542949 Website: http://www.mediczech.com MedicalTourism.com SJO 6767, 2011 NW, 79th Avenue, Doral Miami FL 33122 USA Telephone: 305-600-5763 Fax: 305-397-2893 Website: www.medicaltourism.com Medical Tour Experts, Inc. 340 South Lemon Avenue #7012 Los Angeles, Ca. 91789 USA Phone: 1-800-870-6059 Website: mtmweb.biz Medical Tourism Hungary, Ltd Kengyel Szentendre Hungary 2000 City: Szentendre Country: Hungary Phone: 3670 9454366 Medical Tourism Services Poland Przeslawice 83 Koniusza, Poland 32-104 City: Koniusza Country: Poland Phone: 48600963866 Website: www.medical-services-poland.com Medical Treatments Management 5940 S. Rainbow Blvd. Ste. 1001 Las Vegas, NV. 89118 United States Phone: 1-866-206-4174 Fax: 702-650-2292 Website: www.mte101.com Medichol PTY LTD. 443 The Panorama Gold Coast, QLD Australia 4213

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D I R E C T ORY

Phone: +61 438 932 753 Fax: +61 7 5525 3654 Website: www.medichol.com Medilink (Thailand) Co., Ltd. 404 Phaholyothin Road Samsaennai, Phayathai, Bangkok Thailand 10400 City: Bangkok Country: Thailand Phone: +662 619 2222 Fax: +662 619 2209 Website: www.medilink.co.th MediNav International Pty. Ltd. 18 St Vincents Crt Minyana QLD Australia 4575 City: Minyama Country: Australia Phone: 61 408715697 Website: www.medinavinternational.com Medipassion Healing Inc. 33 Place Des Outaouais L’ile Perrot, QC J7V8K7 Canada Telephone: 514-577 7451 Fax: 1-800-410-0279 MedPro Bavaria GmbH Falkenbach 75 Freyung 94078 Germany Telephone: +49 8551 913528 Fax: +49 8551 913456 Website: www.medprobavaria.de Med Tours Latinamerica 9a Avenue Sur + 12 C.Ote. 22A Colonia Utila. Santa Tecla, La Libertad El Salvador, Central America City: Santa Tecla, La Libertad Country: El Salvador Central America Phone: 503-2229-3000 Website: www.labcofasa.com MedTravel Ecuador Av. de los Shyris 2811 e Isla Floreana Quito, Ecuador Telephone: 593-2 2433307 Fax: 593-2 2445364 Website: www.medtravelecuador.com Mintz Levin Cohn Ferris Glovsky and Popeo One Financial Center Boston, MA 02081 USA Telephone: (617) 348-1757 MOH Holdings Pte Ltd 83 Clemenceau Ave., #15-03 UE Square Singapore 239920 Singapore Telephone: +65-6622-0956 Fax: +65-6720-0980 Website: www.mohh.com.sg Narayana Hrudayalaya NO 258/A Bommasandra Industrial Area, Anekal Taluk Bangalore, Karnataka 560099 City: Bangalore Country: India Phone: 080-27835000 Fax: 080-27835207 Website: www.narayanahospitals.com NursesNow International Av. Hidalgo 2609 Col. Obispado Monterrey, Nuevo Leon 64800 Mexico Telephone: +528181234849 Fax: +528181234851 Website: www.nni.com.mx

September / October 2011

Obesity Solutions International 9516 Star Bird Court Elk Grove, Ca 95758 City: Elk Grove, Ca Country: USA Website: http://www. obesitysolutionsinternational.com

Puerto Rico Med Links PO Box 1622 Morovis, Puerto Rico 00687 USA Telephone: 787-270-4060 Fax: 787-270-4061 Website: www.prmedlinks.com

OneWorld Global Healthcare Solutions LLC 300 East Club Circle Boca Raton, FL 33487 USA Telephone: 248-250-3221 Fax: 248-547-7769 Website: www.oneworldglobalhealthcaresolutions.com

Re:Group Inc. 213 West Liberty St. Suite 100 Ann Arbor, MI 48104 USA Telephone: 734-327-6606 Fax: 734-327-6636 www.regroup.us

Operations Worldwide Ltd Trans-World House, 100 City Road London, EC1Y2BP United Kingdom Telephone: +4402078710172 Fax: +4402078710101 Website: www.yoursugeryabroad.com Orbicare, LLC 2731 Executive Park Drive Suite 7 Weston, Florida USA 33331 City: Weston Country: USA Phone: 954 217 1116 Fax: 954 217 1113 Website: www.orbicare.com Passport Medical Inc. #355 W Olympic Blvd. Beverly Hills, CA 90212 Telephone: 800-721-4445 Fax: 866-716-4449 Website:www.passportmedical.com Perot Systems Services Mariano Otero 1249 WTC Torre Atlántico Piso. 7 Col. Rinconadas del Bosque Jalisco 44530 México Website: www.perotsystems.com.mx Physicians Alliance Limited #3 Grosvenor Close, Shirley Street, PO BOX EE17022 Nassau Bahamas Telephone: 242-326-4460 Fax:242 326 8874 Website: www.physiciansalliancelimited.com Premier Healthcare Professionals Inc 2450 Atlanta Hwy, Suite 601 Cumming, GA 30040 USA Telephone:678-460-1008 Fax: 678-460-1009 Website: www.travelphp.com

RSU Healthcare Company Limited 11th Floor RGU Tower 571 Surhumvit 31, Surhumvit Rd Wattana Dist, 10110 Bangkok, Thailand City: Bangkok Country: Thailand Phone: 66 2 610 0300 Fax: 66 2 259 7787 Website: www.RSUHealth.com Sanivisit International LLC City: Reston, Virginia Country: USA Phone: 1-877-836-3233 Fax: 1-703-910-3545 Seattle’s Convention and Visitors Bureau 701 Pike Suite 800 Seattle, WA 98101 Telephone: 206-461-5828 Website: www.visitseattle.org Shanghai Sunshiny Health Consulting Co. Ltd. Rm 2208 No. 337 Zhon Zhu Road Shanghai International Medical Zone Pudong 201318 Shanghai China Phone: 0086-571-87215526 Fax: 0086-571-8726575 Siam Wellness Services Ltd. 622 Emporium Tower 22nd Floor 22/7, Klongton, Klongtoey Bangkok, Thailand 10110 Telephone: +66 2664 9091 Fax: +66 2664 9094 Website: www.siamwellness.com Southeastern Spine Center and Research Institute 5922 Cattlemen Lane Suite 201 Sarasota, Florida 34232 USA Phone: 941-371-9773 Fax: 941-556-0341 Website: southeasternspinecenter.com

Premiere Medical Travel Company, LLC James McCormick MD 6303 Owensmouth Avenue, 10th Floor Woodland Hills, CA 91367-2622 Telephone: 818-917-6189 Fax: 818-936-2101

Spur Interactive 3701 Kirby, Suite 1290 Houston, Texas 77098 USA Telephone: 713-357-7101 Fax: 281-664-4745 Website: www.spurinteractive.com

Proglobal Today Inc. 362 Maple Avenue Washington, PA 15301 USA Telephone: 724-328-3139 Fax: 724-222-9525

Stackpole & Associates 1018 Beacon Street, Suite 201 Brookline, MA, 02446-4058 USA Telephone: 617-739-5900 Website: www.stackpoleassociates.com