Medical Tourism Magazine - The Path Of Asia by MT Association

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I n t e r n a t i o n a l

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Medical Tourism

The Path of Asia ISSUE 19

Pg 8

Promoting Quality and Patient Safety~

The New Integrated Hospital Accreditation Program Pg 14

Implementing Medical Tourism in Japan~

A Cultural Challenge Pg 19

A Recent Trip to Taiwan, Vietnam and Shanghai Pg 25 ÂŠ Copyright Medical Tourism Association

February / March 2011

THESE HOSPITALS ARE AMONG

THE BEST

INTERNATIONAL

ALL HOSPITALS ARE MEMBERS OF THE MTA

HOSPITALS

IN THE WORLD

AFRICA

THE NAIROBI HOSPITAL www.nairobihospital.org

BAHAMAS

ISRAEL

ASSAF HAROFEH MEDICAL CENTER www.assafh.org

JORDAN

SPAIN

PLATAFORMA TURISTICA DE MADRID www.madridnetwork.org/red/turismo

TAIWAN

DOCTORS HOSPITAL www.doctorshosp.com

JORDAN HOSPITAL www.jordan-hospital.com

TAIPEI MEDICAL UNIVERSITY HOSPITAL www.tmuh.org.tw

BRAZIL

THE SPECIALTY HOSPITAL www.specialty-hospital.com

TAIPEI MEDICAL UNIVERSITY WAN FANG HOSPITAL www.taiwanhealthcare.com

CHINA

PRINCE COURT MEDICAL CENTRE SDN. BHD. www.princecourt.com

COLOMBIA

ALMATER HOSPITAL www.almater.com

HOSPITAL ALEMAO OSWALDO CRUZ www.hospitalalemao.org.br BEIJING UNITED HOSPITALS & CLINICS www.ufh.com.cn

CLUSTER DE SERVICIOS DE MEDICINA Y ODONTOLOGIA MEDICAL AND DENTAL SERVICES CLUSTER www.medellinhealthcity.com

COSTA RICA

HOSPITAL CLINICA BIBLICA www.hcbinternational.com

GUATEMALA

HEALTH & WELLNESS TOURISM COMMISSION, AGEXPORT www.healthwellnessguatemala.com

INDIA

MALAYSIA MEXICO

PANAMA

HOSPITAL PUNTA PACIFICA www.hospitalpuntapacifica.com

PERU

PROGRAMA DISFRUTA SALUD PERU www.peruhealth.org

SOUTH KOREA KOREA INTERNATIONAL MEDICAL ASSOCIATION www.koreahealthtour.co.kr

MOOLCHAND HEALTHCARE GROUP www.moolchandhealthcare.com

SEOUL WOORIDUL SPINE HOSPITAL www.wooridul.com

MEDANTA – THE MEDICITY www.medanta.org

SEVERANCE HOSPITAL YONSEI UNIVERSITY HEALTH SYSTEM http://www.yuhs.or.kr/en

TAIPEI MEDICAL UNIVERSITY SHUANG HO HOSPITAL http://eng.shh.org.tw

THAILAND

BUMRUNGRAD INTERNATIONAL www.bumrungrad.com

UNITED ARAB EMIRATES

AMERICAN HOSPITAL DUBAI www.ahdubai.com GMC HOSPITAL www.gmchospital.com

UNITED STATES

BAPTIST HOSPITAL www.baptisthealth.net

VIETNAM

FV HOSPITAL – FAR EAST VIETNAM LIMITED www.fvhospital.com

NARAYANA HRUDAYALAYA www.narayanahospitals.com SEVENHILLS HOSPITAL www.sevenhillshospital.com

February / March 2011

Editorial

WHICH PATH DO YOU TAKE?

WHERE IS YOUR

ECONOMIC MOAT?

s we enter a new year I think we all have to think about where we as an industry have been and where we are headed. With introspection we look at where we have been and what we have accomplished over the past year and then we find ourselves at a crossroad. We see the road lying ahead of us, but diverging into two distinct paths in different directions, which one do we take? This is where many industry participants currently are finding themselves in the medical tourism industry. They are wondering what strategies we should implement and what areas do we focus on in the years to come. Since more hospitals and countries have entered the medical tourism space, there has been more competition than ever. Competition is fierce.

plan. Are there any unique services or benefits that you can provide that no one else can? Try to think about how you can develop a brand name and reputation that will supersede your competition and land you more patients. This year when you are looking at which path to take, what strategies to implement, focus on taking the path that will set you apart from your competition and create a sustainable long term business approach for your organization.

Renée-Marie Stephano

A perfect example of how fierce the competition can be found through a case study of a facilitator and hospital which found a niche procedure affording them over 100 patients per month within a 10 to 12 month period. The goal was set for two hundred patients per month for this specific procedure in 2011. Competitors caught on and immediately the game changes from only a handful of competitors to fifty to one hundred competitors. The facilitator and hospital see the effects as their patient volume dips. I can’t imagine the anxiety of having absolute total success stripped away and diluted as competitors copy and take business away from innovators in the industry. But we have to face it; as the saying goes, unfortunately, “it’s a dog eat dog world.” As you choose which path you will progress down this year, I would highly suggest everyone in the industry focus on locating where is your “economic moat?” This means, what in your business strategy do you have that protects you from competitors taking away all your business or a good portion of it. Very few people have heard of this or even focus on it. You need to make it a priority if you want to survive and stay in the game. There are too many hospitals, facilitators and governments getting involved and promoting medical tourism. You need to set yourself apart. Where is your “economic moat?” A facilitator and hospital who found a niche procedure and are having amazing success almost reaching 100 patients a month today, may find 100 competitors jumping in. Immediately they will see every individual way the “successful” company is attracting patients and copy it, from internet advertising, to advertising on social networks, to the content on the innovating company’s website. In today’s online world, anyone can copy anyone and try to duplicate what they are doing. Think about what they can’t duplicate and incorporate that into your 2011 business

Renee-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. Renee-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

February / March 2011

MEDICAL TOURISM

EDITOR-IN-CHIEF & PUBLISHER

Renée-Marie Stephano, Esq.

ASSOCIATE EDITORS

Jonathan S. Edelheit Vivian Ho Gabriella Vicuña

ONLINE MAGAZINE EDITOR

Marinés Mazzari

REGULAR AUTHORS

Renée-Marie Stephano, Esq. Jonathan S. Edelheit Bill Cook Dan Cormany Dr. Prem Jagyasi Gabriella Vicuña Michael Bina Vivian Ho

CONTRIBUTING AUTHORS

Glauco Fonseca Daniela Abratt Shawn Austin Yehuda Dror Anne-Line Crochett Fredric Havens Paul Reed David Goldstein Cristina Garcia Amanda Shaw Apoorv Surkunte J. Dennis Wolfe John M. Quinn Lola May Coker

ART DIRECTOR

Renée-Marie Stephano, Esq.

ART DEPARTMENT

Dinier Quirós

MAIN OFFICES

10130 Northlake Blvd. Suite 214-315 West Palm Beach, Florida 33412 USA Tel:561-791-2000 Fax: 866-756-0811 info@MedicalTourismMag.com www.MedicalTourismMag.com

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February / March 2011

February/March 2011

Medical Tourism AT A GLANCE

Editorial

Which path do you take? Where is your Economic Moat?

As we enter a new year I think we all have to think about where we as an industry have been and where we are headed. With introspection we look at where we have been and what we have accomplished over the past year and then we find ourselves at a crossroad. We see the road lying ahead of us, but diverging into two distinct paths in different directions, which one do we take?

BY RENEE-MARIE STEPHANO

The Path of Asia

BY AMANDA SHAW AND ANNE-LINE CROCHET

A Recent Trip to Taiwan, Vietnam and Shanghai

I recently had the pleasure of sneaking out of the office and traveling to Shanghai, Taipei and Ho Chi Minh City (Saigon) so speak at conferences and workshops. I love traveling to new and old places meeting up with old colleagues and meeting new ones.

Implementing Medical Tourism in Japan ~ A Cultural Challenge

As the Asian medical tourism market grows, governments want to map their countries in the industry by initiating committees and actions, as Thailand did recently. However in Japan the idea of an established medical tourism industry remains abstract. BY ANNE-LINE CROCHET

BY JONATHAN EDELHEIT

Features

Kameda Medical Center ~ Attracting Foreign Patients

Founded 350 years ago, Kameda Medical Center is a family-run hospital located in Kamogawa city, Prefecture of Chiba in the Japan east cost. Kameda is one of the few hospitals in Japan receiving international patients. But it is only three years ago that John Wocher, Kameda’s Director and Vice President, started considering medical tourism as a niche market.

BY ANNE-LINE CROCHET

China Soars ~ Beijing United Family Hospitals & Clinics Take Lead

Medical Tourism Magazine interviewed Alan R. Kahn, Vice President of Marketing and Communications for United Family Healthcare in Beijing to learn more about the medical tourism industry in China and what a patient would want to know when exploring this fascinating destination.

Economics

Duty of Care Versus “Duty of Dollar”

BY SHAWN AUSTIN

Responsibilities at Time of Sale

For a foreigner peering into the European realm, the continent seems to function as a single entity, a region that shares a currency, a set of values, an identity. So should healthcare be an added commonality? Unlike that of the United States, Europe’s healthcare is universal. But up until the beginning of this year, citizens did not have full access to their health rights.

BY DANIELA ABRATT AND ANNE-LINE CROCHET

Insurance professionals know that medically underwritten rates and policy exclusions are essential to the availability and affordability of travel insurance and other health insurance products. However, enforcing these coverage terms often leads to accusations of hiding behind the small print to avoid paying claims. Indeed, when a claim is denied based on exclusion or a failure to disclose material information during the application process, policyholders seldom agree with the decision.

BY PAUL REED

BY MEDICAL TOURISM ASSOCIATION

European Union ~ Healthcare Without Borders

Globalization has brought today’s travelers to new, farflung locations that they would not have visited even just a decade ago. From engineers and doctors to information technology specialists and banking/financial executives, more and more people in a myriad of industries are traveling around the globe.

Health Care and Employers ~ Innovative Solutions for a Changing Marketplace

BY DAVID GOLDSTEIN

February / March 2011

February/March 2011

Medical Tourism AT A GLANCE

Columns

Accreditation Corner Promoting Quality and Patient Safety ~ the New Integrated Hospital Accreditation Program

Hospital accreditation by a recognized quality certifier is an increasingly important way for hospitals to demonstrate their clinical expertise and commitment to patient safety. In the past, accreditation has been seen as a ‘ticket to trade’ instead of the strategic business asset that it can be. That is changing rapidly with the new NIAHO InternationalSM Hospital Accreditation which is based on DNV Healthcare’s hospital accreditation program approved by the US Centers for Medicare and Medicaid Services to accredit hospitals in the United States.

BY YEHUDA DROR, DNV HEALTHCARE INC.

News and Insights

Health Insurance for Expatriates in Spain

Health policies are sold in Spain in two modalities. The first one provides healthcare services through a closed list of doctors and hospitals that have agreed to work with them. The second one permits free access to any doctor or hospital. The company reimburses the cost of the service to a percentage afterwards.

BY CRISTINA GARCÍA

Brazil ~ Your Best Choice for Healthcare

Brazil... home to rolling hills, rainforests and pristine beaches. Singer Jorge Ben Jor described it best in a song: “Moro num país tropical, abençoado por Deus e bonito por natureza.” He sings that Brazil is a tropical place blessed by God and beautiful by nature. This pure wonderland is the largest country in South America and the economic power in the region.

Saving Lives

Are You And Your Company Ready To Travel

BY FREDRIC HAVENS

Corporate Duty of Care and Risk Mitigation in the Developing World ~ Medical Evacuation and Outpatient Care for Employees

Over past couple of decades, banking industry witnessed technology innovation in the form of credit cards, ATMs and online banking which substantially reduced administrative costs and made banking simpler for end user. The innovation in chip technologies enabled hardware industry to bring down cost of computers which lead to higher demand and reduced cost for the industry.

Overcoming the Challenges to Wellness in the Work Place

Over the years, rules have changed dramatically and soon, despite the new federal law mandating insurance coverage for everyone, finding insurance at an affordable premium will be difficult if not impossible. This is the hidden agenda of what many call “ObamaCare” aka The Patient Protection and Affordable Care Act (PPACA).

BY J. DENNIS WOLFE

February / March 2011

Is your company’s Wellness program waning? Has the program become stale and banal? If so, now is the perfect time to reassess, reclaim and reinvigorate your Wellness program. Starting a program can be relatively easy but maintaining a program takes effort. Wellness programs often get stale, loose touch and stop being effective.

BY KAYE KENNEDY

BY APOORV SURKUNTE

Health Care…Who cares?

Across all sectors and industries, the developing world has continued to see market growth and significant foreign direct investment (FDI). Despite recent economic stagnation, and in some sectors, decline in the developed world, developing nations offer great opportunities in manufacturing, construction, and various services in the growing field of peace and stability operations.

BY JOHN M. QUINN AND LOLA MAY COKER

BY GLAUCO FONSECA

Technology Innovation, US Healthcare and Health Reforms

Antibiotic-Resistant Superbugs ~ A Rising Threat for Medical Tourists

The rise of multidrug-resistant “superbugs” poses a growing threat to populations worldwide, including those who travel overseas for medical treatment. Alleviating the problem may require the use of novel, synthetic antimicrobial molecules specifically designed to mimic the body’s natural defense against infection.

BY RON NAJAFI, PHD

ÂŠ Copyright Medical Tourism Association

February / March 2011

MEDICAL TOURISM

The Path of

Asia By AMANDA SHAW AND ANNE-LINE CROCHET

Medical tourism is booming in the south and southeast regions of Asia. With more than a million medical travelers per year, Asia is considered a top choice destination. From cancer treatment to hip replacement to cosmetic surgery, Asia can make everything possible. Generating revenue high into the billions and comprising 12.7 percent of the global market, medical tourism is expected to grow a whopping 17.6 percent and revenues up by 23 percent by 2012. Asia is one of medical tourists’ most favorite destinations because it combines healthcare and tourism together cohesively.

sia is often seen as an exotic destination for travelers from other regions captivated by the landscape and the cultures. From big cities with skyscrapers and retro scenes to smaller villages with beautiful, peaceful ocean access and calming, soothing surroundings of nature’s presence, there’s always a place for urban and/or natural enjoyment. Oriental culture has always attracted passionate travelers: The traditional dances, the majestic temples or even the new Asian pop culture from anime to the cinema of Bollywood bring them from thousands of miles away. Food also is delightful for its different tastes and unique health benefits. It’s no wonder Asia attracts millions of tourists each year. Although Asia is much different culturally from the U.K and U.S, ironically, it has been reported that tourists from these countries feel less of a cultural shock in Asia than any other country because of its modern infrastructure and the way the region is developing as a whole. Also, again, the majorities of the physicians in the bigger countries and cities in Asia were trained in the U.S. and have colleagues and counterparts here. As a physician, being able to speak the same language as your

February / March 2011

patient, you are trusted more by your patient and they become more relaxed in your care and oversight. All over the world Asian countries feed the reputation of being a privileged place for wellness, spa, healing, and relaxing. Asia, viewed as the land of well-being since the earliest civilization, illustrates culture of traditional medicine and natural healing throughout the years. With these traditions and the integration of modern technology and evidence based medicine, Asia has much more medical services to offer including: cardiac surgery, cosmetic surgery, general and cosmetic dentistry, pre- and post-operative care, hair transplants, alternative therapies, hip and knee replacements, orthopedic surgery, ophthalmology,

In some countries throughout Asia, it is against the law to market hospitals internationally. © Copyright Medical Tourism Association

stem cell transplant, and more. Studies show Asians are not only living older than Americans or Europeans but also living healthier lives. Australian, North-Americans, Canadians and also Europeans are most likely to come to Asia to undergo surgery. Asia also takes advantage of circulating medical tourism through the numerous countries within, giving it a high ranking of Chinese and Japanese medical tourists as well. The accessibility and the proximity of Asia plays a role when choosing a medical tourism destination but the low cost associated to the top quality procedures attracts people from all over the world. For instance, a heart bypass costing an average of $144,400 in the USA will cost $5,200 in India and $15,121 in Thailand. Generally, medical travelers are going overseas for major procedures or treatments which would have an expensive cost in their country, but checkups and minor surgery, such as dental procedures or ophthalmologic surgery, also are popular among medical tourists.

As a physician, being able to speak the same language as your patient, you are trusted more by your patient and they become more relaxed in your care and oversight. For the past ten years, Asia has shown its medical tourism potential growing from amateur in the industry to first choice destination. Inclusive of public or private players, investments in medical tourism are thriving, multiplying hospitals at every corner. Governments have invested billions of dollars over the years to increase awareness of medical tourism. In countries lacking government support, physicians are even splitting proceeds with public hospitals to organize their own private businesses to make their marks in the medical tourism industry. First class procedures at reasonable prices while enjoying a new culture under the sun, very tempting. But despite the fact that hospitals offering low cost surgery to medical tourists are booming in Asia, each country, each hospital, and each patient should be able to balance economic growth and risks taken. Not every hospital offers high quality services and not every country offers the same procedures in the exact same conditions; however, quality management and first class services control exist via accreditation systems such as JCI or ISQUA accreditation. Being internationally accredited, in Asia as well as everywhere else, may guarantee an English speaking medical staff, high quality services, and regulations on physicians and equipment. Countries possessing superior growth in unique infrastructure and skilled physicians are seeking to take part on the up rise of medical tourism. Though faced with common hurdles such as language barriers, they are readily identifying the key factors, which will meet and exceed their foreign patients’ expectations. They also still offer inexpensive services in comparison to their neighboring countries, especially the U.S. In addition to their weaknesses in language and regulations, they are also struggling with government support, making it a challenge to become another mega destination in Asia. In some countries throughout Asia, it is against the law to market hospitals internationally. Studies show Asia’s medical tourism market is expected to be worth more than US$4 billion by 2012, a growing pie which everyone wants a share of. Drawing a global picture of the Asian medical tourism market we will highlight in this issue

Japan, China, India, and Taiwan focusing on their involvements in medical tourism, their engagements, expectations, and the obstacles they are facing. In order to better understand the path of Asia towards medical tourism we will illustrate the current position of the different Asian countries through the examples of selected hospitals. n

About the Authors Anne-Line Crochet is Communications Intern for Medical Tourism Association. With a Masters degree in political science, a Minor in journalism, Anne-Line provides professional expertise to our public relations and editorial functions. Previously a staff writer for French publications Fragil and Ouest-France, she is fluent in English and French; and conversant in Spanish and Russian languages. AnneLine writes for MTA’s Medical Tourism Magazine and Health Tourism Magazine. She can be reach at AnneLine@ medicaltourismassociation.com Amanda Shaw is currently an intern at MTA, focused on Sustainable Healthcare & Hospital Development. Ms. Shaw holds a Bachelors of Arts degree in Journalism from Columbia College in Chicago. She was a member of the National Society of Collegiate Scholars at Columbia, and a journalism intern at Chicago Splash Magazine. Her interests in medical tourism include global healthcare development, healthcare reform, healthcare quality and international marketing.

February / March 2011

MEDICAL TOURISM

Dutyversus of Care

“Duty of Dollar”

By SHAWN AUSTIN

Globalization has brought today’s travelers to new, far-flung locations that they would not have visited even just a decade ago. From engineers and doctors to information technology specialists and banking/financial executives, more and more people in a myriad of industries are traveling around the globe. Companies are also expanding operations internationally, with a growing population of expatriates stationed around the world.

t the same time that worldwide business travel is increasing, so is the frequency of natural disasters, political unrest, and terrorist incidents affecting travelers and expatriates. Disasters – both natural and manmade – pose a host of health, security, safety, and risk concerns for individuals traveling on business. For instance, a medical evacuation can cost at least $10,000, according to the U.S. Department of State, and can easily have a price tag in excess of $100,000 in more remote areas of the world. Now, more than ever, employers are faced with the challenge to control costs. At the same time, employers have a legal, fiduciary, and moral Duty of Care for their employees. This responsibility extends globally and must apply to employees stationed in all corners of the world.

Meeting this very important and essential Duty of Care obligation is more challenging than ever. The question becomes: “How can employers balance the need to send employees overseas and protect these employees, while still keeping an eye on the bottom line?” One solution is a comprehensive travel risk management program that incorporates extensive international security and medical assistance services available on a 24/7 basis for overseas travelers and expatriates.

Now, more than ever, employers are faced with the challenge to control costs. February / March 2011

MEDICAL TOURISM Benefits of such a program include: protecting the health and safety of traveling employees, mitigating potential legal and financial liability, protecting the company’s brand and reputation, fulfilling corporate social responsibilities, meeting shareholder and stakeholder expectations, and contributing to the recruitment and retention of key employees. Even in times when increasing scrutiny of expenses has become the new norm and will continue despite an improving economy, providing Duty of Care must continue. But, even with business travel expected to rebound - particularly to emerging regions of the world – human resource directors, risk managers, and travel managers still need to watch expenses.

Once you’ve selected a provider and have a program in place, make sure you communicate this information to your employees on an ongoing basis. HR professionals are tasked with evaluating and selecting a cost-effective benefits program for their employees. Increasingly, they are being called upon to provide, evaluate, and select comprehensive travel risk management programs that incorporate extensive international security and medical assistance services. When evaluating travel risk management options, company decision makers should look for a provider that offers cost management solutions, while continuing to provide highquality service. These solutions should also take into account and help address Duty of Care requirements. Since no two organizations are the same, you want a program that can be customized to meet the unique needs of your organization. For instance, you may want a program that has assistance and insurance benefits integrated into one solution or you may want a program that has assistance services that can be fully integrated with your existing insurance approach. For example, if the assistance program is fully integrated with a company’s travel management program and there arises the need to provide last-minute or business class travel for an injured or ill executive, the costs could be substantially lowered. Also, you want a travel risk management program that provides travel alerts and warnings for high-risk destinations. When speaking to potential travel assistance providers, make sure to ask how they will keep your employees informed on up-to-date health and safety information while your employees are traveling. Some providers maintain dedicated customer or member web sites and/or provide the capability to send e-mail alerts and text messages with the latest updates. In addition, examine the cost drivers once you have fully assessed a provider’s quality. Ask these questions: Is there a fee for service? Is there a mark-up for third-party expenses? If you currently have a program, but you’re not sure if it’s working as efficiently as it possibly could or providing all the services your company needs, request that an assessment be performed. Some providers will do this free of charge, and it is a great way to compare your program to industry best practices so that you get an objective view of your company’s travel risk practices. Make sure that the assessment takes a

February / March 2011

look at such items as your travel medical policy, travel security policy, pandemic policy, expense patterns, crisis response plans, governance and strategic development and team composition. Lastly, but possibly most vital, is that once you’ve selected a provider and have a program in place, make sure you communicate this information to your employees on an ongoing basis. It doesn’t do your employees any good if you have a great travel risk management program that they are not aware of when they travel. Offer this information in your company newsletter. Also, consider sending internal e-mail blasts that are repeated and instruct department heads to brief their staffers about this program. Communication and understanding of these programs are essential, if they are to be utilized to their fullest potential and greatest benefit to travelers within your company. Knowing this important information in advance is a key component in being able to contain costs and manage an efficient and well-developed travel program. And, at the same time, you can provide Duty of Care and quality care for employees who are venturing out to the far reaching corners of the globe. n

About the Author Shawn Austin is Senior Vice President, Employer Markets, Accident & Health Division of Chartis. Chartis is a world leading property-casualty and general insurance organization serving more than 45 million clients in over 160 countries and jurisdictions. With a 90-year history, one of the industry’s most extensive ranges of products and services, deep claims expertise and excellent financial strength, Chartis enables its commercial and personal insurance clients alike to manage virtually any risk with confidence. The Accident & Health Division of Chartis is an industry leader and innovator, with 50 years of experience in developing and providing tailor-made solutions for the employee benefits, specialty risk, occupational accident, educational and travel insurance markets. The Accident and Health Division of Chartis offers a comprehensive portfolio of need-driven solutions to help our clients manage risk, help protect their people and be well prepared for the unexpected.

ÂŠ Copyright Medical Tourism Association

February / March 2011

MEDICAL TOURISM

Promoting Quality

and Patient Safety ~

The New Integrated Hospital Accreditation Program

By YEHUDA DROR, DNV HEALTHCARE INC.

n the US, independent accreditation is required by law for hospitals receiving reimbursements for governmentinsured patients (Medicare and Medicaid). Increasingly, private insurance companies and other stakeholders are demanding successful accreditation as part of their contracts with hospitals. The Medicare mandate for accreditation was established in the 1960’s and with the advent on new innovation from accrediting organizations like DNV is gaining stature as a symbol of quality, not just an administrative responsibility. One of the key drivers of the international expansion of hospital accreditation is patient mobility. More people are

February / March 2011

seeking to go outside their own country for medical procedures, attracted by the quality, access and cost advantages that are no longer defined by geographic boundaries. Adding to this trend are newly emerging pan-regional initiatives to improve access, such as the European Union’s Cross-border Healthcare Directive. In turn, healthcare providers realize they must not only communicate a level of clinical competence but also prove they have organization-wide quality procedures in place. Accreditation is an effective means for accomplishing that. It has the additional benefit of being a recognized discipline with elements of standardization that allow hospitals and citizens everywhere to understand its value.

Breaking New Ground On September 26, 2008, DNV Healthcare (DNVHC) was granted hospital deeming authority – the status to accredit hospitals – by the US Center for Medicare and Medicaid Services (CMS). DNVHC is a wholly owned subsidiary of Det Norske Veritas (DNV), an international, autonomous foundation established in 1864 in Norway and operating in more than 100 countries. DNVHC corporate headquarters is in Houston, Texas, and its primary office for US accreditation is in Cincinnati, Ohio. Achieving hospital deeming authority was an historic feat for DNVHC, which became the first new CMS-approved accreditor in 40 years. DNV’s NIAHOSM hospital accreditation program consists of an accreditation standard that closely follows US Medicare Conditions of Participation and at the same time integrates the principles of the internationally recognized standard for quality management, ISO 9001:2008, hence the acronym of the DNV National Integrated Accreditation of Healthcare Organizations. When adopting the principles of NIAHOSM internationally and forming NIAHO InternationalSM Accreditation, DNV has found that the majority of the requirements of the standard are applicable globally, and when there is a need to adopt a national requirement or regulation, it is adopted as a countryspecific measure. Within the NIAHOSM accreditation process, hospital surveys are conducted annually; they focus on observing the actions of caregivers but also enact an exhaustive review of written policies and procedures. Herein lies the big difference in the DNV approach; it places greatest emphasis on how things can be improved, not on marking them as deficient. The process is rigorous but highly collaborative, with DNV surveyors willing to share insights gained from other hospitals. Following a survey, any findings of nonconformity to the NIAHOSM requirements must be addressed by the hospital which is responsible for preparing a corrective action plan and a tracking system to validate corrections. The choice of ISO 9001 principles as the management system model for hospitals is not accidental. The continual improvement requirements which are the core of that standard make it the preferred quality system around the world adopted by complex businesses of all types. The key breakthrough made by DNVHC was finding a way to smoothly integrate the hospital-specific requirements from CMS with ISO, so that the program operates uniformly without requiring extra time or staff from the hospital. This combination has been also proven to teach hospitals the value of focusing on processes resulting in meeting and exceeding quality objectives set by the organization. This emphasis on continual improvement is also congruent with emerging trends that show hospitals adopting so called “industrial” quality management concepts borrowed from other sectors, among them Aviation, methodologies that include Lean and Six Sigma, and naturally, once hospital migrate to the more advanced quality management principles, they embed the unique requirements of the NIAHOSM chapters into their system such that it truly becomes the hospitals’ way of doing business. Hospitals adopting NIAHOSM universally report that it feels both “new” but also “familiar” at the same time, which increases its acceptance across all departments and stakeholders within the hospital, from administration, to finance, to clinical to boards of trustees. The strong emphasis that DNV Accreditation’s places on the leadership’s involvement that is supported by Management Reviews, Internal Audits and Corrective and Preventive Measures, which are closely echoed by similar points in the

Medicare CoPs; this integrated approach enabled the accredited hospitals to utilize accreditation as a vehicle to an effective, stable and consistent pursuit of a sustainable improvement. This hospital accreditation program address 25 chapters (table 1) TABLE 1. NIAHO InternationalSM Hospital Accreditation Program Chapters - Quality Management System

- Medication Management

- Governing Body

- Surgical Services

- Chief Executive Officer

- Anesthesia Services

- Medical Staff

- Laboratory Services

- Nursing Services

- Respiratory Care Services

- Staffing Management

- Medical Imaging

- Rehabilitation Services

- Nuclear Medicine Services

- Obstetric Services

- Discharge Planning

- Emergency Department

- Utilization Review

- Outpatient Services

- Physical Environment

- Dietary Services

- Organ, Eye and Tissue Procurement

- Patient Rights - Infection Control

Annex

- Medical Records Service

- Country specific annex

How NIAHOSM Works The first NIAHOSM chapter, Quality Management System stipulates the need to adopt and comply with the principles espoused by ISO 9001, especially with the emphasis it places on Quality Management System, The Management Responsibility, Resource Management, the Service Realization and the Measurement, Analysis and Improvement requirements. While there are quite a few hospitals around the world that have adopted the principles of ISO 9001, very often on the

February / March 2011

MEDICAL TOURISM or a registered nurse. The Generalist usually comes from a hospital administrative or managerial background. The PE/ LSS would have experience in hospitals’ life safety, medical devices management, infection control and/or Safety, Health and Environmental (SHE) background. Using observation of services, interviews, tracer methodology the survey team will cover all aspects of hospital operations in accordance with the standards 25 chapters. The training of the surveyors ensures that the qualified personnel are also competent and proficient in not only the subject matter they survey but also in the way NIAHOSM expects them to conduct such surveys. NIAHOSM expects each surveyor to attain what is known as the three “C’s”, i.e. Consistent, Collaboration and Cost effectiveness. misconception lingers that it is “a manufacturing standard,” not something invented for healthcare specifically. With the advent of the DNV NIAHOSM program, however, for the first time hospitals have a way to engage ISO in a uniquely healthcare package. It is altering the old misperceptions about ISO and promoting new enthusiasm for a reliable continual quality tool that is recognized widely. Hospitals who do put in the effort and achieve full NIAHOSM accreditation become vocal proponents of ISO. “It was an epiphany. We learned that not only could ISO be used by hospitals it should be used by hospitals,” Quality Director of Jordan Valley Medical Center, Utah said. “It works better than any other quality system we’ve tried.” DNV’s understanding that implementing a quality management system in itself is a process, is requesting its accredited hospitals to achieve compliance with the ISO 9001 principles in three years from first accreditation survey, providing guidance during the subsequent years of servicing the hospital. Notably, hospitals can and have achieved the compliance with these ISO 9001 principles faster. An organization that selects DNV accreditation would undergo the initial steps of application and contracting. Once that is settled, they would face the survey process. In addition to the standard itself, NIAHOSM accreditation process is uniquely characterized by the following features that make it very useful to the hospitals:

• NIAHOSM surveys are annual. Barring any findings that impede patient safety the point of Jeopardy in line with the CMS requirements, the survey findings fall into three types: Noteworthy efforts – where hospitals are doing well • Opportunities for improvement (OFI) – issues that do not constitute yet any breach of requirements but have been observed elsewhere to create an environment where such breaches may occur • Nonconformities where surveyors found issues that are out of compliance with NIAHOSM or ISO Requirements. Nonconformity must always show what the breach is and what the supporting objective evidence that demonstrate such breach is. There three types of nonconformities (table 2): TABLE 2. Nonconformities During Surveys Type Nonconformity

Category 1 Completely or Condition Level substantially out of compliance with the standard Category 1

•

Category 2

• An isolated nonfulfillment of a standard requirement that is otherwise properly documented and implemented, or,

• The surveys are conducted annually, resulting in a consistent standard which becomes the way hospitals conduct their business, rather than having an accreditation process that is a mere “preparing for an exam” • The surveys focus on sequence and interactions of processes throughout the hospital, enabling the medical and hospital staff to understand better the areas of high risk and enabling them to take necessary measures to mitigate this risk • The surveys do not include a “tipping point” in the process that results in varied levels of accreditation of the surveyed organization. Rather, for any findings of nonconformity to the requirements the organization is responsible for preparing a corrective action plan to address these findings. Once a hospital decides to adopt NIAHOSM accreditation concept, it would undergo the initial steps of application and contracting. Once that is settled, they would face the survey process. The survey team consists of three types of surveyors: Clinical, Generalist, and Physical Environment/Life Safety Specialist (PE/LSS). The Clinical surveyor must be either a medical doctor

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Definition

Consequence to Hospitals Follow-up survey is usually required

The absence of one or more required system elements or a situation which raises significant doubt that the services will meet specified requirements.

Hospital submits evidence, including performance measure(s) data, findings, results of internal reviews (internal audits), or other supporting documentation, including • A group of category timelines to verify 2 non-conformities implementation of the corrective indicating action measure inadequate implementation or effectiveness of the system relevant to requirement of the standard

• Inconsistent practice compared to other areas of the customer, or,

Hospital submits a robust corrective action plan. Validation of effective implementation of the agreed corrective action plan will take place at the next annual survey

The absence of “failure points”, coupled with the need for corrective/preventive action and their verification in the annual survey, makes accreditation part of the hospital’s normal workflow, there is no need for special preparations for the survey as the hospital is at constant readiness. The “gap analysis” issued by DNV after the hospital is accredited, to pinpoint current conditions and necessary improvements enables hospitals to realize that complying with these principles is much simpler than initially perceived by the hospitals. After the three-year accreditation cycle, the hospital would be also considered compliant with ISO 9001:2008. The testimonials the DNV accreditation receives from its accredited hospitals in the US, Brazil and India reveal that the intent of the accreditation is indeed met. The benefits expressed by NIAHOSM accredited hospitals can be validated by contacting hospitals on the NIAHOSM reference hospitals, gleaned from the NIAHOSM website (www.dnvaccreditation. com) can be summed in the following categories (table 3). TABLE 3. Hospital Statements Regarding Benefits of NIAHOSM Enhances our continuous improvement in quality and patient safety Embraces our ability to utilize our competence to innovate Drives us to adopt best practices

DNVHC accreditation, labeled as a “Breakthrough in US hospital accreditation”, is making its mark also on international accreditation scene. It has already begun to gain a relatively early but strong following and coupled with the experience that DNV gains from the risk management evaluation of the NHSLA in the UK is hoping to ensure hospitals learn not only how to manage risk and continually improve but also to enable hospitals to receive an objective rating based on its “risk maturity model” to the benefit of the patients and hospitals alike. n About the Author Yehuda Dror is the President and CEO of DNV Healthcare Inc. the first new hospital Accreditation Organization approved by the US Centers for Medicare and Medicaid Services (CMS) in the last 40 years. Trained as an engineer (MS from Massachusetts Institute of Technology) and business manager (Executive MBA from University Houston) Yehuda has more than 30 years experience in developing and implementing services that safeguard life, property and the environment. For additional information Yehuda Dror can be reached at DNV Healthcare Inc 1400 Ravello Drive, Katy, TX 77449. Phone: +1 281 396 1869, Mobile: +1 281 685 9996, Fax: +1 281 396 1903, Web: www.dnvaccreditation.com

Demands we discard ineffective practices Fosters improved communication between hospital and medical staff Reduces the costly need for implementation and preparation for the program Improves understanding of all hospital processes and drives up efficiency Performed in a collaborative manner that is geared to identify what works best and remove what doesn’t

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www.MedicalTourismCity.com

A New Social Network Has Been Launched!

Join “The City” Today and Begin Networking on a Global Scale >> Medical Tourism City helps facilitate an open forum and communication amongst those professionals involved in medical tourism and global healthcare and to facilitate business networking. >> The social network has reached over 1300 members from over 75 different countries since it started. >> Users range from insurance companies, health insurance agents, medical tourism facilitators, hospitals, doctors, governments, consultants and more. 18

February / March 2011

www.MedicalTourismCity.com

MEDICAL TOURISM

Implementing

Medical Tourism

in Japan~

A Cultural Challenge By ANNE-LINE CROCHET

ituated in the northeastern part of Asia, Japan is often seen as a land unto themselves. The area of Japan is equivalent of the size of California and its population, counting over 126 million Japanese, is spread on four main islands. Winter wonderland, cherry blossom and Harajuku style; for most people Japan is a dream vacation spot, but even though Japan’s government is encouraging tourism to grow the language barrier remains a big turn off for travelers. Medical tourism on another hand is an industry to handle with caution in Japan. Besides being a very domestic corporate country, there is an important lack of enthusiasm from the population and the hospitals in welcoming foreigners. In addition, compared to other Asian countries, the Japanese government creates the impression of giving lukewarm support to medical travel, combining hard efforts to be part of the medical tourism industry to cultural reticence.

SUPPORTING MEDICAL TOURISM On the contrary, the Japan Medical and Health Center, branch of the Japan Travel Bureau, positions itself in favor of medical tourism. But, even though the JMHC has faith in the medical travel industry’s impact in Japan, as its General Manager and Founder Nobuyoshi Takahashi talks, the medical tourism remains a future concept as it is not set in the population mind yet. First of all the population is culturally hostile to foreigners. In essence, this animosity towards non-Japanese can be seen as a shield to preserve cultural purity and feed the belief of ethnocentricity. In addition, healthcare wise, Japanese fear that foreigners will have priority or a better treatment than they do, while the healthcare system is supported by the taxpayers. “Japanese citizens will accept this concept gradually as international interaction from a humanitarian and an industrial

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MEDICAL TOURISM point of view,” assures Takahashi, “medical tourism will get popular in Japan.” Far from being won, the government tries to draw the country‘s image as a tourism hub according to Takahashi. “The government developed this project as a new growth strategy, they’ve tried to do it so aggressively since last year, 2009, and the local governments tend to go with them.” But, according to John Wocher, Executive Vice President and Director of International Patient Services Kameda Medical Center, Chiba, Japan, the government is “rather neutral” and not really encouraging hospitals to step in the medical tourism industry. Indeed, hospitals tend to opt for local rather than international accreditation. Besides not being fully informed about international accreditations, the costs implied are too high and the international criteria very different from the Japanese health system. According to Wocher, Japanese hospitals have no intention to undergo the long process of being JCI accredited, without a little help. (Read our article on Kameda Medical Center)

We’re facing a lot of problems to develop this project, like Japanese regulations or public opinions. Even though the system is changing at a very slow pace, the JMHC has good hope for Japan. Takahashi sees medical tourism as the first challenge for Japan to globalize medical services under the current healthcare system. “We’re facing a lot of problems to develop this project, like Japanese regulations or public opinions,” he says, but the JMHC wants to participate actively in mapping medical tourism in Japan. “Therefore, we should build a business model as soon as possible combining the management strategy of hospitals with the marketing, planning and development, sales and distribution of medical tourism in Japan to offer all the countries supply-chain management as a coordinator in the world.” The Japanese government also is trying to boost medical tourism and is planning to initiate different actions. Its objectives are making Japan a high class medical tourism destination focusing on the quality of the medical services and the diversity of tourist attractions. The effects are still not visible but the government is taking actions creating committees and plans for the next few years. The Japanese government wants to transform Japan into a first class healthcare destination

putting the emphasis on Japan’s assets and culture including: longevity, oncology, check-ups, preventive medical care, heart disease and cosmetic surgery. To do so, the government set its goals as increasing the number of non-Japanese tourist by 25 million by 2020, facilitating the acquisition of visa for tourists, considering the dispersion of holiday taking and other local holiday systems. But also creating highly attractive sightseeing spots, everything from marketing to attracting tourists, however stimulating hospitals towards international accreditations and medical tourism is not part of their program. Already in December 2010, the government announced that starting January 2011, visa requirements for people seeking medical care in Japan will be renewable, multi-entry sixmonth visas, replacing the single-entry, 90-day visas previously available. Even though Japan is entering the race, the Asian medical tourism market is expanding at a fast pace. India, Thailand, Malaysia or China are offering competitive prices while Singapore and South Korea are focusing on providing cutting edge technology and ultra-high standard medical services. Japan is trying hard to be in the race for medical tourism, although it remains the black sheep of the Asian medical tourism market. Culturally, it will be more difficult for Japan than a country such as Thailand, which lives from tourism revenues, to adapt interacting with foreigners. However, the government seems to take into consideration the importance that medical tourism could have on Japan and the great opportunity to show Japan’s high quality healthcare. n

About the Author Anne-Line Crochet is Communications Intern for Medical Tourism Association. With a Masters degree in political science, a Minor in journalism, Anne-Line provides professional expertise to our public relations and editorial functions. Previously a staff writer for French publications Fragil and Ouest-France, she is fluent in English and French; and conversant in Spanish and Russian languages. Anne-Line writes for MTA’s Medical Tourism Magazine and Health Tourism Magazine. She can be reach at AnneLine@ medicaltourismassociation.com

Medical tourism will get popular in Japan.

February / March 2011

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MEDICAL TOURISM

A Recent Trip to

Taiwan, Vietnam and

Shanghai By JONATHAN EDELHEIT I recently had the pleasure of sneaking out of the office and traveled to Shanghai, Taipei and Ho Chi Minh City (Saigon) to speak at conferences and workshops. As I enjoy traveling, it was very beneficial to see new places meeting up with old colleagues and meeting new ones.

was excited to travel to Shanghai as I had not been back to China since when I was a young boy and my family took us on a trip there. It was amazing how huge, modern and busy Shanghai was. It is a true modern, first world city. I wonâ&#x20AC;&#x2122;t forget the Bund, which is along Huangpu River, with its historical buildings and architecture. It had a very European feel. I met some of the top leaders of healthcare in Shanghai and spoke at a medical tourism workshop. I was extremely impressed with not only the high quality of healthcare and how modern the hospitals were, but the ambitious plans Shanghai has to become a leader in medical tourism, including the building of large hospital projects solely aimed at international patients. Shanghai has very competitive pricing. After my trip to Shanghai, I headed over to Taiwan, which is only about a two hour flight from Shanghai. Taipei is a wonderful place set on an island and surrounded by mountains. I had the chance to visit one of our new member hospital systems, and speak at a Medical Tourism conference meant for healthcare providers and the government in Taiwan. I am looking forward to seeing Taiwan emerge as a leader in 2011 and 2012 as it seems the private and public sector are going to really make an effort to work together and brand the country. One of my favorite places along the trip was my visit to Saigon. The city had a charm that I instantly fell in love with and the Vietnamese people were so friendly. I loved the food, the markets and just walking around the city at night. The best part of my trip to Saigon was finally getting a chance to visit FV Hospital, which has been a loyal MTA member for years. This French owned hospital sits very close to downtown Saigon and is beautiful, modern and has incorporated glass and

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natural sunlight to provide a better healing environment for patients. I was able to have a very productive meeting with the government as they move to make Vietnam a destination for medical tourism. For patients searching for affordability, Saigon is the place. FV Hospital, for example has more affordable pricing than many hospitals and countries in the world and is typically more competitive than Thailandâ&#x20AC;&#x2122;s pricing. Each of these countries and there hospitals are still formulating their initiatives and moving forward to capture their market share of the medical tourism industry. I find each country I travel to has its own unique advantages and special identity and characteristics. What I look forward to most is watching these hospitals and governments we work with grow in the industry and succeed. n About the author 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 can be reached at: Jon@MedicalTourismAssociation.com

February / March 2011

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MEDICAL TOURISM

Kameda Medical Center ~

Attracting Foreign Patients

By ANNE-LINE CROCHET Founded 350 years ago, Kameda Medical Center is a family-run hospital located in Kamogawa City, Prefecture of Chiba in the Japan east cost. Kameda is one of the few hospitals in Japan receiving international patients. But it is only three years ago that John Wocher, Kameda’s Director and Vice President, started considering medical tourism as a niche market.

Kameda includes 31 operational departments however, the hospital’s specialties revolve around spinal surgeries, breast procedures, cardiology, oncology and cardio-vascular surgery.

patients’ safety. “Our primary goal was not for marketing purposes, or chasing after a niche in medical tourism,” Wocher says, “but we do receive international patients.”

Offering first class services, Kameda has been ranked as one of the best hospitals in Japan in a 2005 Nikkei Shimbun survey. It is also the only Joint Commission International accredited hospital in Japan. “The global standards are very strict,” John Wocher, Director and Vice President of Kameda Medical Center says, “we took a year to prepare for JCI credentialing.”

According to Wocher, Kameda first received foreign patients six years ago, “before medical tourism became a buzz word.” Situated near a military basis, military families were coming to Kameda to receive health care. And the first step was made

Wocher explains that Kameda has been accredited in 2009 largely to enhance the hospital’s reputation and improve overall

Hospitals in Japan are reluctant about JCI accreditation February / March 2011

MEDICAL TOURISM into the medical tourism industry. “Last year, we received around 720 foreign patients,” Wocher says. “But only 50 were inbound patients.” According to Wocher 65 to 75 percent of the foreign patients are coming to Kameda for check-ups or oncology purposes. Checkups can last one night to two days and cost average around U.S $4,000 inclusive of a private room and a variety of tests such as a coloscopy and PET CT scans. Expatriates and military families are more likely to come to Kameda than foreign patients coming intentionally and specifically for medical tourism. However the low number of medical travelers at Kameda is not an isolated case, Japan is not a top choice destination when it comes to medical tourism. “There is not a lot of information on Japan’s healthcare system,” Wocher complains. According to him, the government should take medical tourism more seriously, as it’s becoming a niche market in other countries. “The government is not very supportive,” Wocher says, qualifying the Ministry of Health “not very enthusiastic about it or may be allergic to foreign patients.”

Japan is a safe country there’s no bombing, no terrorists’ attacks, the water is clean and people are educated Wocher takes the example of South Korea which has offices in New-York and Los Angeles promoting medical tourism as well as a medical tourism board. “Foreign patients can get a medical visa in 24 hours,” he says. “In Japan, we don’t even have a medical visa category.” Also, JCI accreditation is not well known in Japan and most of the Japanese hospitals are locally accredited. According to Wocher, the local accreditation process is very easy. “Hospitals in Japan are reluctant about JCI accreditation,” Wocher says, “the process is intimidating and most of the hospitals are not able to afford the JCI out-of-pocket costs for credentialing.” Motivation is lacking in Japan when it comes to international expansion for the country’s health care plans. For instance, medical records are written in Japanese while in the medical tourism industry insurers and facilitators ask for medical records in the English language. According to Wocher, Japan is unlike “Singapore and India for example who have their medical records in English.” The opposite is true; most Japanese hospitals don’t have a bilingual staff and cannot read English medical records. “U.S Insurers are tough, they have unreasonable expectations,” Wocher says. However, culture wise, the country as a whole is reluctant and there are lots of disincentives. According to Wocher, there is a strong corporate culture of domesticity in Japan. Embedded by the law, foreign doctors are not allowed to practice unless they take and pass the Japan national examination for medical practitioners. But, the problem doesn’t come from the medical industry only; Japan is a country where the Japanese language, the Japanese culture and the Japanese themselves are the most important factors,

February / March 2011

overall. This can be seen pejoratively or as a quality, one or the other, by implementing medical tourism there is a feeling of betraying the Japanese people by letting foreigners benefit from the care in Japanese hospitals and which specialists could deliver. It’s an S.O.S Wocher is sending out, to progress in the medical tourism industry and move forward, “we are pressing the government” Wocher says. Wocher sees the medical tourism as a niche market for Japan. “I want to get the word out,” he says. At Kameda, most medical travelers are coming from China and some from Russia. To increase the traffic of Chinese patients, Kameda medical center recently hired five Chinese nurses who have Japanese medical licenses and two Chinese physicians. Their role is to advise Chinese patients when necessary. “Chinese patients are very comfortable coming here,” Wocher says. “We can also provide chinese food to them.” Indeed, Kameda takes particular pride in offering to patients more humility and empowerment in the care they are getting. For example, patients have access to their medical records 24/7 or control over the access to media. “They are partners more than spectators,” Wocher says. Kameda patients’ benefits also includes gourmet meals, “and wine, if their medical condition allows it,” smiles Wocher. Japanese or foreign, patients are kings at Kameda. However, westerners are not likely to come to Japan. According to Wocher, Japan is seen as a far away country for westerners or Oceanians compared to the rest of Asia. Besides, “Japan cannot compete with these low costs, but the longest you’ll have to wait at Kameda is two to four days,” he says hoping to attract Canadians and UK patients. “And we are using cuttingedge technology.” However, when asked about the difference between a Japanese and a US hospital Wocher answers that Japan hospitals have to wait longer to get devices and drugs approved than in the U.S. But, according to him there are lots of good reasons to come to Japan. “Japan is a safe country there’s no bombing, no terrorists’ attacks, the water is clean and people are educated,” Wocher says, very eager to accept foreign patients. “Now it’s the time for us to be very active in the medical tourism industry.” For the next few years, Wocher hopes to boost the numbers of medical tourists by 50 percent and to increase awareness of Japan’s potential to the Chinese and Russian market and Hawaii and the west coast of the U.S. n

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February / March 2011

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MEDICAL TOURISM

Are you and your company

Ready to Travel By FREDRIC HAVENS

Is travel insurance really necessary and worth the added expense? According to the leading travel website Expedia, 19% of every traveler cancels or postpones their plans because of work-related reasons. A survey conducted by the Insurance Information Institute corroborated this trend by finding that 17% of travelers, one out of every six, file some type of claim during their business travels or vacations. Are you Ready to Travel? Travel insurance is widely regarded as the best way to protect travelers against a wide range of situations, well beyond emergency illness or injury. Even if your company group health plan covers typical medical circumstances, a business traveler would be well advised to upgrade to a comprehensive travel insurance policy for additional overseas business protection. The first step should be to check with the HR Department about your group coverage. Examine the policy to see what is, or what is not, covered. Does “healthcare abroad” appear in

the policy? How about “medical evacuation?” If your company has an HAS or a Section 125 pre-tax plan, payment for this upgraded coverage would qualify. Don’t rely on the common misconception that credit cards give adequate travel coverage. The vast majority offer protections so narrow that they may as well have none at all.

Medical evacuation is ruinously expensive and almost never covered. February / March 2011

MEDICAL TOURISM The same is true for domestic health insurance companies. Most do not cover foreign travel, nor do they have the logistics to help with most emergencies away from home. They may reimburse for emergency medical procedures incurred while traveling, but what about the rest? Medical evacuation is ruinously expensive and almost never covered. Terror delays are no longer as rare as in the past. Who hasn’t heard about a friend losing their passport at the most inconvenient moment? What if you need translation for a crucial prescription refill and you’re in Outer Mongolia?

The risk of travel delays should not be underestimated. In these unforeseen instances, who pays for the hotel and meals? Who finds the accommodations? Without travel insurance, you do.

A typical comprehensive plan should provide a wide range of assisted services. Here is a sampling of travel risks that many traveling employees typically underestimate:

Traveling abroad should be exciting and adventuresome. Having the foresight to insure away these risks with a comprehensive travel policy helps make this happen. n

• foreign auto accidents • legal help needed unexpectedly • evacuation due to weather or natural disasters • medical evacuation often costing as much as $100,000 • air ambulance from a remote local to a city large enough to host a modern hospital • repatriation, whether for a health crisis, a lost passport or a military coup • terror evacuation or kidnap/ransom protection for dangerous hotspots • sudden departure prompted by a work-related emergency • embassy referrals from experts on the ground

What about lost luggage? That brand new business suit for the important meeting might have to be replaced overseas. Replacing a stolen laptop could deplete your traveling funds. The important documents in your carryon may have to be emergency couriered at a high price tag.

About the Author Recognizing an unfilled need among HR departments for expertise and high-touch service in employee travel needs, Fredric Havens founded SafetyFirstTravelInsurance.com after a thirty-year career in the insurance industry. He also owns and operates HealthcareNow, a group healthcare insurance brokerage, which has consistently won carrier awards recognizing its excellence insuring large national employee groups, celebrities and ordinary individuals alike. Mr. Havens is a graduate of California State University at Los Angeles. He is a member of the United States Travel Insurance Association and of the National Health and Life Underwriters Association.

Travel insurance is widely regarded as the best way to protect travelers against a wide range of situations, well beyond emergency illness or injury.

February / March 2011

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MEDICAL TOURISM

Brazil~ Your Best Choice

for Healthcare By GLAUCO FONSECA

t is truly the best of both worlds. The spectacular landscapes and tourist attractions will take your breath away, and the medical professionals will provide quality service for all your clinical and surgical needs at great affordability. If you want sun, the carnival and one of the best plastic surgery clinics in the world, you should visit Rio de Janeiro. Or, if you’re searching for culture and tranquility, Porto Alegre is your choice, providing world-class dental and bariatric treatments and clinics. Recife is great for sightseeing and has a number of options for eye surgeries.

RIO DE JANEIRO Rio de Janeiro is one of the most beautiful places on earth. Not only does it have beautiful beaches, but it also has gorgeous mountain overlooks. It is a cultural hub of Brazil, and as a guest, you will you have the opportunity to explore a number of cultural hotspots, including the National Library (the largest in Latin America and eighth in the world), Theatro Municipal and Copacabana Palace. You will also interact with the Rio de Janeiro natives, called “Cariocas.” These people have a great peace of mind and sense of humor, and they know how to live

February / March 2011

and share their experiences with everyone they meet. The best time to visit is between March and November. Rio de Janeiro has a number of internationally renowned hospitals and facilities, most of which have separate clinics with English-trained staff to accommodate tourists. One such hospital is Hospital Copa D’Or, which is owned by the largest healthcare provider in the country, Rede D’Or. This hospital has achieved a number of international accreditations and has an excellent emergency and intensive care unit. It has 11 operating rooms and a separate adult and pediatric ICU, one of the few in Brazil that allows loved ones to accompany the patient in the room. The hospital treats its patients as guests, so it features conventional and VIP suites which are serviced by a special hotel service hospital. Hospital Samaritano is known for having the latest technology. Its cardiology department has special monitors which measure patients’ progress by sending ECG results to be analyzed constantly. All its heart physicians are internationally certified in emergency response by the American Heart Association, and its trauma physicians are approved by the American College of Surgeons. It also features a special international patient section and accepts all major health insurance companies.

Casa de Saúde São José Hospital is another famous hospital in Rio de Janeiro known for its multidisciplinary team of doctors and nurses. It specializes in everything from neurology and orthopedics to plastic surgery and urology. It has 27 obstetrics rooms and six suites, 107 rooms and five suites for surgical admissions, accomodation for 40 babies in the nursery, 30 beds in the adult ICU and 22 beds in the neonatal ICU. It also features an international patient department with English-, Spanish- and Portuguese-speaking staff. The city offers highly specialized physicians, including world-renowned plastic surgeon Dr. Ivo Pitanguy. Pitanguy went to medical school in Rio de Janeiro but received further training in the United States at the prestigious Mayo Clinic in Minnesota and later with famous surgeons in France and England.

PORTO ALEGRE If you’re looking for a taste of Europe, you can go to Porto Alegre in southern Brazil. This part of the country is known for great wines, scrumptious dining options and traditional Italian and German cuisine. The old European architecture has been preserved as cultural centers and museums, and the city bustles with theater, music and visual and plastic arts. The temperature is lovely throughout the year, with no snow storms, rain or excessive heat.

Luiz Fernando Moraes ~ Porto Alegre Secretary of Tourism, Renée-Marie Stephano ~ President of the MTA, Jonathan Edelheit ~ CEO of the MTA and Glauco Fonseca ~ CEO of Healthcare Brazil at the First Medical Tourism Workshop in Porto Alegre in May 2010.

An international hub for medical and business conferences, the city has 27 hospitals, 468 dental clinics and four health sciences and medical universities.

Recife is the fourth-largest metropolitan area in Brazil and one of the country’s top business centers. It is centrally located to other parts of the country, and its international airport and two international ports provide easy access for visitors. The city ranks as the second-largest medical center in the country, after São Paulo, with great hospitals and American-trained professionals waiting to assist patients from all over the world. The city boasts quality eye treatments and dental options and is home to the Hospital Real Português de Beneficência Portuguesa em Pernambuco, or “Hospital Português,” one of the most renowned hospitals in Brazil.

Porto Alegre’s airport is 15 minutes from downtown, a quick, traffic-free trip to a hotel, tourist attraction or medical center. An international hub for medical and business conferences, the city has 27 hospitals, 468 dental clinics and four health sciences and medical universities. It is home to Moinhos de Vento Hospital, voted the best local facility by the Joint Commission International, and São Lucas Hospital, which is highly specialized in cosmetic surgery, orthopedics, cardiology, bariatric surgery, neurology and cancer treatment.

Hospital Ana Nery features a large diagnostic imaging center. Its aim is to ensure quick and accurate testing and diagnoses of patients using the following technologies: ultrasounds, digital radiography, biopsies, mammography, multi-slice CT, bone densitometry and magnetic resonance. In addition, its clinical laboratory has received an “excellent” rating every month since 1992 when evaluated by National Quality Assurance, which is managed by the Brazilian Society of Clinical Analysis. It also has 10 top-level technicians and over 40 professional staff members.

Hospital Mãe de Deus is one of the fastest growing healthcare institutions for health techology and patient care. It specializes in cardiology, oncology, neurology and opthamology among others, and it also has a number of institutes within the hospital, including ones for cancer, preventative medicine, transplantation and mental health. It is part of the Mãe de Deus Healthcare System, which includes seven other hospitals in Rio Grande do Sul State. Don’t speak Portuguese? No problem! Communication is no concern because English is the predominant language in the medical field. The Porto Alegre Healthcare Cluster is also a member of the Medical Tourism Association™.

RECIFE Another leading medical city is Recife, located in the northeast. The city has breathtaking natural beauties, with a rainforest and a number of islands, rivers and waterways dispersed throughout. It is generally hot and barely rains between September and March. Recife offers tourist attractions to suit a variety of tastes. Visitors can spend the day exploring the city’s museums, historical monuments and the historic town center in Olinda, named a UNESCO world heritage site in 1982. In the evening, they can party downtown at one of the many clubs and carnivals, and after, they can return to one of the city’s quality 3-, 4- and 5-Star hotels.

Brazilian physicians undergo a combined 11 years of medical school and residency; their qualifications can be verified at the Brazilian Ministry of Health. Visitors from the United States and Canada will need a valid visa for entry into the country, but a visa is not required for most European countries, so check with your travel agent. World-class health options await you. We can guarantee the ultimate tourist and medical experience with great affordability. Whichever city you choose, you will have a wonderful experience. Come to Brazil. You are always very welcome here. n

About the Author Glauco Fonseca is the CEO of HealthCareBrazil.com, a facilitating, on-the-ground company that offers a one-stop-shop for services for patients worldwide. Mr. Fonseca also serves as the regional representative for the Medical Tourism Association™ in Porto Alegre.

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MEDICAL TOURISM

European Union ~

Healthcare

Without Borders By DANIELA ABRATT

new wave of legislation will change the way Europeans travel for medicine. In a vote on Jan. 19, 2011 the European Parliament approved the CrossBorder Healthcare Directive, a law that will enable citizens within the European Union to travel more easily to member states to receive healthcare. The law has created a set of regulations for the free movement of patients, payment policies and patient management while upholding citizens’ health rights. “We unified the different standards set by the European Court of Justice, and we created thus a clear and objective system of references,” said EP President Jerzy Buzek. He told the EurActiv Network that the directive is a “solid, legal basis for dealing with cross-border healthcare in the EU that was hitherto in a legal gray zone.” According to the Parliament’s website, 30 % of EU citizens are unaware of the availability of health services outside their

country, and 25 million citizens have rare diseases that require unique treatment facilities. The law particularly helps these patients by facilitating easier access to specialized medical centers across the region. It also helps those who live on national borders because it makes travel more convenient and has provisions for efficient payment. The directive was first proposed in July 2008, followed by a preliminary reading in April 2009 and a second reading and revision in June 2010, according to the website. The Parliament, whose representatives are elected by the member states’ citizens, and the European Council, whose members represent the states’ interests, settled on a compromise prior to Parliament’s Jan. 19 vote. The Council will give its final approval around the end of February or beginning of March, after which the directive’s text will be finalized and then translated into the 23 official

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MEDICAL TOURISM languages of the member states. It will then be published in the official journal. Though each member state is a sovereign entity, it must conform to the EU’s overriding rules. So at this point in the process, each state has 30 months in which to implement the directive into its national law. Thus, it should take effect by 2013. The aim is to clarify patients’ medical rights as set by the Court of Justice of the European Union, said Françoise Grossetête, a French Member of the European Parliament and the parliament’s rapporteur, to the EurActiv Network. He said Parliament also wants to prevent direct or upfront payment of transnational fees.

30 % of EU citizens are unaware of the availability of health services outside their country, and 25 million citizens have rare diseases that require unique treatment facilities. The directive is intended to mobilize patients, not medical providers, within the Union. Its text clarified that the law is not encouraging medical tourism but rather just ensuring its availability, safety and quality when needed and used. Some private-clinic owners fear that their number of patients will drop as people leave in search for cheaper healthcare. However, studies show that people generally prefer to seek healthcare near their homes. Additionally, patients will need to receive prior authorization from their national health systems in order to receive expensive treatment abroad or if they need to stay overnight in a hospital. This creates a management system to ensure that hospitals do not become overrun with patients and can manage their resources efficiently. Each country can determine its own time period for approval, something which concerns European Consumers’ Organization policy analyst Ophelie Spanneut. She worries the vague time range will create inequalities between countries, so much so that the EU will eventually need to stipulate an enforced time limit.

Monique Goyens, director-general of the ECO agreed. She said that the unknown waiting periods for payments and reimbursements will also increase the inequality. She believes the prior authorization is good but should not become an obstacle. Patients will be denied authorization only if the treatment can be quickly administered in the home country or if there is doubt about the credibility of the physician. Patients do not need to be authorized for small treatments or prescribed medicines. Parliament wanted to strengthen the cooperation between member states by developing “e-health,” the use of communication and information technologies to share data and documents, and by mutual recognition of prescriptions. The Pharmaceutical Group of Europe expressed some concern for patient safety and its ability to assess and validate prescriptions. However, it approved of the directive’s principle that grants them permission to refuse to fill a prescription for ethical reasons or in cases when authenticity or accuracy is questioned. The law also enables them to contact the prescriber directly. Furthermore, the directive requires each country to provide a detailed list of information about health providers, prior authorization requirements and reimbursement procedures. Before the directive was enacted, patients were able to travel for medical care but would not know the cost of their treatment abroad and if they would be refunded. Now, patients will not have to pay their fees upfront. If they do not have prior authorization (i.e. for routine treatments or medications), they will be reimbursed at home-country rates. This means that they will have to pay the difference if a treatment costs more abroad than it does at home. If they do have prior authorization (i.e. expensive procedures and treatments), they will need to pay at the rate of the country in which they received the service. Currently, 1 %, or €10 billion, of public health budgets is spent on cross-border healthcare. The European Commission estimates that the cost will increase by €30 million per year under the new rules, according to the EurActiv Network. But Markus Frischhut, a professor of international business and law at the Management Center Innsbruck in Austria, believes an increase in costs is unlikely. “States should be encouraged to work together to save money,” he said. Each country will be reimbursed the same amount as it would without the directive, so “there really shouldn’t be additional costs. There’s even the possibility to reduce costs.” Travel and hotel expenses will not be reimbursed, refuting the concern that the directive promotes health tourism. Regardless of this measure, Dutch MEP Kartika Liotard still believes the EU is treating healthcare like a marketable product, one which can be exploited to increase revenue for the health tourism industry at the expense of quality care and patients’ rights. “The new EU directive will mean that insurers drive patients abroad in search of cheaper treatment,” she told the EurActiv Network. “Patients from rich countries will be able to travel to less expensive poorer countries where there is a threat that care standards for locals will deteriorate to make room for profitable health tourism.”

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Nigel Farage, leader of the United Kingdom Independence Party, is also concerned. He called the directive a “bureaucratic nightmare” bound for a series of monetary issues. The directive does not have any provisions that regulate the member states’ individual social security systems. Gilles Pargneaux, a member of the French Socialists and Democrats, worries that this lack of regulation will emphasize the differences between a country’s home system and the new EU policy, an incongruence which will ultimately become conflictual. But German MEP Dagmar Roth-Behrendt disagreed. She believes the EU has shaped the law to achieve a balance between the rights of patients and the protection of each nation’s financial and social security systems. According to a 2010 study conducted by the World Health Organization’s Regional Office for Europe, health inequalities have been increasing for most European countries and most health indicators. Eastern European countries generally have higher inequalities than those in west and central Europe. The study found, however, that Portugal had the highest rate of inequality for men and one of the highest for women. Slovakia and Poland followed close behind. The smallest inequalities for both men and women were found in Cyprus, Iceland, Belgium and Austria. The study compared the differences in average health and health distribution in each country and found no significant trade-off between the two. Thus, it asserts that countries should be able to improve their overall health while reducing health inequalities among their socioeconomic classes.

Fruschhut agreed. He said that the directive prohibits states from discriminating against patients by country, race or socioeconomic class. He said that any complications that occur most likely will arise from errors in public management. He clarified the necessity for the directive. The Court of Justice lists a number of “fundamental freedoms,” one of which is the right of EU citizens to travel for medical needs. But, the EU’s laws do not govern public health. Since the Court of Justice has primacy, the EU had to develop a directive that would address this health freedom and apply it to all citizens, regardless of their health status. He said the directive is certainly a positive step for progress, but it is now up to the individual healthcare providers to implement it and decide its efficacy. n

About the author

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. Daniela writes for MTA’s Medical Tourism Magazine and Health Tourism Magazine.

February / March 2011

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To find out how OneWorld Global Healthcare Solutions can benefit your organization, please call 248-250-3221 or visit www.OneWorldGlobalHealthcareSolutions.com. © Copyright Medical Tourism Association 40 February / March 2011

MEDICAL TOURISM

Responsibilities

at Time of Sale By PAUL REED

hey might react by contacting the media, filing complaints with insurance regulators and sometimes initiating legal proceedings. These are uncomfortable situations for any insurance carrier, broker or health plan, particularly because of the reputational damage they can cause. One suggestion to minimize the risk of this happening is to review your sales or enrollment process and ensure that it includes mandatory notices to make applicants aware of, and accept the limitations of the policy. This is by no means a novel idea, but the denial of some claims for these reasons and the consequences for policyholders are recurring themes in the insurance industry. Therefore taking a few moments to review a few fundamental concepts can be worthwhile. It is also relevant to keep in mind the complexity of the different distribution channels, the ripe age of many applicants and the numerous intermediaries that are often involved; opportunities for miscommunication abound and the vast majority of

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insurance litigation cases include a component related to events that occurred at the time of sale. Purchasing travel, expatriate or other types of health insurance can require detailed answers to medical questions for some applicants, depending on age and health. While most applicants understand the importance of obtaining coverage for medical emergencies before travelling, many do not realize the severity of their duty to disclose accurate information when applying for insurance. This situation can lead to omissions on application forms and consequently invalidate the corresponding insurance policies. When this happens the results can seem unfair and extreme to the policyholder, particularly at time of claim. But this general rule about disclosure is a fundamental principle of insurance and can easily be explained to applicants: in order to effectively calculate risk, insurance companies must be able to rely on the information they obtain

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MEDICAL TOURISM during the application process, and applicants are therefore responsible for providing complete and accurate information. If they do not fulfil this obligation, the insurance company is not obligated to fulfil the contract of insurance, which it would not have issued under the same conditions if the applicant’s disclosure had been complete. If a retroactive premium adjustment were the only consequence for misrepresenting relevant information on a health insurance application, there would be an incentive to withhold or misstate facts when applying for coverage. Everyone would “qualify” for the best plan by withholding relevant information, knowing that in case of a claim they would simply need to make an additional premium payment. This would be like applying for insurance after experiencing a loss and it would prevent insurance companies from effectively calculating risk. They would be unable to collect enough premiums to pay for claims and it would ultimately lead to insurance coverage becoming unavailable. As for exclusions, which specify events or circumstances that result in there being no coverage, they are necessary and enforceable, because they ensure that coverage is available and affordable for all situations that are not excluded. For these reasons, insurance companies verify the answers provided on applications for insurance, and the law in most jurisdictions allows them to void the insurance policy when the application contains a material misrepresentation. For certain types of coverage (e.g. travel insurance) this verification is done when a claim is received as it would be impractical or impossible to do so during the application process. The cost of doing so for every application could also make coverage much less affordable and the applicability of exclusions to

the facts of a claim can only be verified after the claim has been made. Nonetheless, in the vast majority of cases the verification confirms that the application is complete and accurate, the policy is valid and the claim is payable. But when the information disclosed on the application is materially different from the insured person’s medical records, or when an exclusion is triggered by the circumstances surrounding the incident, the claim will be denied. The resulting consequences can be devastating, especially because of the incredible costs often charged for healthcare services. To minimize the risk of this happening, we must strive to produce clear application forms and eliminate the possibility of innocent misrepresentations. We must provide ongoing product training to our distribution networks and emphasize the importance of accurate and complete disclosure to applicants. Warnings about the consequences of misrepresentation should also be prominently displayed on application forms and other insurance material. Finally, we must ensure that applicants are instructed to read their policy and pay particular attention to the limitations and exclusions. Misrepresentations and the resulting denial of claims will inevitably continue to arise, but continually raising awareness of this issue will surely have a positive impact. Encourage your distribution networks to tirelessly spread the message to applicants: make sure you disclose all relevant information accurately and completely when applying for travel or health insurance; if you are not sure about what to answer, do not take a chance, ask your doctor! n About the Author Paul Reed is Legal Counsel for GlobalExcel.

In order to effectively calculate risk, insurance companies must be able to rely on the information they obtain during the application process.

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“Your Guide to Overseas Health & Medical Wellness”

�Integrative �Alternative �Homeopathic �Preventitive

www.HealthTourismMagazine.com 44

February / March 2011

MEDICAL TOURISM

Health Care

and Employers ~ Innovative Solutions for a Changing Marketplace By DAVID GOLDSTEIN

In the U.S. health care expenditures are 50% higher than any other country in the world, totaling about 16% of GDP. As costs continue to increase at a rate of 8% per year, which is twice that of the Consumer Price Index, total U.S. healthcare costs will consume about 20% of the economy within the next 6-7 years. Furthermore, employer’s medical costs have increased 80% since 2001, causing many organizations to lower plan benefits, eliminate coverage, or propose more affordable solutions. Likewise, employees have shared the cost burden by seeing their out of pocket expenses quadruple over the last 5 years.

Trade Healthcare Market Expenditures $3 Trillion Projected 2011

Other $1.6 Trillion

Surgery $1 Trillion Rx $400 Billion

75% of surgeries are elective (non-emergency procedures) totaling $750 Billion

Interpretation: Since 75% of all procedures are elective, patients have enough time from the point of diagnosis to surgery to weigh their options and make informed decisions. With a proper model in place, there is plenty of time to research and choose a provider or treatment based on cost, quality, experience, and results. Unfortunately, many companies and their employees don’t have the means or infrastructure to research addition surgical options. As a result, many employers continue to miss out on one of the best opportunities to improve quality outcomes while reducing their healthcare costs.

SURGICAL BENEFITS MANAGEMENT

Surgery benefits management is quickly becoming one of the best ways in which employers can reduce their healthcare costs without compromising healthcare quality. Implementing a program like this can be simple and very effective if two major components are utilized: Medical travel: A Medical Travel program is a voluntary employee benefit program offered as a supplement to an

February / March 2011

MEDICAL TOURISM employer’s self-funded health plan. Currently, thousands of U.S. patients utilize supplemental surgery networks every day, saving millions of dollars for their employers. The providers in these networks can perform surgeries consisting of anything from a major complex cardiac procedure to a simple minimally invasive out-patient treatment. The purpose of using a defined program is to simply bridge the gap that exists between the employee who needs the surgery and a network of specialized health care providers that can perform the surgery.

Medical travel programs are being implemented by employers to expand their employee’s options and to improve their outcomes, while lowering the overall health care costs. Interpretation: Implementing a Medical Travel program presents a tremendous opportunity to receive higher quality treatments while reducing costs for both employees, who benefit by paying little to no out-of-pocket expenses, and employers that typically save between 20-60% per procedure. This is not a new concept - medical travel has been around for many years, which simply consists of somebody leaving their local community to get treated somewhere else. In the past, it was predominately used by wealthy or those with chronic conditions or diseases such as cancer or organ transplants. But today, medical travel programs are being implemented by employers to expand their employee’s options and to improve their outcomes, while lowering the overall health care costs. Using a quality medical travel partner is paramount to a successful program as they pre-negotiate discounted global case rates which usually include pre and post-surgery consultation, physical therapy if necessary, and all hospital and surgery expenses. Expert Diagnosis Services: A team of 3 -5 experts review the records of each patient in detail. Afterwards, they summarize the issues presented and recommend a specialist who will review the case in detail. Often times this process involves even reworking tests and examinations through their comprehensive provider networks. Comparing this method to a traditional second opinion, expert diagnosis services are proven to be effective at helping to ensure patients get the best treatment possible. Interpretation: Published data states that approximately 20% of surgeries are deemed unnecessary, resulting in nearly

$220 billion in wasted costs each year. Expert Diagnosis Services helps to prevent unnecessary procedures, and shorten the recovery time by making certain the right diagnosis and the right treatment approach has been chosen. Adding this step into your treatment algorithm will improve the health of employees and reduce unnecessary health care costs. On the surface the outlook for employees may seem grim with out-of pocket expenses continuing to increase in the form of high deductible, co-pays, and co-insurance. However, employers can make an immediate difference by taking an active approach to neutralize these trends. An understanding of where and how health care dollars are being spent is the key to uncovering potential solutions. Top organizations are turning to surgery benefits management as an alternative to increasing costs and reducing medical coverage. In conclusion, we believe managing surgical costs is an innovative technique that will improve outcomes, reduce costs and deliver consistent results. n

About the Author

David Goldstein, President of Health Options Worldwide (HOW), has extensive experience in the healthcare industry. Through his exposure to the inner workings of hospitals and physicians, he learned of the inefficiencies that exist in the healthcare industry and was inspired to make a difference. His professional experience in dealing with business owners, benefits managers, physicians, and hospitals has been a large reason he’s lectured and presented to companies ranging from startups to Fortune 500 organizations. Founded in 2008, Health Options Worldwide (HOW) has worked hard to develop solutions to counter the ever rising costs of healthcare. As a healthcare IT company, HOW delivers a tailored network of global medical facilities within our technology platform to engage employees into bettering their health as well as reducing overall healthcare costs. Since launching in 2010, HOW has quickly become a top destination for physicians, hospitals, employers, and patients. As a trusted, unbiased resource, HOW’s free online marketplace provides patients with direct access to top medical institutions and physicians, often providing fixed rates for treatments. HOW works with many self-insured employers, carriers, and other partners to help reduce their overall healthcare costs while demonstrating outcomes. For more information on HOW visit Http://www.HealthOptionsWorldwide.com or contact David Goldstein at David.Goldstein@healthoptionsworldwide.com.

Since 75% of all procedures are elective, patients have enough time from the point of diagnosis to surgery to weigh their options and make informed decisions.

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Our Experience

Over 15 years of experience thousands of patients coordinated from North America to overseas.

Our Network

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Door to door pickup and drop off of Patients VIP Travel Assistance Coordination of Medical Records Coordination of Claims Payments Coordination of Aftercare

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www.SurgicalTrip.com

February / March 2011

info@surgicaltrip.com

MEDICAL TOURISM

Health Insurance

for Expatriates

in Spain By CRISTINA GARCĂ?A

oth types present a time limit of three months when covering healthcare assistance abroad. So, when a family has to move to a foreign country for a long period or has to send the kids to study abroad, the healthcare problem arises for there are very few countries that have a public and universal heath service like Spain or that have exchange agreements for mutual service. INESE, the Spanish insurance publishing division of Reed Business Information, published in 2008 an in depth study that compares the different healthcare products for expatriates available in the country. The study clearly sets two groups of actors in this market: health insurance companies -that provide higher capital limits for hospital and out-patients care- and travel insurance companies.

policies range between 500,000 and 7 million Euros, enough to face the costs of any pathology, as serious as it might be. In this point, it gets important to get acquainted with the health system of the country of destination as well as with the different contingencies that might arise during a recovery process.

Health insurance policies, as a hole, are structured in modules that permit multiple combinations of the different types of healthcare: hospitalization, out-patient assistance and maternity, which permit the insured to choose covers according to his/her needs. Capital levels for hospital services in these

The difference between health and travel insurance policies for expatriates also reflects in premiums. They depend on the amount of capital offered for each cover, the geographical area of the country of destination and the size of the group to insure. n

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If all this is known beforehand, the insured will be able to purchase a policy that meets his/her needs. For an executive that travels a lot to foreign countries, travel insurance policies would suit him/her perfectly, for he/she will most probably get coverage at a very good price without having to make a second policy. Besides, travel insurance policies usually include other interesting covers like the one that sends a deputy executive to replace the one that gets ill, allowing the company to reduce the cost of sending a replacement.

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Global Benefit Options (GBO) is a Medical Tourism Consulting firm that specializes in developing strategic Medical Tourism Benefit solutions for the US Health insurance market. GBO’s main focus is US Health insurance carriers, Self Funded Employers, TPA’s, Health Insurance Agents and other US health insurance “buyers” to develop, design, implement, and enroll a tailored Medical Tourism Benefit into the US health insurance plan for employees. GBO also works with International Hospitals and healthcare providers and Government organizations in helping them implement a medical tourism initiative aimed at US buyers. Global Benefit Options is the only consulting firm in medical tourism with over 10 years of direct experience in the US Corporate Health Insurance Benefits Market. By working exclusively within the United States insurance industry GBO’s marketing strategy, and custom solutions produce efficient and effective results for clients. Global Benefit Options partners with a select few clients per year interested in penetrating the US marketplace and having business relationships with US health insurance companies, employers or health insurance agents. For more information go to: www.GlobalBenefitOptions.com info@globalbenefitoptions.com PHONE:201-433-2222

February / March 2011

MEDICAL TOURISM

Technology Innovation,

US Healthcare and

Health Reforms By APOORV SURKUNTE

ookstores went online and companies like amazon brought down the cost of books by cutting down entities involved in the supply chain. There are numerous such examples across various industries where technology has played key role. However, Technology innovation has not worked as well with US healthcare industry as it did with other industries; it is one of the reasons why America spends 17.2% of GDP or about $2.5 trillion on healthcare. The healthcare expenses have been growing at significantly higher rate than inflation. U.S. healthcare system stands last for its performance among seven industrialized nations, despite spending the most, according to a new Commonwealth Fund report 2010. Technology innovation has not succeeded in improving US healthcare the way it did in other industries and the actions being taken by federal government to promote Healthcare IT.

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1. Slower Adoption of technology: Implementation of innovations that could bring down costs has been slow in US healthcare industry. Implementation of Electronic Health records is one such example. Partial to full penetration of EHRs in European nations such as Norway, Sweden is about 90 % whereas it stands at meager 23% in USA, according to a report. Administrative efficiencies could be achieved with innovations such as Real time claims adjudication and ICD 10 implementation. CMS report suggests that hospital productivity gains have been “small or negligible” over the past quarter century.

America spends 17.2% of GDP or about $2.5 trillion on healthcare.

The usage of basic communication medium like E-mails also is not widespread between patients and doctors. Usage of smartphones in healthcare is catching up, however it still has long way to go.

$55.5 billion to US healthcare every year according to a study. Doctors also pay hundreds of thousands of dollars a year in malpractice insurance. These expenses can be limited to an extent with Electronic Health records implementation.

2. Higher Costs of Technology: Due to patent protection laws, manufacturers need not worry about price competition when they launch new medical equipment/drug; emphasis is on recovering the costs before patent expires. Insurers do not have enough bargaining power to negotiate lower prices on these costly treatments. Because of this, technology drives up the healthcare costs.

8. Failure in reining the inefficiencies: Significant innovations are required to rein in the key areas of system inefficiency such as administrative inefficiency, Provider errors, lack of care coordination, unnecessary care, fraud and abuse etc. $40 billion of costs could be saved in the U.S. health system in terms of inefficiencies reduction with implementation of EHRs, according to Mckinsey report. Fraud and abuse are prevalent, more prominently in Medicare. Healthcare costs would be significantly lower (A Thomson Reuters report claims that almost $700 billion are spent in wasteful spending and significant chunk here can be saved) with innovations in this area which has not happened so far.

3. Consumer price insensitivity: Once members pay the premium, there is decreased motivation to opt for drugs, treatments that cost less as members tend to believe that costlier treatment is better. Costlier treatments and equipment are demanded by patients and physicians on the grounds of quality. Cost of new technology consistently accounted for 20 percent to 40 percent of the rise in health expenditures over the past forty years. Perverse incentives like this push the healthcare costs up despite innovations happening in the system. 4. Limited incentives for doctors / hospitals for cost reduction: Many of the technology innovations have not lead system efficiency or reduced healthcare costs. On the contrary, Congressional Budget Office estimates that an astonishing half or more of the increased spending on health care in past decade is due to technological, surgical and clinical advances. An article in The Journal of the American Medical Association points out that simple surgery that eases pressure on the nerves has been replaced by complex fusion surgery to relieve lower back pain. Surgeons were paid 10 times as much for the complex surgery, hospitals were paid three and a half times as much, and manufacturers made $50,000 worth of implants for the complex surgery compared with little or no profit from the simpler fusion surgery. 5. Overutilization of technology: Overutilization of technology, increases spending with limited additional benefits. At the same time, market-based competition among provider organizations to use the latest equipment increases the utilization of expensive technology at the expense of older, less expensive alternatives. This clearly seems to be the case with US healthcare where returns in terms of improved healthcare are not in proportion to investments on technology. 6. Lack of innovation in chronic disease prevention: Prevention is the key to both better health and lower healthcare costs. One third of American population is overweight (about 97 million people) and America spends whopping 75% on chronic diseases which can be prevented to large extent by closely working with consumers. However the focus is more on disease care rather than on preventive care. According to a recent New England Journal of Medicine article, over 2 million Americans die due to preventable reasons like smoking, high blood pressure, obesity, diabetes etc. United Health Group estimates that Diabetes may cost America approximately $3.4 Trillion in the next 10 years. Improper eating habits and unhealthy lifestyle are prime reasons behind these problems. Innovative ways to promote prevention may go long way to bring down healthcare costs. Solutions need to be introduced and implemented to involve all stakeholders and push consumers to lead healthier lifestyle. Health 2.0 technologies could go long way to promote healthier lifestyle. 7. Defensive Medicine costs: In many cases, physicians opt for comprehensive treatment that include extra tests and scans to make sure that they donâ&#x20AC;&#x2122;t have to face litigation for medical malpractice. This practice of defensive medicine costs

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$40 billion of costs could be saved in the U.S. health system in terms of inefficiencies reduction with implementation of EHRs. Federal government is pushing the changes which would enable Healthcare IT to usher into new era where technology would simplify healthcare with big ticket implementations such as HIPAA 5010 changes, ICD 10 implementation, Grants of $19.2 Billion to address the meaningful use of health records and privacy / security concerns associated with the electronic transmission of health information as part of ARRA act of 2009. PPACA act of 2010 has outlined various changes with regards to healthcare IT. The proposed changes include implementation of health benefit exchanges, promoting administrative simplification with enhanced interoperability, promoting new models such as Accountable care organizations which would need various technology innovations ( Remote health monitoring, telemedicine) to be successful, creating Innovation Center within the Centers for Medicare and Medicaid Services and performance bonuses for organizations that demonstrate successful implementation of HIT initiatives among other steps. The change that all these reforms are set to bring in would not be easy on stakeholders involved in US healthcare, however if Healthcare industry has to be transformed into an efficient one, this change is a bitter pill that the stakeholders would have to swallow!! n

About the Author Apoorv Surkunte works as Lead Business Analyst in Healthcare IT area with one of leading Health insurance companies in USA with experience of 7 years. His areas of interest include healthcare innovations, health reforms, Electronic Health records and ICD 10 implementation, health 2.0. Apoorv is certified project management professional (PMP) and possesses various international healthcare certifications from AHIP. Apoorv can be reached at apoorv.reddy@gmail.com

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MEDICAL TOURISM

Healthcare... Who Cares? By J. DENNIS WOLFE

The next time you’re at the grocery store, buy $100 worth of groceries. Tell them you will pay them $25 and for them to send the receipt to your bank for the remaining $75. How many of you think there is any chance of getting out of that store without being arrested for shoplifting?

ow, consider this scenario. Call a doctor’s office to schedule a visit and tell them you have no health insurance. You might not even get an appointment. There was a time when this was how we all received health care service… we paid for it! For the few patients who had insurance, it was their responsibility for filing claim forms to receive reimbursement. The provider was paid by the patient. Over the years, rules have changed dramatically and soon, despite the new federal law mandating insurance coverage for everyone, finding insurance at an affordable premium will be difficult if not impossible. This is the hidden agenda of what many call “ObamaCare” aka The Patient Protection and Affordable Care Act (PPACA). Marketed as universal access, the key problem is that limited capacity leads to rationing of care. Ultimately, the government will decide who gets care and who does not. Welcome to President Obama’s “Signature Legislation”!

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The new Patient Protection and Affordable Care Act is worse than a solution. No matter how well-marketed, this legislation has geometrically compounded the problem of delivering affordable health care to all. If not immediately defunded and ultimately repealed, it will irreparably harm the health of our nation. This legislation was never about health care, rather it was about taking control of every American citizen’s personal life. The path that led to its passage is directly tied to many years of apathy by Americans. When it came to Healthcare...Who Cares? Now, with eyes and minds open, it is time to examine a better solution. Make no mistake about it - we desperately need healthcare cost-delivery reform. Readers would do well to review the potential damage almost caused by a “reform” called “Section 89” over 20 years

ago. I said almost because it was immediately repealed. What’s the big deal about Section 89? It was a lighter version of the PPACA mandate component, recently - and fortunately - ruled unconstitutional by a federal appeals judge (this dispute will now go to the U.S. Supreme Court). Section 89 was repealed because it was so laden with red tape and discriminationtesting requirements for employers that it would have made doing business impossible. So, how bad is the PPACA? As of the date of this article, The Department of Health and Human Services (HHS) has already granted 222 known waivers exempting some very large national companies and unions from new mandates that are far worse than the old Section 89 compliance rules. If small businesses are the backbone of America and large employers receive waivers for compliance mandates on the grounds it would destroy their ability to do business, what will The PPACA do to America’s backbone? This is why I believe that the current healthcare legislation is the most malicious and malevolent act ever passed by the United States Congress. A sales phrase called “Post-Purchase Cognitive Dissonance” (PPCD) means that after a purchase, the buyer may get the feeling that something is not right. In some cases it results in cancellation of the sale; the item is returned or other action taken. Once the transaction is reversed, the buyer feels better. What we citizens have been demanding is reform to the economic relationship between healthcare providers and cost protection mechanisms. Candidate, now President, Obama won election to The White House with that promise. Senator Harry Reid abused long-standing rules of the Senate to pass PPACA; in the House, Speaker Pelosi used an emotional appeal laced with arrogance, urging passage so the country could find out what was in the bill. In early 2009 in a video I posted on YouTube, I warned then that Congress would use “Reconciliation” to pass this because it could not stand up to public scrutiny and that is exactly what happened.

No matter how well-marketed, this legislation has geometrically compounded the problem of delivering affordable health care to all. What we have now discovered is that we do not like its contents. What we got was rationing and, as people understood what was done to them, a groundswell of anger grew. The result was visible last November. Now we want our money back! Unfortunately, the health care industry has become part of everyday life for Americans. Worse, it is too complex for the majority of people to understand. The natural tendency, therefore, is to become frustrated, angry, then walk away muttering about blaming someone else for this mess. The only question now is whether or not the American people will stay focused and continue to hold Congress’ feet to the fire. By their actions in the lame duck session, it is obvious that Democrats don’t think so. The Republicans also fear any potential public resolve because they would have to actually develop a backbone of constitutional principles. However, there is hope to fix this looming man-made disaster. It starts with every single American each learning

about this subject. There is currently ample motivation because this is a different situation than the early 1990’s healthcare costdelivery crisis. This time the problem is compounded because of the longevity of the parents of baby boomers who need more care and the baby boomers themselves simultaneously now drawing down on the system for care. Our education continues by understanding that our healthcare delivery system is a monopoly. You and I cannot hang a shingle outside our office and say we are practicing medicine. From one perspective this is a good thing. It protects the quality of care. It also means a healthcare provider (private physician/ hospital, etc.) can charge any amount that the market will bear. The provider does not have to contract with any insurer nor accept Medicare or payment from any governmental agency for that matter. There are providers in America not contracted with major insurance companies and government agencies, who reimburse for health care services. They still accept cash. They are also a small minority. When the majority of local providers want more money for their services, they do not go on strike. They simply “renegotiate” their contract by quietly raising their fees above the existing contractual allowances in their insurance reimbursement contracts. This ultimately leads to an increase of contractual allowances in various geographical areas as new reimbursement contracts for providers are written. That in turn leads to higher premiums and a perfect monopoly… except for one small problem. There is no additional money to continue this inverse supply and demand equation. In simple language we have addicted our healthcare providers to a steady stream of external revenue sources and that stream is drying up at the most inopportune time, at the highest demand.

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MEDICAL TOURISM The worse solution we could implement is to ration the money because that, in turn, will lead to rationing of healthcare. Yet that is exactly what PPACA did. We wanted healthcare cost-delivery reform and we not only got rationing of money, we got rationing of healthcare. Another crucial component to the problem is the current cost-protection system. The insurance industry is one significant source of cost-protection and government, at all levels is another one. Of course it is understood that consumers are paying more and more as well. Insurance companies raise premiums to cover increasing costs; the public screams about the evil insurers. What about the outcry when government is forced to raise taxes to pay for the healthcare cost protection that its many programs provide?

Wouldn’t it make more sense to design a system that uses the insurers instead of economically strangling them and by extension, America? The only difference is that consumers generally dislike the concept of insurance and there are no regional or national spokespersons extolling its value. On the other hand, we elect politicians who promise to help us get affordable healthcare. I say to Congress no more help, please! A better solution involves factoring in the predictability of human random actions This simple but complex-sounding component is the reason why the new law was mortally wounded on arrival. It seeks to control everyone by uniformly rationing care and federally mandating citizens to buy a product - insurance! To craft a workable solution we must view the situation as a jigsaw puzzle. This means ridding America of The PPACA and crafting a new federal law that addresses true cost-delivery reform. Let’s call it The FEDERAL HEALTH Act. It will not ration care and there will be no federal mandates. This unpredictability can now be factored into the solution. We all function differently - earning power and lifestyles. Each community across the country has its own identity because we are human beings who individually decide where we live, what we do, etc. Everything about each of us is unique. Therefore, we are the key to true healthcare cost-delivery reform, not the politicians and bureaucrats in Washington! It is essential to weave our individuality into a system that allows people to freely move throughout the country and access care wherever they are. This innovative solution is based on capitalism. It injects competition into the present monopolistic system of how health care services are currently delivered. To develop this comprehensive approach, which will lead to a better, affordable delivery system, we do not need to reinvent the wheel. This is going to absolutely shock everyone reading this when I say what a crucial role the IRS needs to play. However, that role is not as an enforcer. The reality is that although we fear and dislike the IRS, like every governmental agency, it is not going away. Therefore, we need to use the IRS

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to ensure that each local community/region gets its share of funds needed to provide care. I see this as a far better use of the IRS instead of how The PPACA creates and funds 16,000 new agents, then charges them with the task of seizing our money to fund an unaccountable, bloated federal government that offers false promises of free healthcare. I have an even deeper question. Why would our federal government mandate the purchase of something we generally dislike -insurance? I unequivocally believe it was NOT done to force you to buy insurance. Instead, President Obama did this to eventually eliminate the insurance industry from the equation. The result is a single payor system. However, what few seem to know is how powerful the insurance industry really is; buildings named after carriers, etc., Like them or not, they move money through our society. Intentionally creating legislation designed to destroy the biggest mover of money through our economy is malicious and speaks to a hidden agenda in The PPACA. Wouldn’t it make more sense to design a system that uses the insurers instead of economically strangling them and by extension, America? It is true that insurers pad every cost factor that goes in a rate under the global umbrella of actuarial science; you either pay the premium or go without coverage. However, The PPACA creates more and more bureaucracies with more and more tax dollars and give us things like the new agency, The PCORI. It is under the direct control of The President. The Patient-Centered Outcome Research Institute ultimately will decide who lives or dies by regulating the care received. How is this better healthcare? Where is the reform? True reform should NOT be implemented by passing a law allowing a group of unaccountable people in The White House under direct control of one person - The President- to implement rules that control your life. In other parts of the world we call this a dictatorship. Having been a guest on radio shows all across our country and a newspaper columnist on healthcare I consistently state one request of all Americans. “Stay healthy. Stay tuned. Get involved. Learn what is being done. Your life now does indeed depend upon it.” n

About the Author Dennis began his insurance career in 1976 after graduating from San Jose State. Immediately Dennis began to specialize in group health insurance. His clients range from small companies to Fortune 500. One of his favorite achievements involves a huge multi-national law firm who in 1997 contacted him out of the clear blue. He walked in and they told him before he sat down that he was their new broker and they needed him to fix their benefit problem. His ground breaking work on this matter set precedent for how the national individually-franchised network of Blue Cross and Blue Shield companies today work across state lines. In 1977 he won a national award for his work in creating what we all know today as Community Health Fairs. In 1986 he began a book (published in 1991) that forewarned of the coming health care cost-delivery crisis, while also offering an innovative solution that is now - almost twenty years later - gaining traction, especially now. Dennis can be reached at Dennis.Wolfe@comcast.net.

ÂŠ Copyright Medical Tourism Association

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MEDICAL TOURISM

Corporate Duty of Care and

Risk Mitigation in the Developing World ~ Medical Evacuation and Outpatient Care for Employees By JOHN M QUINN AND LOLA MAY COKER Across all sectors and industries, the developing world has continued to see market growth and significant foreign direct investment (FDI). Despite recent economic stagnation, and in some sectors, decline in the developed world, developing nations offer great opportunities in manufacturing, construction, and various services in the growing field of peace and stability operations. War, conflict and general political and social instability continue to plague these dynamic environments, and in many regions these are on the rise. 1, 2, 3

isk for the many companies sending workers abroad and hiring local national staff is rising as well. Transnational companies, especially those in the public sphere, have a responsibility to offer Duty of Care to their employees. This Duty of Care applies not only for emergency and medical evacuation situations but also for sub-acute and even chronic medical conditions for employees traveling and working abroad. Identifying risk for employees traveling to the developing and least developed world, mitigating risk for the corporation once in-country and managing risk once exposed are basic principles for any management team with personnel abroad. Health risk assessment for any foreign operation working abroad involves medical best practices, due diligence, health economics and cost effective analysis. This article seeks to better define the risks undertaken by corporations deploying to the developing world, define the risks associated with utilizing both self-insurance and underwritten insurance and examine best practices in mitigating the risks involved with medical evacuations and assistance providers. And finally, we define the responsibilities that corporations must meet and exceed to fulfill Duty of Care towards their employees.

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DUTY OF CARE The concept of Duty of Care in the corporate sector has grown exponentially in recent years. The basic concept in both English and American common law is that the Duty of Care falling within corporate responsibility includes basic health and safety standards and practices for employees. This means that corporations must apply duty of care for employees traveling for work abroad and for basic work in all corners of the globe. We have seen in recent years that this unclear definition has started to apply even to situations when gross acts of negligence by the employee causes them harm. For businesses working in international settings today, Duty of Care includes medical evacuation and medical treatment for workers when they fall ill and need a standard of care. Additionally, “the duty of care addresses the attentiveness and prudence of managers in performing their decision-making and supervisory functions.”4 This ‘business judgment rule’ presumes that directors (and officers) carry out their functions in good faith, after sufficient investigation, and for acceptable reasons. In sum, major companies are increasingly being held responsible

for the medical evacuation and other medical treatment costs for their employees working abroad – regardless of the contract and insurance cover prior to the incident. The risk that serious medical injury and emergency increases while traveling and working is severe.5, 6, 7

SAVE MONEY ~ SELF-INSURE? Most large corporations have found it cost effective to selfinsure for the medical calamities that may befall their employees while traveling abroad or otherwise on the job. Self-insurance is a decision to retain risk within the company, as opposed to transferring the risk to a third party. In self-insurance cases, an amount of money is set aside to compensate for the potential future loss (medical evacuation, extreme medical costs or any other associated loss) by the company. If self-insurance is approached as a serious risk management technique, the money set aside must be enough to cover future and uncertain losses, and actions taken to reduce the probability of the risk occurring, and its impact should it occur. This amount is calculated using the actuarial and preexisting insurance information of the company. The underlying goal behind self-insurance is provision of a necessary service to defined levels at the optimum price, and cost containment through the elimination of annual insurance fees. Purchasing an annual insurance policy (healthcare, medical evacuation or ‘other’ travel medical insurance policy) will cover, subject to Terms and Conditions of the policy, the loss incurred less certain “excesses” which are the amounts that the company will pay on certain types of claims. The real decision is which will cost less, an annual insurance policy or self-insurance?

While the insurance industry is heavily regulated, no regulatory body exercises control over Assistance providers. To minimize the impact of litigation loss from user groups, firms can use a number of risk management approaches, including self-protection, self-insurance, or market insurance. Self-protection involves measures to minimize the occurrence of litigation, including screening clients for high-risk behavior prior to acceptance and continuation.8, 9 The risk that is associated with self-insurance is clear. Many countries have differing legislation for transnational companies that prefer the selfinsure option. In sum, for many companies operating globally, the debate continues to self-insure or not and many decisions fluctuate to fit different markets and dynamic sectors. 10 The case for purchasing an annual insurance policy is not as clear as a financial decision and as a risk mitigation tool. The cost of an annual insurance policy will not only cover the patient’s evacuation and medical treatment but may remove a great portion or even all indemnity and liability from the employer, shifting it to a Third Party Administrator (TPA) or Assistance companies. The TPA is usually an organization that can process insurance claims and handle certain aspects of any employee benefit plans for a separate entity; this can include medical evacuation and coordination. The cost of international health insurance from the large assistance companies and insurance brokers throughout the world has risen significantly in the past ten years. This rise in cost has forced many companies to review their policies and to opt for self-insurance, sometimes without disclosing such directional changes for the health and safety of their staff.11 The initial cost savings of selfinsurance can be quite large, however hidden costs including

self-administration (i.e. selecting appropriate care packages, negotiating fixed tariffs, and handling claims), can lead to unforeseen financial losses and legal exposure. One such small mechanism that can help mitigate this loss is purchasing a “stop loss” insurance policy to pay amounts that exceed pre set claim limits. Stop loss policies are sometimes less expensive than standard health insurance plans and can help to pay for large loss claims. Despite such stop loss policies, Duty of Care may not be fulfilled and exposure not entirely mitigated. This is seen in recent litigation cases. These range from companies not providing appropriate medical or emergency cover for the employees working abroad, companies not reacting promptly to medical emergencies causing injury or loss of life to companies being ill equipped to deal with political and social upheavals. Taking out adequate private Insurance can mitigate all of the above. Self-insurance often results in a fiscal struggle between a positive balance sheet versus patient care. The endless strive for cost containment reduces patient care, decreases medical standards and eliminates continuity of care.12 All this jeopardizes the corporations’ Duty Of Care towards its employees. True mitigation of risk can easily be lost with the company’s first medical evacuation or death of an employee working overseas. Indeed, while self-insurance can lead to immediate financial gain, the strive for cost saving measures may inversely effect medical treatment standards and ultimately employee satisfaction and tenure.

CONVENTIONAL MEANS ~ LESS THAN CONVENTIONAL HEALTH OUTCOMES A word of warning for corporations that purchase private Insurance, while the insurance industry is heavily regulated, no regulatory body exercises control over Assistance providers. It is up to an Insurer to conduct its own due diligence when selecting an Assistance company. Unfortunately there are not many assistance experts within the Insurance industry to be able to distinguish the capabilities of one provider versus another. An Insurer may have their own set of criteria to fulfill when selecting an Assistance provider such as language capabilities, geographical locations, medical expertise, fees or cost containment capabilities and while most Assistance providers can fulfill these requirements there are no formal regulations in place to ensure the provider does not misrepresent its capabilities. Most Assistance companies claim to be offering a comprehensive one stop-shop solution when in fact most outsource work to a number of external providers. It remains up to the Assistance companies to vet these providers to their internal standards and requirements, if they have any, or and this is often the case, to select them without prior investigation and true due diligence. While subcontracting is necessary, as no one company has the capabilities to run a case without the assistance of an external provider, be it a taxi company or a ground ambulance provider there is need for greater transparency and control within the Assistance industry. 13

MITIGATION OF RISK Regulatory compliance with local and international laws of Duty of Care is required for all companies operating abroad. In a recent risk management article printed in the Journal of Peace and stability Operations, Jasbir Dhillon argues that it is critical for organizations to ensure that they have a robust policy for their employees outlining how they may travel safely.14 It is important for any firm working abroad to ensure that their teams are covered on any short or long term work related trips and to ensure that the location and specific travel are

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MEDICAL TOURISM covered on the policy. In 2003, for example, many companies that had purchased insurance before the Iraq War found that their policies did not cover their immediate and emergency workers when first deploying to Iraq. Many companies also lacked standard operating procedures for disasters, including essential contact information and procedural guidelines; some even opted out of drafting a basic travel and work safety policy while operating in war and conflict zones. These negligent actions are not in compliance with the Duty of Care concept, to which companies must adhere.15,16

PROGRESSIVE MEANS ~ UNCONVENTIONAL HEALTH OUTCOMES There are many Assistance providers to choose from, most claim to be the leading industry specialist, to have the most comprehensive suite of services and to offer the fairest pricing structure. The market is saturated with Assistance providers and while some are more experienced, diverse and known than others none can claim to be industry leaders. For an Assistance provider to be truly an industry leader, it would need to set precedence and seek to establish a regulatory governing body to ensure that all Assistance companies operate adequate systems and controls to mitigate significant operational, medical, Duty of Care and financial risks. The Assistance industry is long overdue a transformation to address the shortcomings described above. Likewise the Insurance industry needs to review its selection criteria and ongoing audit function of their Assistance Service Providers. In the current economical climate Insurance companies tend to change Assistance providers as a money saving exercise and whilst for some this is a must rather than an option it is crucial to conduct a comprehensive due diligence prior to making a move to avoid legal as well as financial exposure.

CORPORATE SCRUTINY Despite the many medical programs and travel assistance solutions that corporations have employed for their staff and subcontractors throughout the developing world, many governments such as the United States and the United Kingdom hold ever increasing standards for implementation.17 Adequate insurance must support the health and safety of workers and may provide liability protection when crises such as natural disasters, unanticipated conflict and war and acts of war occur. This paper does not attempt to address all aspects of corporate compliance and duty of care law across borders. Civil law and occupational health and safety laws require significant due diligence practices by all major companies for expatriate and local workers. After all, the imbalance of power between the legislative requirements of companies and the corporation as an entity is explained by the Draconian consequences of an indictment and the elastic notions of corporate criminal liability.18

CONCLUSION Opportunities for work in the developing world are growing and are abundant at present with few signs of diminishing. Corporations continue to deploy workers abroad and hire an increasing number of local employees both in peaceful as well as politically unstable parts of the world. The developing world offers great opportunity for transnational corporations and start-up companies alike, but will only be truly successful when approached with calculated risk. Corporations hold implicit responsibilities towards their employees; Duty of Care is not only the provision of emergency and medical evacuations but also basic medical coverage while traveling and working abroad. Companies must decide whether to self-insure for the provision of medical evacuations and care or to purchase an

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annual insurance policy to fulfill Duty of Care and mitigate risk. Gone are the days of unaccountable corporate risk exposure. n 1 Kahler, M, Walter, B, Territoriality and Conflict in an Era of Globalization, (ISBN-13: 9780521675031 | ISBN-10: 0521675030) 2 Echevarria, LTC Antulio J. GLOBALIZATION AND THE NATURE OF WAR, US Army War College, Strategic Studies Institute, March 2003 ISBN 1-58487-118-0 9, accessed August 12th 2010: http://www. strategicstudiesinstitute.army.mil/pdffiles/PUB215.pdf 3 Ritzer, G, The Blackwell Companion to Globalization, Wiley-Blackwell, August 2007 ISBN: 978-1-4051-3274-9 4 Alan R. Palmiter, Corporations: Examples and Explanations, 5th ed. (New York: Aspen Publishers, 2006), 192 5 Prociv P. Deaths of Australian travellers overseas. Med J Aust 1995; 163: 27-30. 6 Leggat PA, Carne J, Kedjarune U. Travel Insurance and health. J Travel Med 1999; 6: 243-248. 7 Hargarten SW, Baker TD, Guptill K. Overseas fatalities of United States citizen travellers: an analysis of deaths related to international travel. Ann Emerg Med 1991; 20: 622-626. 8 Huss, H.F. and Jacobs, F.A. “Risk Containment: Exploring Auditor Decisions in the Engagement Process”. Auditing: A Journal of Practice and Theory, Fall 1991: 16-32. 9 Johnstone, Karla M. “Client Acceptance Decision: Simultaneous Effects of Client Business Risk, Audit Risk, Auditor Business Risk, and Risk Adaptation”. Auditing: A Journal of Practice and Theory, Spring 2000. 10 Jason, T, Global Implications of Admitted, Non-Admitted and SelfInsurance, Risk Management, Saturday October 1st, 2005 11 Kreuze, J, Newell, G, Langsam, S, Self-insurance: Should corporations make disclosures? Journal of Corporate Accounting & Finance, Volume 8,Issue 2, pages 133 – 138, Winter 1997, DOI: 10.1002/jcaf.3970080211 12 WILSON v. REBSAMEN INSURANCE INC, O’Neal WILSON, Appellant, v. REBSAMEN INSURANCE, INC. d/b/a Insurisk Insurance Services, Jim Moorhead, and John Doe, Appellees. No. 97-14. December 04, 1997 13 Actuarial Standard Board, Actuarial Standard of Practice No. 12 , Risk Classification (for all areas of practice) Developed by the Task Force to Revise ASOP No. 12 of the General Committee of the Actuarial Standards Board, Adopted by the Actuarial Standards Board December 2005 Doc. No. 101 (accessed August 12th 2010: http://www.actuarialstandardsboard.org/pdf/ asops/asop012_101.pdf) 14 Saltanat Berdikeeva, Journal of International Peace Operations, Volume 6, Number 1 – July – August 2010, page 9 [available at: http://web.peaceops. com/pdf/journal_2010_0708.pdf] 15 Keith, N, Walsh, G, International Corporate Criminal Liability in the Workplace, Serving the Specialist of the Safety, Health and Environmental (SH&E) Profession. Also Available at http://www.asse.org/practicespecialties/ docs/CoPSArticleoftheMonth8-09.pdf and http://www.asse.org/ practicespecialties viewed September 14th 2010. 16 Carel H. T., Contracting for helicopter emergency transport services. Healthcare Financial Management, Sunday, August 1 1993. 17 Bagshaw, Roderick; McBride, Nicholas (2008). Tort Law. Longman. ISBN 1405859490 18 Jonathan N. Rosen, Journal of International Peace Operations, Volume 6, Number 1 – July – August 2010, page 19 [available at: http://web.peaceops. com/pdf/journal_2010_0708.pdf]

China Soars ~ Beijing United Family Hospitals & MEDICAL TOURISM

Clinics Take Lead

“I

n China, we are seeing a growth in patient numbers who seek all types of different procedures ranging from Traditional Chinese Medicine (TCM) to Orthopedics. Beijing is an ultra-modern, world-class city that continues to boom after hosting the 2008 Olympics, and Shanghai is arguably the most dynamic city in the world.” Kahn said. In reality Thailand, Singapore, Hong Kong (SAR), and other such hotspots certainly are the standard when one thinks of warmer destinations with beaches and natural places to recover from illness. Therefore, it is likely that Southeast Asia will continue to be the region’s leader in medical tourism in the foreseeable future. The main Beijing United Family Hospital is located in Beijing’s Lido area northeast of the city. Beijing United Family Hospital and Clinics (BJU), the flagship facility of China’s first and largest foreign-invested international healthcare group, United Family Healthcare (UFH), is one of China’s only two truly full-service international standard hospitals — the other is

its sister, Shanghai United Family Hospital and Clinics (SHU). BJU has internationally recognized and certified doctors from 15 different countries and regions, including the U.S., U.K., Australia, Belgium, China, Malaysia, Hong Kong and Canada, and a fully English-speaking, 180-strong nursing staff treating patients from over 110 countries every month. A full-service, 50-bed, inpatient and outpatient facility, the United Family Shunyi Clinic is a satellite facility that provides family medicine and dental services in Beijing’s Shunyi villa area near Beijing’s airport. In addition, the United Family Liangma Clinic in Beijing’s new No. 3 Embassy area is located behind the U.S. Embassy and provides primary care services. The United Family Jianguomen Health and Wellness Center provides several governments like the United States, Australia and Spain with health-check services for thousands of Chinese traveling abroad in addition to other community care. The newly opened United Family New Hope Oncology Center, located only a few blocks from the main hospital next to a

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MEDICAL TOURISM park, is China’s first state-of-the-art cancer treatment center. It provides a unique, multidisciplinary effort in a comfortable environment and is designed to improve the quality of life for each patient receiving day treatment. It is China’s first medical facility built to the U.S Green Building Council’s LEED standards of environmental sustainability. In fact, the ribbon was recently cut by the U.S. Secretary of Commerce, Gary Locke, during the opening ceremony. With unmatched quality of care at all our inpatient and outpatient facilities, BJU is proud to be recognized by the Chinese government, the U.S. government and international medical groups alike as the clear exemplary leader in China’s private healthcare field. Since opening in 1997, BJU has become the healthcare provider of choice for thousands of families in Beijing due to its emphasis on patient-centered quality care. With the highest standards in medical practices and management, we ensure that patients are pampered. We offer premium, single-bed VIP services, highly trained staff from Korea, Japan, Russia, China, Europe and elsewhere, and a range of other detailed service practices similar to those of fivestar hotels. In early 2011, BJU will triple in size and become a 100-bed, ultra-modern medical facility that will greatly expand in capabilities and services for patients in Beijing.

China’s first medical facility built to the U.S Green Building Council’s LEED standards of environmental sustainability. Please tell us more about UFH in China and treatment opportunities for medical tourists. Beijing United Family Hospital is a full-service hospital and a pioneering, international standard healthcare organization in China whose sole mission is to provide comprehensive, integrated healthcare services in a uniquely warm and caring patient and family service-oriented environment. • Dentistry, Orthodontics and Implants • Dermatology and Laser skin care • ENT (Ear, Nose and Throat)

• Oncology • Ophthalmology • Integrative Medicine, including Traditional Chinese Medicine (TCM) o Acupuncture o Nutrition & Wellness consultation o Naturopathic medicine o Smoking cessation program • Radiology/Imaging including the latest CT scanners, digital X-ray ultrasound equipment

What is the role Beijing UFH will take within the medical tourism industry? To date, Beijing United Family Hospital has been a medical destination for patients from areas in East Asia where premium medical care is unavailable, such as eastern Russia, Mongolia, Khazakhstan, Turkmenistan, Tajikistan, some South Asian countries and elsewhere in the region. Additionally, the

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majority of our patients continue to come from Beijing’s expatriate community, representing over 110 different countries and living, working or studying in China for short or more permanent stays. We often provide medical services for visiting U.S. delegations such as the White House and U.S. government whenever American presidents come to China. We are also the designated medical facility for the National Basketball Association, Major League Baseball, National Football League, international television stations, Hollywood movie productions teams, several petroleum companies and a host of other Western organizations when they visit, perform or carry out long-term projects in China. BJU has a membership database that includes direct agreements with hundreds of multinational corporations, as well as partners like International SOS and dozens of the world’s top insurance companies like BUPA, Blue Cross, Cigna and Aetna, with which we have direct billing arrangements. As one of the few hospitals in China possessing Joint Commission International Accreditation, UFH’s commitment to offer world-class services to international patients is quite clear. How did you reach the decision to pursue such accreditation and what do you believe are the top benefits from this accomplishment? Obtaining JCI accreditation ensures patients that we at UFH have a commitment to improve constantly the quality of patient care and recognizes us for having the highest level of excellence in regards to patient care and safety. BJU was the first hospital in China to be accredited by JCI in 2005. Currently, together with Shanghai United Family Hospital, it comprises China’s only accredited quality healthcare network. The goal of UFH is to be at the very pinnacle of quality medical service in Asia by offering the best in international standard care; JCI accreditation is a tremendous measure of our efforts. One of the biggest concerns of expatriates coming to China is the availability of quality healthcare. With our JCI accreditation, they are given considerable piece of mind. UFH is often the first point of contact for many embassies and multinational companies once they determine our service level, and JCI accreditation speeds this assessment process. We

also see benefits when working with international insurance companies that quickly recognize the effort we put into receiving such accreditation. Government support is an essential part of a destination’s success in offering their services to international patients. How is the Chinese Government reacting toward medical tourism and UFH’s involvement in medical tourism? The Chinese healthcare scene is changing rapidly this year as the Chinese Government is undergoing a massive three-year healthcare reform process, committing hundreds of billions of U.S. dollars to improving healthcare throughout the farthest reaches of the country. Getting basic healthcare services to 1.3 billion people is the goal. It is not an easy task to anticipate the growth pattern of the medical tourism industry in China for the following reasons: China’s State Council (or cabinet) has just officially encouraged the development of private healthcare, the government is improving the social healthcare system, and the United Family is being used as model for which private healthcare facilities can emulate. We do recognize that several local governments, such as the Shanghai city government, are very keen on promoting medical tourism on a grand scale. While Beijing UFH continues to consider all possibilities in terms of the latest medical service offerings for patients, our main focus is on developing the very best patient-centered, premium-quality care hospitals and facilities to all of our patients as a whole. This alone helps naturally to draw people in Asia to us as they seek the level of trust, care and expertise we bring in treating them.

What procedures are most sought after by patients who travel to you for treatment? We are the only 24/7 International Emergency Room service provider in China, so many tourists and travelers come to us instead of leaving the country. Patients also look to us for treating Trauma and difficult Orthopedic maladies. In addition, our top-notch Primary Care is a very popular service among many Asian executives, seeking preventative, wellness treatment and diagnostics through our thorough Executive Health Check-Ups. Additionally, our Pediatric team is renowned throughout the region. We also receive a large number of international cases, as parents wish to have our experienced physicians treat their children.

Are you offering the same services to Chinese residents and medical tourists? If not, how is it different? Yes, no matter where they are from, all our patients are treated with the same level of quality, personalized care. We have excelled at understanding the cultural sensitivities of patients from different backgrounds. We also offer a number of personalized services to our foreign patients to facilitate their stay at our hospital, such as helping them extend visas, arrange travel and receive translations.

Which nationalities are you seeing the most? Any particular reasons for that? In terms of medical tourists, the answers are Mongolian, Russian, Kazakhstani, etc. In terms of expatriates, American, Canadian, British, Australian, and German patients make up a significant portion of our patient base. However, we monthly have patients from places like Zambia, Fiji, Bulgaria and over 100 other countries, as they are part of diplomatic corporations or multinational companies working here.

What is the difference between UFH in China and a hospital in the U.S.? There is very little difference in terms of management and standard practices in many of the best hospitals in the U.S. However, there are tremendous differences in terms of the level of care we can afford to give patients by capitalizing on the economic advantages of a place like China. As one of the top premium care facilities in the world, United Family hospitals actually offer a standard of patient care that is rarely found in hospitals in most U.S. cities, with an inpatient nurse to patient ratio of 1 to 2 at times. Our nurses, all English-speaking, are mostly trained abroad in places like Australia, Singapore and Canada, and then choose to come back to China to practice. Our patient services staff members are at patients’ beck-andcall, and our medical staff is deeply experienced in satisfying patients and has the very best bedside manner for people from 110 different countries and cultures.

United Family Healthcare (UFH), is one of China’s only two truly full-service international standard hospitals. One thing China has is people, and we take advantage of this for the benefit of our patients. This means that our Chinese doctors have had to go through rigorous training and beat out competition to get to the very highest levels of Chinese medicine. This is before they then chose to practice with us. More and more international physicians are willing to come to China. We can afford to have much more staff, and our arrangement with the medical products division of our company ensures we have top level equipment. Our prices, therefore, can still come in at the 70th percentile of the top 100 U.S. hospital pricing, while in most cases offering a much more personalized and higher level of service.

What are your goals for the future regarding medical tourism? The main goal is to continue improving our quality and personalized care while maintaining a value in the prices offered at other facilities throughout the world, making it more appealing to international patients to seek treatment in China. We also are looking carefully at developing offerings in areas such as stem cell research, functional medicine, wellness, fertilization, genomics and other areas that are increasingly sought after by people across the region and in the West. We see great potential for regional medical tourism in fields. Finally, we are being proactive in outbound tourism; emergency medicine, wellness and preventative check-ups and other premium services, as they are increasingly sought after by Chinese traveling abroad. Beijing United Family Hospital and Clinics is a member of the Medical Tourism Association™ and for more information you may visit www.ufh.com.cn. n Beijing United Family Hospital and Clinics (BJU) (In Chinese “Beijing Hemujia Yiyuan”) Address: #2 Jiangtai Lu, Chaoyang District, Beijing, CHINA 100016 Tel: +86 (10) 5927-7000 / For Emergencies: +86 (10) 59277120 / Email: patientservices@ufh.com.cn

February / March 2011

MEDICAL TOURISM

Overcoming the Challenges to

Wellness in the

Work Place

By KAYE KENNEDY Is your company’s Wellness program waning? Has the program become stale and banal? If so, now is the perfect time to reassess, reclaim and reinvigorate your Wellness program. Starting a program can be relatively easy but maintaining a program takes effort. Wellness programs often get stale, loose touch and stop being effective.

ompanies are busy. The primary focus of any company is to be profitable. Most companies are tightening their belts, looking to cut cost and do more with less. We are all doing this to some degree. But remember this ever important fact: Your employees are your number one asset. The service or product you offer is only as good as the employees who offer it. Take care of them and they will take care of business – your company’s business.

Understanding the challenges that Wellness programs face is important to figuring out how to maximize results and create a successful program. According to the National Worksite Health Promotion Survey (NWHP), there are five primary challenges facing Employee Wellness programs. While these challenges are significant they are not insurmountable. This article will explore those challenges and offer suggestions to help propel your Wellness program forward.

LACK OF STAFF MEMBER INTEREST

A successful employee Wellness program motivates workers – before and after signup.

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Make sure you have a real time understanding of the needs of your employees. Employees are dynamic and everchanging. Your Wellness program must also be. A quick way to take the temperature in the room, so-to-speak, is to survey your employees. A survey is a good way to get valuable data and feedback. Furthermore, employees want very much to be heard. Let them tell you what matters most to them, what

health issues they are facing and what they would like to learn more about. No doubt, you will find some common themes. Be prepared to take follow up once you have heard from your employees. You might also consult with your company’s health care provider. They can provide a group aggregate report that will yield useful information regarding rates of chronic diseases such as diabetes, hypertension, and hyperlipidemia in your employee population. Armed with this knowledge, you can concentrate your efforts accordingly.

10% of your employee base is consuming 80% of the health care costs. If your Wellness program is already established, review past successes. What were employees most excited about in last year’s program? What activity or program component had the most participation and yielded the greatest results? If employees are still talking about the chair massages they received at last spring’s health fair, that is your first clue! Why not build on that by making chair massage a staple in your program? Chair Massage Mondays could be a hit in your organization.

INSUFFICIENT STAFF RESOURCES A Wellness program is not going to run itself. While there are many low cost options and low effort activities that can be done in the name of Wellness, resources will need to be invested to get maximum participation and results. The best way to start is by establishing a Wellness committee that meets regularly. If possible, they should be employees from all levels of the company that represent every department of the organization. Your committee will need a budget in order to be effective. How much you ask? Keep in mind that the return on investment for a Wellness program is generally $3 for every $1 spent and it takes roughly three years for a program to yield significant returns. Companies who invest small tend to see small results. That is not to say that only big investments count. Smart investments make a difference. Make sure your Wellness committee is equipped with the resources needed to create the best possible program.

INADEQUATE FUNDS As previously stated, a good program will need a budget. That budget should allow for the printing of materials, marketing, occasional speakers, fitness classes, and on-site screenings. Whatever your employees deem most important and whatever the company is willing to pay for should be accounted for in the budget. One of my corporate clients did a great job establishing a Wellness committee but the company failed to give them a budget. So, every time I suggested a program offering they had to go back to the Operating Committee to approve the expenditure. While many of the programs were approved they often did not get off the ground because the funding was approved at the last minute. This left little time to market the programs to employees and garner participation. The planning for the next year’s programs now includes a discretionary budget for the committee. Companies should also budget for an incentive program. If your program does not include an incentive program you are missing out on one of the most necessary and effective components. According to Maritz Inc, the world’s largest employee incentive company, “a successful employee Wellness program motivates workers – before and after signup.” I work with clients every day who cringe at the thought of offering incentives. Mention incentives and all employers see are dollar

signs. The reality is that if healthy habits were that popular everyone would be doing it. We all need a little motivation and some more than others. Companies should remember that Wellness programs are indeed an investment and over time, they do offer a great return. Furthermore, incentives do not have to break the bank. Do not underestimate the power of a t-shirt! I have met employees who would kill to have a prime parking space for a month. Ever thought of offering employees an opportunity to have coffee with the boss? I once worked for a company that randomly selected me to have coffee with the CEO. We sat for 15 minutes and he answered my questions and I answered his. Upon my return to my desk, everyone was dying to know how they, too, could be selected to enjoy coffee with the boss. Not to mention, I felt valued as an employee. I particularly like this incentive because it involves upper management, which is critical to the success of any program. There are many such low cost, super effective incentive ideas. Understanding your company culture and staying in tune with your workforce can provide the insight needed to create an effective inexpensive incentive program.

FAILURE TO ENGAGE HIGH RISK EMPLOYEES If your company is like most, 10% of your employee base is consuming 80% of the health care costs. It does not take a rocket scientist to tell you who your primary focus should be when developing a Wellness program. Addressing this segment of your employee base will produce significant returns. This segment, however, tends to be the hardest to reach. I notice that most of the time it is the 5K runners, power walkers, and the Yogis who attend my on-site fitness classes. Their participation is important but they do not represent the 10% that will really move the needle as far as health care savings. To reach high risk employees, survey them to understand what types of activities interest them. I recently did a Lunch N Learn seminar entitled Create a Fitness Program That YOU Love for one of my corporate accounts. While the group was small, it was mostly

February / March 2011

MEDICAL TOURISM the high risk guys that showed up. Many knew they needed to do something about their health but they were never going to be gym rats and had no desire to be tri-athletes. The seminar helped them to discover activities they enjoy commit to doing them and build a fitness program around them. By all means, incentivize these employees (all employees for this matter). Free is always good. Many of my corporate clients pay for the majority of the Wellness programs I bring in. This is an important piece when trying to engage high risk employees. Finally, I believe that at the end of the day my health is ultimately my responsibility. There is nothing wrong with placing some of the onus upon your employees. Why not make some of the programs you offer mandatory for employees who choose to participate in the company’s benefit package?

INABILITY TO ELICIT THE SUPPORT OF UPPER MANAGEMENT I shared my example of how coffee with the CEO affected me. That happened some 12 years ago and I still remember it like yesterday. The company I was with had 3 different CEO changes while I was there but like most of my co-workers, I felt the company thrived more under the CEO who got to know us and got involved in what was happening at our level. I get to speak with members of corporations at every level. Many times I get the approval for programs from VP’s and when I implement the programs to the general population I get plenty of feedback on the success or failure of those programs. The future of a program is more times than not linked to the buy in of upper management. Last year, I launched on-site fitness classes with a small corporate client. Attendance was lackluster. I began to inquire why as I would talk to employees in the hallways. Many were reluctant to participate because they felt they would be perceived as not being serious about their careers if they took a noon hour class. I took that feedback back to the Operating Committee. As soon as department heads and

members of the Operating Committee started taking classes, it broke the ice. Employees followed their lead. Wellness programs are certainly not without challenges. They are a significant undertaking that require constant attention and resources to achieve their greatest potential. Nonetheless, I have yet to hear of a company or an employee regretting their efforts. In fact, those that stick with it are most certainly glad they did. For a list of references pertaining to this article please email Kaye@MBSWellness-SF.com. n

About the Author Kaye Kennedy is certified in group exercise, personal training and Pilates. She is the Director of Corporate Wellness for MBS Wellness, a company that specializes in creating and implementing employee wellness programs. The company provides cutting-edge, hands on consulting to assist companies in achieving the maximum results from a wellness program. The MBS’ team of experts includes doctors, physical therapists, nutritionists, trainers, and insurance brokers. The company offers a comprehensive array of products and science-based programs with proven results – health impact, cost impact, and ROI. MBS Wellness has consulted and/or implemented successful programs for companies like The Boston Store, Johnson Controls, Jamba Juice, the Oakland Athletics Baseball Company and others. To learn more about starting a Wellness program for your employees or enhancing an existing program, visit www. MBSWellness-SF.com, email Kaye at Kaye@MBSWellness-SF.com or call 510.547.1763.

Companies should remember that Wellness programs are indeed an investment and over time, they do offer a great return.

February / March 2011

ÂŠ Copyright Medical Tourism Association

February / March 2011

MEDICAL TOURISM

Antibiotic-Resistant

Superbugs~

A Rising Threat for Medical Tourists By RON NAJAFI, PHD

hose planning travel overseas for medical treatment naturally expect to return home healthier than when they set out. Yet with increasing frequency, health authorities in several countries are reporting a development that puts medical tourists at grave risk. This is the rise of new varieties of bacteria with resistance to nearly all known antibiotics. Here we will briefly describe these particularly virulent types of bacteria, assess the extent to which they are being spread by international travel, and propose ideas for curtailing their further advance.

NDM-1 AND ITS SUPERBUG COUSINS Recent media reports have shared stories of NDM-1 (“New Delhi metallo-beta-lactamase”), a gene carried by bacteria that alters them and makes them resistant to almost all known antibiotics. It can manifest itself in many different ways and

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is often found in bacteria such as K. pneumoniae, which can invade the lungs, and E. coli, commonly found in the digestive tract, triggering conditions such as urinary tract infections and pneumonia. What makes bugs such as NDM-1 so serious is that they are known to be resistant to the carbapenems, often the last “good” antibiotics active against bacteria that already were resistant to more standard drugs. Even worse, their advent comes at a time when many pharmaceutical companies are curtailing the search for new antibiotics in favor of more lucrative product lines.

Research must be undertaken regarding the ultimate impact of antibiotics in the environment. © Copyright Medical Tourism Association

The November 18, 2010 issue of the journal Eurosurveillance focused exclusively on superbugs and how they are affecting healthcare around the world. In an editorial, Dominique Monnet of the European Center for Disease Prevention and Control, who has studied how NDM-1 is spreading in Europe, notes that dealing effectively with superbugs will require the joint efforts of researchers and healthcare providers in many nations. Also vital will be a concerted awareness campaign focused on the transmission of bacteria as well as such issues as the overuse of antibiotics, a point to which we will return below.

MEDICAL TOURISM ~ FANNING THE SPREAD? Some 77 cases of NDM-1 have now been detected in 13 European countries, including Britain, France, Germany, Spain, and Italy, from 2008-2010. About two-thirds were in Britain, and seven of the infected patients have died. Despite news reports in 2010 of three cases in the United States, NDM-1 is not yet widespread in that country. Yet carbapenem resistance has been a problem in the US for about a decade, according to researchers at the Antimicrobial Resistance and Characterization Laboratory of the US Centers for Disease Control.

Congress has urged farmers to stop the overuse of antibiotics in animals because it is creating new, drug-resistant strains of bacteria that can spread to humans. Some researchers fear the global spread of NDM-1 could be accelerated by medical tourism. (In fact, NDM-1 was first identified in 2008 from a patient repatriated to Sweden after treatment in a hospital in New Delhi, India.) As reported by M.J. Streulens et al. in the November 18, 2010 issue of Eurosurveillance, of the 77 cases referenced above, 55 have a recorded travel history, and 38 of these 55 had a link either to the Indian subcontinent or to the Balkan region. Among the 29 cases in the UK, 17 had traveled to India or Pakistan in the year before the detection of NDM-1. Among the 29 cases from other EU countries, 22 had traveled in the month before diagnosis to a foreign country: 13 to India, three to Pakistan, two to Kosovo, two to Serbia, one to Montenegro and one to Bosnia and Herzegovina. Most of the patients with recent travel had been hospitalized in a foreign country prior to the detection of NDM-1. In the UK, 14 of 29 patients had been admitted within the three years before detection of NDM-1 to a foreign hospital, including eight in India, four in Pakistan, one in India and Dubai, and one in Spain. In other reporting countries, 18 of 26 patients had been admitted in the month before detection to a foreign hospital, including 10 in India, five in the Balkans, and three in Pakistan. It appears that the majority of these cases were admitted to foreign hospitals due to an illness or accident that occurred during the journey, although a minority were traveling for medical tourism. Some researchers are calling for incoming hospital patients to be screened for superbugs if those patients had previously received healthcare in countries known to have hosted cases of superbug infection. Additionally, it has been proposed that such patients be isolated in single bedrooms and behind barriers for the extent of the screening period, with isolation continuing if they test positive for superbug infection.

ÂŠ Copyright Medical Tourism Association

THE ROLE OF REFORMS AND NEW TECHNOLOGY What can be done to arrest the progress of superbugs and extend the functional life of our antibiotic arsenal? A set of proposals follows. First, we must stop and assess the use of antibiotics as additives to the feed of our farm animals, and specifically prevent the unnecessary use of antibiotics in animals that are not sick. This is an important part of making the public more aware of the excessive use of antibiotics and the associated potential health risks. In a CBS News report last July, Katie Couric highlighted the overuse of antibiotics in farm animals. Congress has urged farmers to stop the overuse of antibiotics in animals because it is creating new, drug-resistant strains of bacteria that can spread to humans. Next, we should assess and monitor the impact of antibiotics entering our public and farm waste-management systems. Research must be undertaken regarding the ultimate impact of antibiotics in the environment. Sub-lethal quantities of antibiotics are known to create an environment for the development of resistance and multi-drug resistance mechanisms. The fast replication cycles of bacteria coupled with the mistakes made during replication give these pathogens a Darwinian advantage in responding to and overcoming antibiotic drug pressures. We need to monitor the fate of all the mega-quantities of polysporin, Neosporin and Bacitracin that are consumed off the store shelves: do they end up in our wastewater systems and landfills and become a breeding ground for new superbugs? What happens to the groundwater runoff from farms, sewage systems and landfills? Third, we must undertake more research to provide us with safe and effective antibiotics utilizing new mechanisms without the development of resistance. A new class of agents is being developed with a novel mechanism of action that kills pathogens without showing resistance. Such compounds mimic the human bodyâ&#x20AC;&#x2122;s own natural defenses against infection. Since our immune system works without ever creating resistance, there is great potential for studying the effective and rapidly acting molecular defenses that function within us, and creating stable analogs of these molecules. Unfortunately, developing additional antibiotics in existing classes of compounds that are

February / March 2011

MEDICAL TOURISM showing drug resistance may not help. This is because bugs that have developed a resistance to a member of a specific class of drug can apply the same resistance mechanism to the rest of that class. Resistance mechanisms can also be transferred to other bacteria, making the resistance issue a larger problem. Fourth, when we attack bacteria with agents targeted against one particular cellular mechanism the bugs simply mutate that mechanism to make it resistant, and then pass the mutation around until all bugs are resistant and the agent is useless. This will always be true of targeted agents, so we need more of these agents every few years, and limiting their use in agriculture (including aquaculture) is a great idea. We urgently need a parallel initiative in the development of multi-target agents that attack so many targets that the bugs cannot sidestep them. All bacteria are susceptible to phenol and chlorhexidine, even though these compounds have been used since Florence Nightingale. The trick, with multi-target agents, is to make sure that the human host is not one of the targets. Consequently, we need subtle agents that attack multiple bacterial targets, while being non-damaging to human tissues.

A new class of agents is being developed with a novel mechanism of action that kills pathogens without showing resistance.

Finally, we should encourage and incentivize the pharmaceutical and biotech industry to develop safe and effective non-antibiotic anti-infectives that could replace all topical antibiotics for eyes, skin, ear, over-the-counter antibiotics, etc. Once a topical antibiotic develops resistance, that resistant gene will find its way into all sorts of bugs. Bugs love to share survival mechanisms. Overall, we need to understand the sources of antibiotic resistanceâ&#x20AC;&#x201D;whether it originates in farms, sewers, landfills, or other locationsâ&#x20AC;&#x201D;and find ways to save our precious few antibiotics for systemic blood-borne infections. We also must aim for appropriate use of antibiotics in humans and in our farm animals, have a better understanding and guidelines for infection control, and strongly encourage antibiotic stewardship. Otherwise, the overall result will be fewer effective drugs to treat bad bugs. As discussed above, those who are planning overseas travel for medical treatment ought to be aware of the advent of superbugs and the havoc they are capable of causing as they spread from country to country. Although the sheer scope of the problem is intimidating, it might ultimately be resolved through the reform of a range of current practices, such as the curtailment of excessive antibiotic use. Additionally, the development of non-antibiotic antimicrobials may advance treatment options beyond any in wide use today. Antibioticresistant superbugs may loom large as a concern for medical tourists, but they are one that wise choices and new technology can overcome.

About the Author

Ron Najafi, PhD is chairman and CEO of NovaBay Pharmaceuticals, Inc., an Emeryville, CA-based biotechnology company developing anti-infective compounds for the treatment and prevention of antibiotic-resistant infections. He can be reached at rnajafi@novabaypharma.com.

February / March 2011

ÂŠ Copyright Medical Tourism Association

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

THREE LEADING HEALTHCARE CONFERENCES

ONE LOCATION World Medical Tourism & Global Healthcare Congress

ONE EXHIBIT HALL

3X THE TRAFFIC

AN INTERNATIONAL HEALTHCARE DEVELOPMENT CONFERENCE

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