Medical Tourism

Editorial

America is viewed as the land of the great and the land of opportunity.Unfortunately, that is painting a pretty rosy picture that isn’t exactly true. At theend of the day our health care system is broken. It really upsets me that Americansare so disenchanted with our U.S. health care system that some have to traveloverseas. The fact that hard working taxpaying Americans, whether white, black,Hispanic, Indian, or Asian or any race have no access to affordable healthcare in theU.S., while in some cases illegal immigrants get free and better care than Americans isvery frustrating.

The reality is, at the end of the day, almost 50 million Americans have no access tohealthcare, 120 million do not have dental insurance, and the number is growing eachday. Working in the healthcare industry the trend is simple, more and moreemployers are canceling their group health insurance because the cost is too high,and more and more individuals can no longer afford medical insurance.

It gets really bothersome to see the politicians constantly talking about Health Carebeing broken in the U.S. Some offer no solutions. The rest offer unrealistic solutions -Nationalized healthcare, mandatory health care, etc. The politicians talk, but don’t doanything. Massachusetts passed a law, which soon will go into effect and requirespeople to have mandatory health coverage or pay penalties. Hillary Clinton hasproposed mandatory health care also with the possibility of Tax credits. If our healthcare system is broken and costs are too high, then why do politicians believe forcingpeople to buy health care will solve our problem. It will only continue us down anegative path, as each year goes by Americans are forced to pay higher prices for everincreasing cost of health care. Eventually everyone will have mandatory healthinsurance they can’t afford.

Why isn’t anyone attacking the actual problem? Why has not one politicianactually stood up and acknowledged the problem. Some of the major costs of ourU.S. health care system today are medical malpractice, high costs of labor, andinflated costs of medical supplies and prescription drugs. Why do parts for a surgicalprocedure in the U.S. cost almost $9,000, while the same parts by the same U.S.manufacturer for a procedure in India cost only about $2,000? Why does aprescription drug that costs $1,600 in the U.S. cost $800 in Costa Rica? How is itthat a U.S. trained and board certified doctor in the U.S. can perform a procedure inIndia and Thailand for almost up to 80% less than the United States? Why is it thatfor certain heart procedures in Asia, American patients spend almost 5 times longer inthe hospital to recover than American patients in American hospitals? Have we givenup on providing quality care in America, and instead race to send the patient home?

When will Politicians stop putting band aids on our health care problem and reallytry to fix it? When will everyone in America stand up and say enough is enough andband together? Obviously not yet! Because on October 2nd a U.S. farmer traveled toIndia for surgery he couldn’t afford in the United States. In October a single motherof two, who hasn’t been able to hold down a job for two years because of a brokenback and tremendous pain, is going to India for surgery she can’t afford in the U.S.

Apparently, no one cares that we are sending Americans overseas for surgery. Sinceno one cares, then that leaves us one option. We are in a Global Health Care world,and we all need to come together to focus on the best quality of care and bestoutcomes for Americans going overseas. We need to pull together, because MedicalTourism is the only real viable solution to America’s health care crisis. Am I ashamedthat we are sending hard working Americans overseas and insome cases around the world, because that is the only placethey can receive affordable, quality care? Yes, I am. Do Ibelieve that Americans can get care equal to or in some casesbetter care than here in America? I absolutely do.

I hope everyone can come together within this industry andshow everyone how amazing Medical Tourism is, and thecutting edge medicine and care available globally.

By JONATHAN EDELHEIT

The MTA Advisory Board includes

ROBERT K. CRONE MD, President & CEO of Harvard Medical International;

Boston, Mass.

JOHN F. P. BRIDGES PhD, Assistant Professor at Johns Hopkins Bloomberg

School of Public Health; Baltimore, Maryland

PRADEEP THUKRALHead of International Marketing at Wockhardt

Hospitals Group; Mumbai, India

THOMAS JOHNSRUD Senior Consultant, N.A., Parkway Hospital; Singapore

BRAD COOK International Benefits Director at Hospital Clinica Biblica;

Costa Rica

KAMALJEET SINGH GILLGM, International Business Development Unit of National

University Hospital; Singapore

JONATHAN EDELHEITPresident, Medical Tourism Association, Inc.;

Palm Beach, Florida

RENEE-MARIE STEPHANOEsq., General Counsel for Medical Tourism Association

and Editor of The Medical Tourism Magazine

STEPHEN M. WEINEREsq., Chairman of the Health Law Practice of Mintz, Levin,

Cohn, Ferris, Glovsky & Popeo, P.C.; Boston, Mass.

SCOTT A. EDLESTEIN Esq., of Counsel at Squire, Sanders & Dempsey, LLP;

Washington D.C.

DANIEL BONKExecutive VP ~ Central Region, Aurora Healthcare; Wisconsin

FREDERIC J. ENTINEsq., Partner at Foley & Lardner, LLP; Chicago, Ill.

MARY ANN KEOUGHProfessor at Eastern Washington University;

Washington State

DALE C. VAN DEMARKEsq., Member of Epstein, Becker & Green,

PC; Washington, D.C.

KEVIN RYANEsq., Member of Epstein, Becker & Green, PC;

Washington D.C.

LAURA CARABELLOPrincipal of CPR Communications,

Publisher of Medical Travel Today Newsletter; New York

RUBEN TORALProprietor of MedNet Asia, Ltd.; Bangkok, Thailand

DAVID C. KIBBEMD, MBA, Principal of The Kibbe Group LLC;

North CarolinaPresident

Medical Tourism Association

20COLUMNS

JCI CORNERThe Value of Accreditation

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

LEGAL ISSUESSurrounding Medical Tourism

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

BINA BUZZUnaffordability Ebola Spreading Throughout Healthcare

Driven by the number one concern of adults and businesses in theUS, an insatiable, immutable “Unaffordability Ebola” is attackinganother compliant US host: the American healthcare system.BY MICHAEL BINA

EDITORIALS

Time to Rally Around Medical Tourism

FEATURES

Costa Rica: The Great OpportunityVice-Minister of the Costa Rican Council onCompetitiveness, Jorge Woodbridge Gonzalez speaksout about the challenge of competitiveness in medicalservices and international accreditation.BY JORGE WOODBRIDGE GONZALEZ

Who are Those Masked Men?The physicians of Costa Rica undergo educationalrequirements comparable to those in the U.S.

Costa Rica: Big Trip Little CountryTraveling to a foreign country can be intimidating, so inorder to assure a good trip, you should do your researchahead of time.BY RENEE-MARIE STEPHANO

Deep Venous Thrombosis:The Traveler’s Disease

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

5 Elements to Choosingan International Hospital

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

Got a Passport? Gain a Smile.The dental possibilities in Costa Rica are endless andaffordable.BY EUGENIO J. BRENES, DDS

Patient Processing, Clinica Biblica StyleAs the draw to Costa Rica accelerates for medicaltourism, Clinica Biblica has created their in-housemedical tourism company to provide excellent service tointernational patients. We live a day in the life of aninternational patient.

Costa RicaEcotourism to World Class Healthcare

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

Medical TourismMedical TourismDecember 2007

AT A GLANCE

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Medical TourismMedical TourismDecember 2007

AT A GLANCE

ECONOMICSWhat are the True Financial Savings in Medical Travel?

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

Self-Funding Your Medical TravelMedical Tourism is a perfect fit for AmericanEmployers with self-funded health plans.BY JONATHAN EDELHEIT

The Boomers are Coming!The Boomers are Coming!

Every day, almost 11,000 baby boomers turn50 – one every eight seconds. How are wegoing to pay for their healthcare?BY BOB MEISTER

Pay for Performance:Here Today…Here Tomorrow?

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

The Fully Insured MythHospitals should not expect massive amounts of fullyinsured Americans to travel overseas for healthcare.BY JONATHAN EDELHEIT

NEWS & INSIGHTSSelecting a Medical Travel Destination

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

Psychological Barriers toMedical Tourism

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

Planning Your Medical Trip Abroad:Recovery Retreat or Hotel?

While both have their advantages, the medical touristneeds to do their homework to find their home awayfrom home. An interview with Jim Holt ofIntercontinental Hotel Group.BY LOURDES GASPARONI

Engaging Your Family Physician in Medical TravelThe concerns of returning home after surgery are plentiful.How do you bring your doctor onboard?BY THOMAS C. JOHNSRUD

What is Your Country’s Ranking?The World Health Organization surveyed the internationalhealthcare systems in 2000 and ranked the quality of care.Where does your destination fall?

The Lure of Medical Tourism in AsiaWhat makes Americans travel thousands of miles for healthcare?The first world treatment at third world prices is justpart of the puzzle.BY GERALDINE CHEW & NORZILAWATI MT

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Editor-in-Chief

Renée-Marie Stephano, Esquire10130 Northlake Boulevard

Suites 214-315West Palm Beach, Florida 33412

866-756-0811 [email protected] Medical Tourism Association

M E D I C A L T O U R I S M

By GERALDINE CHEW & NORZILAWATI MT

Would you travel across the globe for a heart bypass if it will only cost you atenth of the usual US $122,000?

The concept of medical tourism started thousands of years ago. People have beentraveling across the continents in search of cures for any imaginable illnesses andmaking therapeutic trips for health wellness. In ancient Greece, pilgrims and patientscame from all over the Mediterranean to the sanctuary of the healing god, Asklepios atEpidaurus, and from the 18th century wealthy Europeans have been traveling to spasfrom Germany to the Nile.

In recent years, medical tourism is becoming more popular with patients seekingtreatment for health and well-being purposes abroad.

Why Are People Traveling?

If you can get your ailing heart cured or get your flat-nose fixed at home, why botherto travel across the globe for medical treatment?

Patients seeking treatment abroad are motivated to do so by various reasons. Manyare attracted by the low cost factor or they are simply dissatisfied with the existingmedical care in their home country. Frustrated by the long waiting times, inadequatemedical care and exorbitant medical expenses, many go abroad in search of medical care.

The steep medical costs in America have contributed to many Americans flying toother countries in search of cheaper alternatives. According to the Census Bureau, asmany as 46.6 million Americans were uninsured in 2005. As these uninsured Americansare not able to afford the costly medical care, many will jump at the opportunity ofgetting treatment abroad at a fraction of the price at home.

In the UK it is not uncommon to hear patients grumbling fromhaving to wait for as long as six months to get treated by thepublic health service due to the system being too stretched tocater to everyone. Otherwise they will have to opt for privatehealth services which is very expensive.

The Guardian wrote a classic case example on the medical carehiccups in Britain. George Marshall, a violin repairerfrom Bradford was diagnosed with coronary heart disease.He was told that he could either wait for up tosix months for a heart bypass operation on the National HealthService or pay $38,000 to go under the scalpel immediately.He chose to outsource his operation to India instead. He wentfor an operation at the Wockhardt Hospital and Heart Instituteand paid only $9,763.24 for surgery including travel expenses.

Research and studies have shown support on the increasingtrend in medical tourism.

Dr Arnold Milsein, medical director of the United States basedmedical group Pacific Business Group, told a U.S. SpecialCommittee on Ageing in 2006 that the typical combinedhospital and doctor’s charges for operations in “technologicallyadvanced hospitals in lower-wage countries” such as Thailandwere 60 to 85 percent lower than charges in the US hospitals.

An independent survey on medical tourism prices in 2006 byEuropean Research Specialists commissioned compiled data from108 clinics, hospitals and healthcare providers in 30 countries.Research revealed that patients from UK can save up to 80percent by going overseas for surgery and medical treatment

Medical Tourism Takes off the Runway

Medical tourism is made possible and has gained popularitydue to the advancement in medical technology, more affordabletravel and the availability of information provided by the massmedia.

As medical costs accelerate, patients are finding alternativesfor low-cost treatment, and going abroad to get healthy seemsvery appealing. Lured by the promise of high quality,reliable medical care at a lower cost, patients areflying across the globe for medical treatment that theyotherwise would not have access to easily due to prohibitivecosts, long waiting time or unavailability of treatment in theirhome country.

The promise of medical care and the attraction ofexotic places are taking people places for medical care.

First World Treatment at Third World Prices

International patients are flocking to Asia for elective andcosmetic procedures, an increasing pool of patients are gettingtheir ailing heart fixed or have hip replaced in countries such asSingapore and India.

Choices are also not limited to medicine or western treatment;there are growing interests in alternative medicine providingholistic therapy to patients. Alternative medicine such as

6 DECEMBER 2007

Ayurveda, acupuncture, osteopathy,chiropractic and homeopathy etc. are gainingpopularity among medical tourists. Countriessuch as China and India are promoting alternativemedicine to international patients searching forholistic cures.

Hospitals in Asia are carving out an outstandingreputation for themselves, drawing overseaspatients with top-notch doctors, low cost,high-tech equipments and high quality patientcare. Countries such as Thailand, Singapore,India, Philippines, South Korea and Malaysiasee a combined 1.3 million tourists each year formedical treatment. This move is expected tocontribute at least US $4 billion by 2012 to theAsia medical tourism industry and US $40 billionglobally.

Experience Asia’s Best

Amazing ThailandThailand better known among foreigners as a

popular destination for leisure tourism hasearned for itself a name in the medical tourismindustry. The Thai government is quick inrealizing and identifying the great opportunitiesthat medical tourism will bring. They have madesignificant inroads as an early investor in medicaltourism with strong support from the healthcareinstitutions in the country, making Thailand intoone of the leading medical tourist destination inAsia. The medical tourism industry is expectedto attract two million medical tourists intoThailand by 2012.

Hundreds of hospitals and clinics catering toforeigners are establishing themselves across thecountry like mushrooms on a rainy day. Theyoffer everything from dentistry and cosmeticsurgery to heart operations and sex changeprocedures to preventive care and healthtreatment.

Catering to the alternative medicine market,Tria, the new kid on the block introduced intothe market by the Piyavate Hospital is aspecialist spa promising to bring wellness to anew level. Equipped with the latest in modernscience combined with homeopathic and othertreatments to provide preventive care and healthtreatments, the four storey complex boasts 19consultation rooms, four detoxification roomsand two colonic-hydrotherapy rooms.

Incredible India

Medical tourism is not new to India – housingsome of the world’s best medical care providersthat are equipped with technologicalsophistication and infrastructure, India drew anestimated 150,000 overseas patients last year.Coupled with its vast experience in dealing withoverseas patients, medical tourists have noqualms about traveling to India to receive medicaltreatment.

The Escorts Heart Institute and ResearchCentre ranks as having the best cardiac hospitalin India. Equipped with state-of-the-artinfrastructure and equipment, the 332-bed

Institute has nine operating rooms and carriesout nearly 15,000 procedures every year.

The Wockhardt Hospitals Group has anassociation with Harvard Medical International,the global arm of the Harvard Medical Schooland is the first super specialty hospital in SouthAsia to achieve accreditation from JointCommission International (JCI), USA. Thisestablished Group has a chain of super specialtyhospitals such as Wockhardt Brain & SpineHospital, Wockhardt Hip Resurfacing Centreand Wockhardt Liver & Kidney Institute,Kolkatta, catering to specific needs of theirpatients.

Uniquely Singapore

SingaporeMedicine, a multi-agencygovernment initiative, aims at developingSingapore into one of Asia’s leading destinationsfor international patients. Looking at thevisibility that Singapore has gained as a topdestination for medical travelers, SingaporeMedicine is fast on its way to achieving thisobjective. Through their aggressive campaigns,Singapore is expected to attract over one millionforeign patients annually by 2012.

Singapore’s efforts in promoting medicaltourism have shown success. According to recentreports, Parkway Group Healthcare received170 Russian patients last year with average billbetween $10,000 and $60,000 for each patient,and Raffles Hospital, for example, boasted a 36percent of its occupancy by foreign patients.

DECEMBER 2 0 0 7 7


WOW Philippines

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

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

Jade del Mundo, Health Undersecretary of the Philippines said that atotal of 200,000 foreigners came to the Philippines for medical treatmentsuch as cosmetic surgery and eye or dental treatments. He said that thebustling medical tourism program of the Philippines is expected tocontribute between US $300 million and US $400 million next year. ThePhilippines health department, estimates as much as US $200 million hasbeen generated from medical tourism alone.

Medical Tourism Whetting Appetites

The spurt in the industry has created a vacuum that is quickly being filledwith organizations or professionals eager to capture a share of the pie.Everyone from finance, insurance, travel, hospitality as well as healthprofessionals, who have seen the potential of this industry with itsgrowing audience, are looking for opportunities to fill in the gap in themedical tourism puzzle.

Though many are eager to be the right pieces in the puzzle, many are stillstruggling to get the right fit. There are a number of concerns and riskfactors for patients getting treatment much less seeking them abroad.

Some additional concerns for patients include a consistent quality of care,lack of extensive dialog between the patient and the doctor, lack ofpost-op follow up, cultural differences and difficulty in obtainingsufficient insurance coverage.

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

Medical Tourism – The Other Side of the Story

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

The Medical Tourist

There are many testimonies supporting the claim of quality medical careand low cost expenses by those who have been there and done that,however what about the potential medical tourists.

Where can they find quality information on the services provided abroad?How do they know who’s good and who’s not. Although there are a fewindisputable medical centers who have already carved their name in theindustry, there are a great many more that are less well known. Should thishave a bearing on whether they are capable of providing quality healthcare?

Take for example India; there are thousands of hospitals sprawling acrossthe country. Some have already been identified as the place to go formedical treatment, however, there are still many that are below the radar.The richer hospitals are able to afford to provide patients with the luxuryof five star accommodation and service with equally advanced treatmentsand services, but the hospitals that are less well funded are only able toprovide medical care minus the other peripherals. So how do the medicaltourists choose?

Medical Tourism Riding on the Waves

The term and concept of modern medical tourism may have been aroundfor the last decade but it is still in its infancy stage. There are manychallenges and obstacles ahead as with any burgeoning industry.

There are a few players who are already paving the way and leadingfrom the front but there is significantly more who are jumping onto thebandwagon. It is crucial that in this race to be the best and offer the most,the travelers/patients do not get ‘marginalized’ in the industry.Continuous training for healthcare workers to ensure consistent qualityof care is essential as is consistency in the service that a patient receivesbefore and after deciding on their doctor or the medical centre where theywill be receiving treatment. Medical referrers and those providingconcierge services need to have a strict understanding of the quality ofmedical care provided by those that they are affiliated with and ensurethat that information as well as the risks is clearly brought across to thetravelers.

Each player must play their part in ensuring that the medical tourismindustry will continue to grow and benefit those that are in it – bothpatients and providers.

Both Authors work for Avail Corporation, which had puton a conference called International Medical Travel Conference(www.MedicalTravelconference.com), in November 2007 atManila, Philippines.

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

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SELECTING A MEDICALTRAVEL DESTINATION

By DARREN TAN & DR JEREMY LIM

According to the National Coalition on Health Care,approximately half a million Americans travelledinternationally to seek surgical treatment in 2006. Thistrend looks set to continue increasing with the populationaging and the prospect of lower healthcare costs in Americanowhere in sight.

There are 4 D’s one should consider in selecting a medicaltravel destination which have been described by Dr RomeJutabha of UCLA: “Domain, Doctors, Data andDisaster.” Let’s deal with each one in turn, but before that,a few words about the importance of the country ofdestination.

COUNTRY-SPECIFIC INFORMATION

Being left hanging high and dry is the last thing youwould want while you are convalescing. Thus, it isimportant to assess if the country that you would bevisiting is generally safe and has an adequate regulatoryframework to protect you, the consumer. Good sources ofinformation include the US State Department’s regulartravel advisory for US citizens and a recent World Bank

publication – Governance Matters 2007: WorldwideGovernance Indicators 1996-2006. The latter rankscountries in terms of their political stability, governmenteffectiveness, regulatory quality and rule of law, andcontrol of corruption.

Another important consideration would be on who themain driver of medical tourism in the country is. If it weredriven primarily or regulated strongly by the government,then there would be greater assurance that theinternational consumer would be adequately protectedbecause the country’s reputation would be at stake.

Lastly, as most blood banks are run by national orregional governments, it would be prudent to check thequality of the blood supply and the rigor with which bloodis tested for infectious diseases such as HIV and hepatitis.

HOSPITAL-SPECIFIC INFORMATION

Domain- What is the hospital’s clinical focus? Is thehospital really a specialist in the procedure you areundergoing? There is little point travelling thousands ofmiles if the attending physician is not an expert.


With advertorials from international healthcare providers increasingly commonplace, it can be challenging to distinguishbona fide foreign hospitals from fly-by-night outfits which are out to make a quick buck. Offered here is a consumer decision-making

checklist that ensures you board the plane knowing that you will get the care you need at a price you are comfortable with.

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Doctors and Hospitals- The qualificationsof the doctors are important but as U.S. boardcertification requires specialist training to beundertaken in the U.S. and not anywhereelse, there would be relatively few doctorsin the world having American board certifiedqualifications compared to the number ofoverall physicians. Membership and fellow-ship of the Royal Colleges in the UnitedKingdom are the main specialistqualifications for much of theCommonwealth countries in the world suchas Singapore which is a major medical traveldestination. Accreditation with JointCommission International (theinternational arm of the JointCommission) is the usual ‘mark of quality’for hospitals outside the United States butthere are many other accrediting bodies suchas Trent Accreditation Scheme in the UnitedKingdom.

Experience is probably more relevant giventhe diversity of medical qualifications andaccrediting bodies globally. The doctorstreating you should have a good track recordin the procedure and be able to tell you theirown personal results as well as that of thehospital. While scientific publications andconference presentations are not essential toclinical expertise, they are a useful measureof peer recognition and the standing of your

attending physician in his or her medicalspecialty.

The number of clinical trials the doctor orhospital is involved in can also be telling.Pharmaceutical and medical devicescompanies will only work with doctors andhospitals that meet their stringent standardsto be trial sites and you can capitalize on thebackground checks done by them todouble-check the standards of the hospitalyou are about to enter. For example,www.clinicaltrials.gov (a website hosted bythe National Institutes of Healthdocumenting clinical trials worldwide)

Darren Tan. MHS (Mgt), BSc (Biology)leads the Outcomes Research team at theSingHealth Centre for Health ServicesResearch. He and his team worksextensively on evaluating clinicalinterventions, which forms the bridgelinking the endpoints of practicesand interventions with their effectiveness.

Dr Jeremy Lim. MBBS, MPH, MRCS(Edin), MMed (Surg), a surgeon bytraining, Jeremy leads the SingHealthCentre for Health Services Research. Hehas written and lectured widely on healthpolicy and maintains a personal andprofessional interest in public healthcarequality and accessibility for all, especiallythe poorest segments of society.

records that the Singapore National EyeCentre is currently involved in 18 clinicaltrials (Site accessed on Sept 12, 2007).

Data- Nothing beats knowing the doctors’ andhospital’s results are publicly available.However, while many hospitals publish onlinetheir own results, it is often unclear how thedata is collected and whether the data has beensubject to external audit for accuracy. It wouldbe much more reassuring if an independentbody such as the government centrallycollates and publishes this information and thisis already happening. In New York City, theNew York City Health and HospitalsCorporation has begun to put online theoutcomes of certain diseases such aspneumonia and heart attack includingcomplications such as infections. In Singapore,the Ministry of Health regularly publishes notonly the clinical outcomes of procedure, e.g.Lasik and cataract surgery, but also the pricepatients pay for them. Another measure ofreliability of data is the publication of resultsin peer reviewed publications such as the NewEngland Journal of Medicine and the Lancet.

Disaster- Despite the best efforts ofeveryone, disasters can and do happen inhealthcare and you want to know you willreceive the best possible care if somethingunfortunate occurs. As mentioned above, checkthat the blood supply is safe. If you areseeking treatment at a hospital that adopts a‘focused factory’ approach, i.e. it onlymanages heart diseases or orthopedicconditions, then make sure that the hospitalhas ready access to all the specialists youmight need in a medical disaster, e.g.nephrologists in case of post-operativekidney failure requiring dialysis, infectiousdisease physicians for post-operative woundinfection etc.

Traveling outside the United States issomething Americans are seriouslyconsidering in ever-increasing numbers. Likeany other overseas venture, there will alwaysbe uncertainty, but the savvy patient canminimize risk by carrying simple checks andasking the right questions before leaving theU.S

Being left hanging highand dry is the last thingyou would want whileyou are convalescing.

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TheValue of

AccreditationWhy Americans Needing Health CareAbroad Should Choose JCI-AccreditedFacilities

By KAREN TIMMONS

President and Chief Executive Officerof Joint Commission International

As Americans seek care in other countries, they lookfor reassurance that health care organizations abroad meetcertain quality and safety standards they have come toexpect. Therefore, hospitals abroad who hope to attractAmericans to their institutions often seek JointCommission International (JCI) accreditation, which isendorsed by the World Health Organization, because itdemonstrates to the international community that thehospital has voluntarily sought an independent review ofits commitment to safety and quality, and has metstandards that contribute to good patient outcomes.

But in addition, overseas hospitals tell us that they seekour consulting services and accreditation because ourstandards help them learn a common language – like thatused by air traffic controllers – which ensures safety andconsistency in the delivery of health care. Every hospitalearning JCI accreditation must also set up parameters for asafe organization and meet JCI’s International Patient Safetygoals.

JCI is part of Joint Commission Resources (JCR), an affili-ate of the U.S.-based Joint Commission. The Joint Com-mission accredits over 90% of hospitals in the United States.JCI extends the Joint Commission’s mission, which is toimprove the quality and safety of patient care, into theinternational arena through international consultation, pub-lications, education, and accreditation.

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JCI is Different from JC Accreditation in the US

JCI accreditation standards are comparable to JointCommission accreditation standards, but they are different. Thedifference is that the JCI standards and survey process were adaptedfor the international community and designed to be culturallyapplicable and in compliance with laws and regulations in countriesoutside the United States. For example, informed consent bypatients is a JCI requirement, but different cultures handle this indifferent ways. In some cultures, patients fill out a form in front ofa witness, while in others a family member may be the only oneallowed to give consent. JCI accreditation allows for thesedifferences.

JCI standards were developed by an InternationalStandards Subcommittee made up of experts representing five majorregions of the world. These standards address important topics suchas the qualifications of doctors and nurses, properly assessingpatients to match care to their identified medical needs, anesthesiaprocedures, and safe use of medicines.

In addition to accreditation, JCI has extensive internationalexperience working with public and private health careorganizations and local governments in more than 60countries. Part of meeting JCI’s mission is helping individualcountries develop their own accreditation programs. In manycountries, JCI works with the ministries of health to develop theirown standards and establish their own accrediting bodies. JCI’sstandards have also become a model for standards developed bygovernments around the world.

We believe Americans can receive high quality careinternationally, but first, patients needing care abroad must carefullyresearch the physicians and health care organizations they areconsidering using and visit our website to determine if the hospital isaccredited by JCI. Using a JCI-accredited hospital is basically arisk-reduction activity because when hospitals improve patient careand safety, patients are more likely to have good outcomes.

Americans using JCI-accredited hospitals will also find otheradvantages. JCI accreditation requires that every patient is spokento in a language and manner they can understand and that patientsare involved in their care decisions. Patient rights must be protected,including confidentiality and privacy. When a patient prepares toleave the hospital and return home to his country, werequire that the hospital transfer information to the patient andprovide recommendations for follow-up care at home. All of thesesteps make it less likely the medical traveler will have some type oferror or problem with his care.

How Accreditation Works

JCI accreditation is a rigorous process for which most hospitalsprepare at least a year, if not longer. JCI accreditation is for a periodof three years. After three years, JCI will conduct a full, onsitesurvey. Before accrediting a hospital, JCI sends in a team, usuallyincluding a doctor, nurse, and administrator, for a period of 3 to 5days. Although at this time, the JCI surveys are announced visits,JCI may move to unannounced visits in the future.

Our surveyors use a tracer methodology, which is asystems approach, rather than just examining eachdepartment within a hospital. We believe the best way to gauge thequality of care provided by an institution is to trace the journey ofpatients as they move through the institution and examine howvarious departments work together to provide the care they need.Typically we trace 8 or more patients during our site visits.

JCI has approximately 300 standards which hospitals must meetand 1200 measurable elements which is what surveyors examine andscore. Before leaving, surveyors conduct an exit interview withadministrators, and hospital leadership is given a copy of thepreliminary report, which allows them to know whether or not theywill likely receive accreditation. All reports are confidential; all weshare with the public is a list of the hospitals currently accredited byour organization.

There are approximately 140 JCI-accredited hospitals in 26countries. For the names of these hospitals or more information onJCI accreditation, you can visit our website atwww.jointcommissioninternational.com.

Canadian Firms Pushing Cuban Healthcare

Two Canadian-based medical tourism companies are offering overseasmedical care to Cuba. That’s right, even though the US embargo makes itillegal for Americans to spend money there for treatment, these firms believethat the rising costs of healthcare may make some Americans take theplunge. Cuba currently boasts patients from Spain and Italy and manyother countries and is known for high standards of care. While the issue ofhigh standards is often disputed, no one can dispute the cost savings,with prices at about one third of the cost in the US for some procedures.Nevertheless, with Latin and Central America rising in the industry of medicaltourism, and waiting times for some surgeries in Canada of up to 18 months,there will likely be a great rise in the numbers of Canadian patients headingto socialist Cuba.

JCI accreditation standards arecomparable to Joint Commissionaccreditation standards, but theyare different.

DECEMBER 2 0 0 7 13


MEDICAL TOURISM?Financial Savings in

MEDICAL TOURISM?

MICHAEL D. HOROWITZ, MD, MBA

American patients pursue health care in medicaldestinations primarily to save money. Employers andinsurance companies are exploring offshore healthcareoptions for the same reason. Although there has beenmuch discussion about low costs in medical tourism,the magnitude of financial savings actually realized bypatients and third-party Payors is not always clear.

Insurance Company Savings

For insurance companies, determination ofpotential savings is fairly straightforward. Third partyPayors already know exactly how much they pay fortheir beneficiaries to have care in the domesticmarketplace. First, they must establish what thecharges would be for their beneficiaries to haveequivalent care in medical tourism destinations. In orderto make offshore arrangement acceptable toemployers and beneficiaries, third party Payors willalso have to assume some costs that they would notgenerally cover when care is obtained within the UnitedStates, including travel and certain accommodationsin destination countries. Calculating potential savingsfor any given patient is a simple undertaking forinsurance companies with core competency incollecting and analyzing data. However, projectingwhich segments of their beneficiaries can have – andwill agree to – offshore care is a much morechallenging issue.

Patient Savings

For patients who pay for their own care,determining the potential savings available in themedical tourism marketplace is a more complicatedundertaking. Interestingly, the difficulty is notdetermining charges for offshore care but, rather,establishing what a patient’s expenses would be intheir own hometown. To say what the financialsavings are we must have this latter figure. Althoughit is easy and attractive to use stated charges, I believethat this practice leads to erroneous overestimation ofpotential savings. This practice also disregards thefact that a substantial proportion of the posted chargefor procedures done here in the US is never paid dueto either discounts or defaults.

Getting to Best Price and Terms

The number we should use for the cost of care in thedomestic marketplace is the best price that patientscan reasonably get if they are willing to ask for adiscount and commit to clear payment terms.

In healthcare there is a chaotic relationship betweenthe prices that providers charge and the payment theywill actually accept. Most providers are willing toaccept payment of less than posted charges fromself-pay patients – they already do just this forMedicare, Medicaid and commercial insurance plans.In order to get such a discount, a patient must committo reasonable terms and a clear payment arrangementbefore having treatment. (In the context of medicaltourism, a patient who can arrange care in a foreigncountry has the wherewithal to try to do this.)Providers are much more agreeable to anyarrangement if a patient makes a meaningful depositat the time terms are discussed. The increasingnumber of firms that provide financing for medicaland surgical care may allow patients to negotiate evenbetter prices because this frees providers fromcollection costs and eliminates the risk of default. Theprice that a patient can likely get will probably fallbelow the quoted charge but above the paymentprovided by commercial insurance plans.

My analysis compares the total out-of-pocketpayments for unilateral hip replacement surgery inthe US, India and Costa Rica. The data was obtainedfrom the public web sites of several medical tourismagencies, supplemented by information provided byan experienced agent during a telephone interview. Thequoted price for this operation in the United Statesranges from about US$ 44,000 to US$ 62,000. Forthe reasons explained above, I am using the figureUS$ 40,000 for this analysis. In order to make usefulconclusions, it is necessary to control foruncertainties by making certain assumptions in thisanalysis. First, I assume that there are no additional

Dr Horowitz has been researchingmedical tourism and internationalmedical travel since 2005. Agraduate of the University of MiamiSchool of Medicine, Dr Horowitzpracticed Cardiothoracic Surgeryfor more than 15 years and obtainedhis MBA from Goizueta BusinessSchool of Emory University.He can be contacted [email protected].

14 DECEMBER 2007

charges for postoperative complications in any of the groups. Second,American patients having care within the United States incur no chargesfor travel and accommodations. Third, patients travel offshore in economyclass with one other party – a spouse or other companion.

This analysis shows that the medical savings for unilateral hipreplacement are 86.5% and 83.5% in India and Costa Rica, respectively.The calculated savings are actually quite close to the commonly citednumber of 90%. But American patients are not particularly interested inmedical savings. They really want to know what their total savings willbe since this is what truly affects them. For this analysis of hipreplacement, the total cost savings are 75% for both India and Costa Rica,as compared to what a patient would really pay in the United States,presuming reasonable efforts to get a discounted price. Although medicalcosts are US$ 1200 less in India than in Costa Rica, much of the savingsare consumed by the greater cost of travel to Asia than to Central America.

Opportunity Cost: the Overlooked Factor

Opportunity cost is a very important issue that has not beenaddressed in any analysis of savings in medical tourism that I have seen.If a patient has surgery in their own hometown, their spouse might missa day or two of work. But a trip to a foreign country may well result inprolonged unpaid absence from fruitful employment. Furthermore, if apatient and partner are away for several weeks there may be expenses forchildcare and/or elder care. On the other hand, in certain situations,offshore health care allows some patients to enhance their savings bycombining their medical travel with previously considered or plannedtourism activities. Opportunity costs, the expenses created by absencefrom home and the enhanced savings are extremely variable and not wellsuited to quantitative analysis. Nevertheless, they clearly have a greatimpact on the financial decision for patients considering offshore healthcare.

In summary, this analysis indicates that patients who have hipreplacement surgery in India or Costa Rica realize total savings ofapproximately 75%, compared to estimated best prices that patientscould reasonably get in the United States.

Cost Date

Cost of Medical CarePhysicians

Facilities

Cost to Arrange CareCommission to agentPre-travel evaluationPre-operative labs

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

Cost at DestinationConcierge servicesHotel ( 5 nights)Meals at destination

Analysis

Medical Cost

Medical Cost (% of US Value)

Medical Savings ($)

Medical Savings (% of US Value)

Total Cost

Total Cost (% of US Value)

Total Savings ($)

Total Savings (% of US Value)

$ 40,000

n/a

n/a

n/a

$ 40,000

100%

$ 0

0.0 %

$ 40,000

100%

$ 0

0 %

$ 5,400

$ 800

$ 2,700

$ 1,100

$ 5,400

13.5%

$ 34,600

86.5 %

$ 10,000

25.0%

$ 30,000

75.0 %

$ 6,600

$ 1000

$ 1,200

$ 1,050

$ 6,600

16.5%

$ 33,400

83.5 %

$ 9,850

24.6%

$ 30,150

75.4 %

Destination United States India Costa Rica

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

2007 Michael D. Horowitz

Cost for Hip Replacement at US and Offshore Medical Centers.

So you manage a hospital or work with a hospital outside ofthe United States and you just cannot ignore the fact that the U.S.health care system is not readily available to just about one-thirdof all Americans. It seems like every day you see the same statisticsquoted in the news media, cited by candidates running for politicaloffice or in the trade press, that as many as 50 million Americanshave no health insurance and that at least another 50 million areinadequately insured. You read the complaints of U.S. businessesthat the cost of providing health care benefits is increasing at arate that threatens global competitiveness, if not corporateviability altogether. You see Michael Moore’s documentary, Sicko,and you know that you just might have an affordable option forcare and treatment to many of these Americans. Finally, you thinkyou understand enough of the public policy debate in the UnitedStates over health care to conclude that fundamental change tothe current system is a long way off.

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

Appropriately, you hesitate and wonder what r isks areassociated with this great opportunity. Although health care inthe United States is heavily regulated, raising tax, ERISA, privacy,licensing and insurance issues, more likely than not, the first thingyou think about is medical liability. If you are a provider, youcorrectly wonder if engaging in the care of American citizensexposes your organization and the individuals who provide clinicaland other services to liability in United States courts. If you helpfacilitate obtaining care for American citizens in foreign hospitals,you also wonder if you will find yourself in court. And if so,what does that mean and can the risk of liability in US courts bemanaged sufficiently to justify a business decision to go after theAmerican market?

The American Judicial System

No doubt you already know that the United States is the mostlitigious country in the world and you expect that you might getsued. Inevitably, some US citizen will experience a bad result andyou wonder if your healthcare facility has adequate defenses toprotect you from liability in our courts. Defenses and post-judgment realities such as personal jurisdiction, waiver, choice oflaw and forum selection clauses, theories of medical liability,

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

To best understand how these issues will be resolved, it is helpfulto note which aspects of the United States legal system have andwill affect medical malpractice litigation. In the United States,different jurisdictions with different principles of law, aggressiveand creative lawyers, and the unpredictability of individual judgeswill have a profound affect on the success of a medical malpracticeclaim. As care is delivered outside of the United States, pooroutcomes will inevitably occur. Patients will quickly realize thatlegal recourse outside of the U.S. courts is unattractive andinadequate by our standards. Once retained by the patient, theirlawyers can be expected to examine every step in the process frominitial patient contact to discharge to follow up care at home, tofind a way to get jurisdiction in a U.S. court and to have that courtapply U.S. law. The same creativity and aggressive lawyering thathas made for large judgments and broad liability here will be appliedto these new factual circumstances. A careful examination of oursystem by those looking to facilitate and provide care for Americancitizens may influence decisions about who is treated, how thepatient is treated and how the services of the provider are marketed.

51 American Court Systems

Unlike other countries, the United States does not have a unifiedsingle body of law for the entire country. Although there is aFederal Court System, liability of the type commonly alleged whena patient has a bad outcome is covered by state law. Each state hasits own legislature that makes the law and courts that interpret andenforce the laws. Including the District of Columbia, that makesfor 51 separate jurisdictions with sometimes subtle and sometimessignificant differences in substantive law and procedure. In theearly part of this decade, the medical malpractice insurance crisiscaused many state legislatures to reexamine state medicalmalpractice law. What resulted is typically American. Some statesdid nothing, many states passed reforms and plaintiff’s lawyersimmediately started challenging the constitutionality of the reforms.The differences from state to state may be substantial enough toinfluence where the foreign provider markets its care.

The incentives to sue are high and the barriers to the courts arelow in America. While the law continues to vary from state tostate, it is clear that judgments and settlements are much higher inall of the 51 jurisdictions than in other country. This is largelyattr ibutable to the abil i ty in almost al l s tates to recover

The United States Court Systemand Liability for Treatment of American Patients Overseas ~ Challenging Jurisdiction ~

By FREDERIC J. ENTIN, ESQUIRE


LEGAL ISSUES

16 DECEMBER 2007

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

Lawyers and the Search for Deep Pockets

The expansion of liability theories in medical malpractice law inthe U.S. can be attributed to the constant creativity of plaintiff’slawyers. Physicians typically carry no more than $1,000,000 ofliability insurance for any one claim. As lawyers seek to increasethe size of judgments, they look for other defendants to share theburden of paying for judgments that exceed the amount ofinsurance of any single physician defendant. Medical malpracticeattorneys have responded aggressively and resourcefully byadvocating new theories of liability which open up the pockets ofothers in the continuum of care to joint and several liability forthe same injury.

Starting with the 1967, Illinois Supreme Court decision inDarling, hospitals have been independently liable under anincreasing number theories for the care delivered to patients. Injuredpatient’s lawyers have successfully applied theories of direct andapparent agency to expand the number of defendants against whomliability could be imposed, even when the care is delivered in thedoctor’s office. And in the quest for even larger awards andsettlements, plaintiffs’ attorneys have convinced courts and juriesof the viability of pain and suffering and new basis upon whichtheir clients can be compensated for non-economic damages. Facedwith a client allegedly injured as a result of care in a foreignprovider, it is not unreasonable to expect the same persistenceand ingenuity to be applied to finding a way to bring the claim toa U.S. court under U.S. law. Anyone arguably involved in the careof the patient can be a target.

Judges are People Too

Just as the law may be different from state to state, theinterpretation and application of the law can be highly influencedby the judge before whom the case is tried. In many states, judgesare elected by the citizens of the county or region in which thejudge will preside. While judges are bound to follow the law andthe precedent from prior cases, the application of the facts of anysingle case to the law can be somewhat subjective even in thesame state. Some judges sit in areas of the same state which arevastly different in culture and perspective. In Illinois for example,Cook County could not be any different than its immediate neighborto the west, Du Page County. Judges and juries in Cook Countyare generally known to be more inclined to side with a plaintiffand if so, the size of the judgment is likely to be higher than in DuPage County. Further, as will be discussed later, a judge facing aruling on whether he has jurisdiction over a defendant may bemore inclined to find some basis to take the case if the alternativeis that a member of his community is left with no adequate legalrecourse if injured in another country.

Assuming the business proposition is compelling enough toencourage you to go forward, what are the defenses that can beraised in the event a lawyer wants to get his client’s claim decidedin an American court of law and what can be done to put theproviders in the best position to defend?

Personal Jurisdiction

A court must have personal jurisdiction over a defendant beforeit can enter a valid judgment imposing a personal obligation on thedefendant. Therefore, first line of defense for a foreign hospital orprovider will be to challenge the court’s jurisdiction. Will the factthat you are located outside of the United States, that you haveno offices or employees in the state where the suit is filed, thatyou have not consented to jurisdiction, and the alleged injury

DECEMBER 2 0 0 7 17

Fredric J. Entin is a partner with Foley & Lardner LLP. A member of the

firm’s Health Care Industry Team, he served as chair of the former Health

Legislation/Associations Practice. Mr. Entin has broad experience representing

hospitals and other health care providers focusing on compliance with a wide

variety of issues including antitrust, Medicare and Medicaid, medical staff

and exempt tax law. He has also represented trade associations and their

subsidiaries for many years. Prior to joining the firm, Mr. Entin served as

senior vice president and general counsel for the American Hospital

Association (AHA) for more than eight years. Fred is an Advisory Board

Member of the Medical Tourism Association.


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

Specific Personal Jurisdiction

A court can exercise specific personal jurisdiction over a non-residentdefendant when the defendant’s activities within the state serve as orare related to the basis of the lawsuit. For example, a patient calls amedical tourism facilitator in another state acting as a representativeof a foreign health care provider, and the representative assists thepatient in the selection of a hospital and the patient alleges he has beenthe victim of negligent care. In addition to suing the hospital andphysicians for negligence, the patient might also allege that the decisionto travel abroad for the procedure and the referral to the specifichospital or physician was the proximate cause of the injury. Beforethe defendants are forced to defend the claim on the merits, they canfirst challenge whether there is proof of the requisite connectionbetween the act allegedly occurring in the state in which suit is sought,the recommendation or referral and the injury. An inquiry of thisnature would not extend to the actual merits of the negligence claim,but if the court believes there is a connection, it will exercise specificpersonal jurisdiction and force the defendant hospital and physiciansto defend or face a default judgment. Even if the defendants aresuccessful in getting the matter dismissed for lack of personaljurisdiction, it will cost time and money to defend.

With extensive use of the Internet to reach out to prospective patients,claims of specific personal jurisdiction are likely to arise. Developingcase law tells us that the interactivity of the website consulted by andused by the patient and the hospital, may give a court sufficientgrounds to find specific personal jurisdiction.

It is important to remember that specific personal jurisdiction is for

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

General personal jurisdiction

As opposed to specific personal jurisdiction, general personaljurisdiction exposes a defendant to the jurisdiction of the courtsfor all actions. A court can exercise general jurisdiction over a personif the defendant’s conduct in the state is “continuous andsystematic”. Because a plaintiff bears a higher burden of proof toestablish general jurisdiction, even the use of a highly interactiveweb site on the internet would be less likely to constitute the kindof continuous and systematic presence in the state to give a courtthe basis to assert general personal jurisdiction. However, themore the website becomes a virtual transactional workplace,developing legal precedents might encourage a judge to concludethat the website is no different than a physical office, that thepresence of the foreign defendant is “continuous and systematic”and that there is jurisdiction for all purposes.

Conclusion

Bad results and poor outcomes occur whenever patients receivehealth care. This will be true whether the patient receives treatmentin the United States or abroad. Methods of compensation formedical injuries in other countries are likely to be viewed asinadequate when compared to the American system. Some patientswill understand that limited compensation in the event of a pooroutcome is one of the tradeoffs for going abroad for medical care.Other patients may not be as forgiving. Those who choose to helparrange for care and those who engage in the treatment of Americansabroad must prepare to defend against clever, resourceful andaggressive lawyers and sympathetic judges.

This article has discussed the first line of defense, challengingjurisdiction. While a future article will go into more detail aboutjurisdictional pitfalls, other articles will discuss how to managerisk in the event a sympathetic judge takes jurisdiction and requiresthe foreign health care provider to defend itself.

18 DECEMBER 2007

LOOK FOR JCI ACCREDITATIONThe Joint Commission is a non governmental agency that certifies US hospitals. The International branch of the Joint Commissioncertifies hospitals outside the US health system that have comparable standards to a US hospital. A list of accredited institutionscan be found at www.jointcommissioninternational.com/23218/iortiz.

LOOK FOR EXPERIENCEMany hospitals outside the United States have been providing services to the local population for a long time. Local reputationis a good indicator of good quality. Look for institutions that have been in the market for over 50 years. This would give youconfidence that things would run smoothly since they have experience. Some hospitals care only for locals, some others care fortourism alone. Seek hospitals that provide a healthy combination of locals and tourists.

CHOOSE SHORT TRAVEL DISTANCES OF LONG ONESAir travel increases the risk of certain complications like deep venous thrombosis (DVT). DVT is the formation of blood clots inyour legs. These clots can migrate up to your lungs and create a Pulmonary Embolism, The risk of DVT increases by 2.93 timeswhen flights are over 8 hours and the risk of Pulmonary Embolism is 1.07 times greater in flights over 8 hours. Health tourists whoundergo surgery, are pregnant, smoke, take birth control or suffer from cancer are at higher risk of suffering this condition than therest of the population. There are many ways to reduce the risk. There are other complications from long haul air traveling, like jetlag, changes in air pressure, humidity, oxygen concentrations. A healthy conversation with your local doctor and your physicianat the destination of your care can help diminish your specific risk. The World Health Organization has published a segment onInternational Health and Travel that includes a segment on the health considerations of air traveling. This segment is available attheir website, www.who.int.

SEEK PHYSICIANS THAT SPEAK YOUR LANGUAGECommunication has been the weak point of humanity ever since it came to existence. The risk of communication failure increasesif two people do not speak the same language. Make sure you ask what percentage of staff and doctors speak English or yourlanguage at the Hospital. Avoid surprises.

COMPARE YOUR OPTIONSWe have been mentally trained to trust our doctors. No matter who we are, the white coat has a halo effect that blinds ourconsumer oriented mentality. Comparing hospitals and doctors is a healthy practice since past performance is the best predictorof future outcomes. Google your procedure and educate yourself about the complications and risk of the surgery or treatment.Ask specific questions about these risks and complications including hospital based risk like infection control. If these are beingmeasured and they are willing to compare, it is a good sign of quality management at that institution.

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

Choosing an

International Hospital

We live in a generation of information overload. With so many choices available to us, it is sometimes difficult to discern truth fromfiction and make sense of the mountain of information that is coming our way. This is especially true when it comes to choosing andtrusting the right hospital for our particular needs.

You and I have the opportunity and the capability to interact with thousands of people and organizations via the internet. With thedevelopment of the worldwide web, experts and non experts alike are filling up web pages of blogs and vlogs, having found an interactivespace to share their lives and experiences with the rest of the world.

As far as hospitals go, the internet also allows us the advantage of “visiting and experiencing” a hospital before physically traveling there.Additionally, sites such as MySpace, Facebook, Hi5 or LinkedIn, help us to find information that will assist us in making a sound decisionabout which hospital to choose. The downside is - these sites also expose us to a variety of opinions and criteria that are hard to verify andcould skew reality. In other words, how do we sift through this mountain of information and ultimately make the correct decision aboutthe best hospital for our needs? Below are some tips to make sense of all that information:

By LIC. BERNAL ARAGON BARQUEROGeneral Director of Hospital Clinica Biblica, Costa Rica.

55 Elementsto Consider When Making Your Selection

Mention Costa Rica to someone and invariably you’ll hearwords such as eco-friendly, misty rainforests and picture-perfectvolcanoes to name just a few. Costa Rica is well known around theworld as a premier ecotourism destination. Its proximity, stunningscenery and friendly locals have been luring North American travelersfor at least three decades, long before the term “ecotourism” becamepopular. With all the focus on Costa Rica’s natural attractions, manypeople are not aware that the country is also a popular destination fortop quality health care at very affordable prices.

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

By WILLIAM COOK


Why Costa Rica?

PRICE

If you have done any research, you will quickly discover that theprice of medical procedures in Costa Rica tends to be at least 40-70%less than what you would pay in North America. This is due in part tolower wages, a favorable exchange rate andlower malpractice insurance. Price is nodoubt the principal reason why patientschoose Costa Rica and other foreigndestinations.

LOCATION, LOCATION, LOCATION

Located just two and a half hours fromMiami, Florida, Costa Rica is one of theclosest off-shore medical care destinationsfor people living in North America. If youchoose, you can literally fly to Costa Rica’s

Costa Rica:From Ecotourism Leader

to World Class Healthcare Provider

20 DECEMBER 2007

capital city of San José on one day, have your surgery that same day,and be on your way home the following day. This, by the way, is notrecommended, but it is an attractive option for less invasiveprocedures. For many, however, the advantage of a relatively shortflight home is what puts Costa Rica at the top of their list of medicaltourism destinations.

Coupled with the fact that Costa Rica is a favored vacation destinationfor American travelers, the country is a convenient option for peoplewho are looking to combine a regular vacation with a health check-upor surgery procedure. I mean, who wouldn’t want to slide into bubblingthermal springs or explore an emerald-green rainforest and then takecare of an ailing health problem all on the same trip?

Add to this picture the luxury of a wide variety of recovery retreats,a feature unique to Costa Rica, and it is easy to see why this countryis such an attractive destination for plastic surgery as well as othermedical procedures.

A LITTLE HISTORY

Even back in the early 1980’s there was already a healthy flow ofNorth American patients coming to Costa Rica for cosmetic surgeryprocedures. The low cost of cosmetic and dental procedures is stillone of the main attractions for patients abroad.

Increasingly however, travel to Costa Rica and other countries formedical care is being driven by North Americans who don’t havehealth insurance or have only minimal coverage. According to theNew England Journal of Medicine, “These patients are not ‘medicaltourists’ seeking low-cost aesthetic enhancement but middle-incomeAmericans who need life saving surgeries and want to evadeimpoverishment by succumbing to expensive healthcare options inAmerica.” 2 This trend of traveling abroad for life-saving medicaltreatments is expected to increase dramatically over the coming yearsdue to rising health care costs, higher deductibles and insurancepremiums that are well beyond the reach of many middle incomeAmericans.

In a typical scenario, Tom, a self-employed roofing contractor, istold by his U.S. doctor that he requires knee replacement surgery.The price he’s quoted is close to $40,000, and, as one of America’s 47million uninsured, Tom has no way of footing the bill.

Through a friend, Tomhears that there may bemore inexpensive optionsabroad. A Google searchbrings up a hospital inCosta Rica where Tomlearns that the exact sameprocedure costs only$9,500. After carefullyresearching the site andtalking to doctors andformer patients, Tomdecides to use the hospitalto arrange his surgery andlogistics. During this timeTom speaks several timeswith his Costa Ricaphysician and is impressedby his warmth andknowledge, as well as byhis credentials and fluencyin the English language.

Tom arrives in Costa Rica a few days before his surgery and takesadvantage of the hospital’s concierge services to visit an active volcano andrelaxing hot springs. A few days later, Tom is picked-up at his hotel by ahospital representative and taken to the hospital for surgery. The hospital’scaring staff and ultra-modern facilities quickly put Tom at ease. Aftersurgery, Tom spends three days in the hospital and an extra week in arecovery retreat before heading back home. Total expenses includinground-trip air-fare? $10,700.

ARE WE FORGETTING ABOUT QUALITY?

Sure, soaking it up at a tropical paradise may sound all fine and dandy.But who’s to say the masked man hovering over me is a qualified medicalprofessional and not some quack that just stayed at a Holiday Inn Express?Is there any kind of government regulation? How does one weed out thegood doctors and hospitals from the bad ones?

First off, just as in life, things usually aren’t so black and white. Whetherin the United States, Canada or Costa Rica, some doctors and hospitalssimply have more experience in certain procedures and are therefore morelikely to have better outcomes. Here or abroad you’ve got many good

DECEMBER 2 0 0 7 21

doctors and then a small few that are not so good. It pretty muchcomes down to doing the research and using common sense. In CostaRica, all practicing medical professionals must be registered with the“Colegio de Médicos” (the College of Physicians) www.medicos.sa.cr,a good place to start your research.

To its credit, Costa Rica also has a long tradition of offering highquality medical care to all it citizens through a national public healthcaresystem. Besides the public health system, the country has a strongprivate health system with hospitals and clinics of great prestige andreputation.

FACTS TO CONSIDER:

• The World Health Organization’s most recent survey of healthcaresystems published in the World Health Report 2000, ranks CostaRica’s health system among the top three in Latin America ahead of154 other countries including the United States, New Zealand andThailand

• In 2004, Costa Rica’s infant mortality rate was nearly as low asthe United States (9.25 deaths for every 1000 born live in Costa Rica,against 6.5 deaths for every 1000 born live in the United States). Thisis especially relevant considering that the United States has moreneonatologists and neonatal intensive care beds per person thanAustralia, Canada and the United Kingdom (not to mention CostaRica) and a per capita income nine times more than that of Costa Rica.

• According to the World Bank, Costa Rica has the highest lifeexpectancy in all of Latin America. With 78.7 years of life expectancyat birth, Costa Rica equals Canada, and beats the United States lifeexpectancy by one year.

Additionally, many of the country’s doctors have trained in the UnitedStates or Europe and a significant percentage speak English or anothersecond language.

THE FUTURE

Traditionally in Central and South America (as well as many otherparts of the world), most medical services have been marketed abroadthrough individual doctors and small clinics. Recently, however, largerhospitals have begun to actively solicit foreign patients. A case in pointis Thailand, which boasts several hospitals that have successfullymarketed their services to an international clientele.

In Costa Rica, the Hospital Clinica Biblica has taken a leading role inpositioning itself as the region’s premier medical institution forinternational patients. This privately owned, non-profit institutionboasts one of Costa Rica’s most technologically advanced medicalfacilities and will soon be the region’s first JCI accredited hospital. TheJCI accreditation is a world-renown seal of approval that indicates ahospital meets high performance standards comparable to hospitals inthe United States and Europe.

Founded in 1927 by North American protestant missionaries, Hospital


Clinica Biblica has a long tradition of catering to resident aliens and morerecently to medical tourists. It recently opened an international departmentand is considering dedicating an entire hospital wing solely for the use ofinternational patients. Presently over fifteen percent of its patients areforeigners and this is only expected to increase.

It is initiatives such as these and others like it that bode well for CostaRica’s incursion into this exploding market. With no end in sight to the U.S.healthcare crises, aging baby boomers and the number of uninsured continuingto grow, the road ahead looks promising as this country reinvents itselffrom solely a top ecotourism destination to a leading player in the globalhealthcare arena.

As Patient Coordinator for Hospital Clinica BiblicaInternational Department in Costa Rica, Bill Cook overseesoperations and customer relationship managementinitiatives aimed at increasing customer loyalty andsatisfaction. Bill also overseas web content developmentand marketing strategy for Medical Tours Costa Rica, alocally based medical tourism operator. Bill can be reachedat www.hospitalbiblicamedicaltourism.com.

1 Milstein and M. Smith, “America’s NewRefugees-Seeking Affordable SurgeryOffshore,” New England Journal of Medicine2006; 355(16): 1637–1640

2 ICT: Llegadas de turistas internacionalespor LA VIA AEREA 2001-2006

References

22 DECEMBER 2007

Costa RicaThe Great Opportunity

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

Costa Rica is the country of sunny beacheson the Pacific Ocean and Caribbean rhythm on itsAtlantic Coast. It is the country with the bestcoffee in the world, of tasty bananas,pineapple and melon consumed on the tables infive continents. It is also a country thatmanufactures microchips, develops software andwhere corporate services of importantmultinationals like Intel, Panasonic, HewlettPackard and others are outsourced. Finally, it isthe oldest democracy in Latin America, a countrywhose President, Dr Oscar Arias Sánchez, wasawarded the Nobel Peace Prize.

The closeness of Costa Rica to the United Statesat just two hours and thirty minutes from Miamilures thousands of Americans to its beaches andvolcanoes for ecotourism. However, the qualityof its medical professionals, the guaranteedinternational level of service in its clinics, thehospitability of its people and its natural beautyand excellent hotel infrastructure lure thousandsof patients to its shores, making Costa Rica thenew convenient destination for medical tourismwhere patients can recover in full and relaxingcomfort.

Competitiveness in Medical Services

The strengthening of a cluster of medicalservices is one of the priorities of thecompetitiveness program being developed by theGovernment of Costa Rica. It is estimated that in2006 about 4,500 medical procedures wereperformed on non-Costa Rican patients. Theimmediate goal for the country is to provide anopportunity for at least 0.5% of Americanswithout medical insurance to travel to Costa Ricato get treatment, which would mean at least230,000 patients.

To achieve this challenge, we are betting on the

competitiveness of the whole system. The mosteffective way to accomplish this goal is first andforemost to safeguard the quality of physiciansand hospitals. In terms of marketing, Costa Ricais developing the potential of receptive offers,particularly from specialized recovery centers,promoting agreements with large internationalinsurers, and promoting medical and nursingcareers in both public and private universities.

The Chal lenge of In ternat iona lAccreditation

Undoubtedly, the main challenge the countryfaces is to promote the internationalaccreditation of its hospitals. Some Costa Ricanstructures have already started certificationprocessed before the Joint CommissionInternational (JCI), the international arm of theJoint Commission (JC), an organization endorsedby the U.S. Department of Health and HumanServices. In the short term, we want all hospitalsin Costa Rica to be duly accredited, since we areaware that only in this way we can guarantee thepositioning and sustainability of an industry witha lot of added value.

In past months, all agents related with the medi-cal services cluster were called by the NationalCompetitiveness Council to work on a strategicdevelopment plan for the sector. Hospitals,physicians, hoteliers, and different Governmententities (among them the Ministry of Health,Ministry of Tourism, Ministry of ForeignAffairs, Ministry of Economy, Industry andCommerce) have committed to make ourcountry a world-class medical center within thenext 10 years.

We trust Costa Rica will be able to succeed inthis challenge, becoming a regional leader in healthcare tourism, so we can again be referred to as the“Switzerland of Central America.”


The immediate goal forthe country is toprovide an opportunityfor at least 0.5% ofAmericans withoutmedical insurance totravel to Costa Rica to gettreatment, which wouldmean at least 230,000patients.

Jorge Woodbridge González may be

reached at [email protected]

24 DECEMBER 2007


Costa RicaCosta RicaWho are those Masked Men?

Costa Rica not only has universal health care,but Costa Rica is considered to have one of thebest health care systems in all of Latin AmericaThe government runs more than 30 hospitalsand 250 clinics. The Costa Rican health caresystem has been in existence for almost 60 years.

Most Americans are shocked to find out thatCosta Rica has been rated higher by the WorldHealth Organization than the US, and in the last2000 WHO report the United States rated 37,below Singapore and Costa Rica.

Requirements to become a doctor

What exactly does one have to do to become aphysician in Costa Rica? Like doctors in theUS, medical doctors in Costa Rica receive formaluniversity training followed by a postgraduateresidency program. The latter ensures that theyhave extensive practice knowledge in theirspecialty. In addition, all medical physiciansmust meet general requirements to be a memberof the Costa Rican Doctors’ and Surgeons’

Association (Colegio de Médicosy Cirujanos [email protected]). Dentists, on the otherhand, are certified by the Costa Rican Surgeonsand Dentists Association ([email protected]).

Obtaining a medical degree in Costa Ricarequires some undergraduate studies in themedical field and a graduate degree in medicine.It takes six years at the National University ofCosta Rica to obtain a graduate medical degree,but even then a doctor is not ready for practice.A prospective doctor must complete a DoctorateTitle in Medicine and one year of social serviceat one of the Social State Hospitals.

For postgraduate residency, the amount of timespent in the various programs depends on thespecialty field. For instance, plastic surgeonsare required to complete an extra eight years ofpost-graduate residency study. Four of thoseyears are spent in general surgery and thefollowing four years in plastic surgery. Thatmeans a plastic surgeon has totally fourteen yearsof study, comprising of graduate study and postgraduate residency study, before they canpractice. Endocrinologists must perform anadditional two to four years post graduateresidency study to become a specialist, and adoctor must spend five to seven years in postgraduate residency study just to qualify ingeneral medicine.

Requirements to become a nurse

The University of Costa Rica requires studentswho are applying for a nursing degree to performaptitude exams with a score of 700 or more toqualify. The private universities, however, do

not require this exam. It takes from three to fouryears for a nurse to graduate from the Universityand four to five years in total to graduate as alicensed nurse. To qualify with a masters innursing, a nurse will spend another one and ahalf years on top of the license nurserequirements. In order to work, nurses need aCosta Rican Accreditation Title and must beaffiliated with the School of Nurses of CostaRica. All other nurse titles require accreditationfrom the Nurses School of Costa Rica.

While Costa Rica has a public healthcaresystem, it has a growing private health caresystem which is starting to focus on attractingAmericans to Costa Rica for medical care aboveand beyond the prior reputation for inexpensivecosmetic and dental surgery. Costa Rica is nowbecoming known for surgeries such as Hipreplacements, back or spinal surgeries and kneereplacements. In fact, laboratory materials areall FDA approved and shipped in from theUnited States.

For Americans traveling to Costa Rica formedical care the healthcare is quite affordable.Many of their doctors not only speak Englishbut also have received training in the UnitedStates, Canada or Europe.

The Two main hospitals in Costa Rica areClinica Biblica and CIMA. Unfortunately, at thetime of writing this article, CIMA hospital hadnot finished completing its hospital floorspecifically for medical tourists. CIMA also didnot provide written information to the MedicalTourism Association regarding its hospital andother items such as infection rates. We hope to

More than Cosmetic & Dental Surgery

26 DECEMBER 2007

include more information about CIMA once theirnew wing has been opened. In the interim, wehave provided some information provided by NewYork raised, Costa Rican CEO, Carole Velosa.

CIMA is an impressive complex of buildings,two of which are high rises, home to 400physicians on a campus and 1500 on staff. Mostof the physicians at CIMA are trained outside ofCosta Rica. CIMA has erected two new medicaltowers, laid stylish like in New York. Nearby, adeveloper plans on building condominiums, ashopping center and even an Imax theater to caterto its hospital staff. CIMA can handle 120inpatients per day and has all the moderntechnology of MRIs, ultrasounds, a 9 bedemergency room and trauma center. The hospitalhas its own helipad for the “five people per weekwho fall and need to be airlifted,” according toCarole Velosa.

Carole Velosa indicated that last year she saw ashift from plastic surgery as the primary soughtafter medical treatment from foreigners to nowabout only fifty percent of foreigners coming forplastic surgery. The other fifty percent are lookingfor general medical care and surgery found inAmerican hospitals. Of this fifty percent, patientsare seeking heart bypasses, lap bands,knee replacements, hip replacements andhysterectomies.

The third floor of the hospital is intended to bethe “Tourist Unit,” Velosa described, “with sixbeds and four suites, all English speaking with aseparate staff, computer room and common area.The unit will have an all American menu and WiFiaccess. CIMA just began their process for JCIAccreditation.”

Hospital Clinica Biblica, on the other hand, hasa dedicated Medical Tourism Department of 5full time employees, who speak both English andSpanish, and also a newly dedicated floor formedical tourists. The two brothers, Brad and BillCook, who run the international department,spent some time growing up in the United Statesand so there clearly is no culture barrier here indealing with them.

Hospital Clinica Biblica is a private hospitalestablished by American missionaries and builtin 1929. The hospital is affiliated with TulaneUniversity in Louisiana with a capacity of 5000

Costa Rica

$24,000

$15,000

$9,000

$12,000

$4,000

$11,000

$25,000

$4,600-$5,000

$3,500 - $3,900

$3,000-$3,400

$2,700-$2,900

$2,000 -$2,200

$3,900 - $4,200

$250-400 per tooth

$250 - $400 per tooth

$700 - $900

$300 - $500 per tooth

$125 - $250

USA

$130,000

$160,000

$57,000

$43,000

$20,000

$40,000

$62,000

$7,000 - $13,000+

$3,000 - $12,000+

$4,000 - $9,000+

$5,000 - $9,000+

$1,500 - $7,000+

$5,000 - $9,000+

$1,000 - $3,000+

$500 -$900+ per tooth

$1,000 - $5,000+

$1,000 + per tooth

$360 - $900+

Medical Procedures

Heart Bypass

Heart Valve Replacement

Angioplasty

Hip Replacement

Hysterectomy

Knee Replacement

Spinal Fusion

Cosmetic Surgery

Facelift

Rhinoplasty

Breast Lift

Breast Augmentation

Blepharoplasty (Eyelid Surgery)

Tummy Tuck

Dental Surgery

Bridges

Crowns

Implants

Porcelain Veneers

Root Canal

Costs of Surgeries In Costa Rica vs United States

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

outpatients and 120 inpatients per day. Most ofthe non-Costa Rican patients come from the US,Canada and Europe, making up a generouspercentage of the 14,400 procedures performedat the hospital each year. At least ten percent ofthe physicians at Clinica Biblica are US boardcertified in specialties such as general surgery,orthopedics, cardiac and urology. With its 800employees, this hospital boasts that all of itsnurses are registered nurses and the nurse topatient ratio is approximately four to one, and allrooms are private and some are suites.

Clinica Biblica has almost completed the lengthyand arduous process of JCI accreditation. It hasspent thousands of dollars in training all itsemployees in resuscitation techniques approvedby the American Heart Association. Even thejanitors are certified. There are state of the artvoice activated video surgery rooms, and hightech infection prevention architecture reducingthe infection rate at Hospital Clinic Biblica toless than three percent .

What was interesting about Hospital ClinicaBiblica was the atmosphere of the facility and itsemployees. The whole hospital is painted in blueand green because research suggests that thosecolors are indicative of emoting calmness, andsuitable for patient healing. There are also TVslocated in ICU rooms which has been shown tocreate good patient outcomes.

The attitude of the physicians is not one ofsuperiority and it is common that patients haveaccess to their doctor’s cell phone numbers. Asone doctor stated, “We are just people helpingpeople.” That being said, your overall experienceat a hospital in Costa Rica may be more than youexpected, especially at the lower costs forservices. If the surgeon is the right one for yourparticular medical condition and the hospitalmeets your approval, we suggest you go for it!

DECEMBER 2 0 0 7 27


ORTHOPEDIC SURGERY IN

COSTA RICAAlthough Costa Rica is known for its excellence in cosmetic and dental surgery,

the specialties found in most American hospitals can be found in Costa Rica.Many of the surgeons are board certified and trained in the U.S. and their

medical practices overseas are second to none.They care for the whole patient, not just the medical problem.

By OSCAR OEDING B, MDWhen I was asked to write an article for publication in a Medical Tourism relatedjournal, I thought of giving a medical report including statistics of results obtained in Total KneeReplacement, Total Hip Replacement, Reconstruction of the Anterior Cruciform Ligament,Rotator Cuff Plasty, etc.

All these are procedures we do in the branch oforthopedic surgery. Instead, I asked some of my formeroverseas patients for advice as to what they would liketo read about in regards to Medical Tourism in CostaRica. Almost all agreed their attention was calledprimarily to the type of care they had received in ourClinic, including my care, the care provided by the medicalteam, as well as the entire staff in charge of their care.

We are a group of professionals devoted to solvingyour medical problems without forgetting to care forthe person behind the ailments. We want to see thatyou recover well from your surgery, but also feelingemotionally well throughout the entire process. Unlikein America, patients are not just numbers in aproduction line. Fortunately, thus far, we have achievedthis commitment. All our patients not only leavesatisfied with the medical result obtained, they leavethankful for having found a different way of medicalcare.

From the medical point of view, it behooves just tomention that in Costa Rica we have the highestlongevity index of Latin America, comparable with USAand Canada. This compels us to have extensive practicein procedures frequently performed on patients beyondage sixty as are joint replacements. With a SocialSecurity institution giving coverage to 100% of thepopulation and offering highly efficient services, wehave experience in handling implants from the bestmanufacturers, both American and European (Biomet,Zimmer, Depuy, Johnson & Johnson, Synthes, etc.)

In sports, our national soccer football team ranks aroundthe 35th place worldwide. This is the most practicedsport in our country, bringing us frequent injuries suchas Meniscus Tear, Anterior Cruciform LigamentRupture, Damaged Cartilage, etc. Needless to say, wehave quite a bit of experience resolving orthopedicproblems.

For years, Costa Rica has been a strong medicaltourism destination with Plastic, Dental and MedicalSurgery. Accordingly, we have plentiful experience withprivate hospital infrastructure and patient recovery andwe have excellent rehabilitation centers that ourorthopedic patients now are using.

I look forward to some day showing you the CostaRican way we care for patients.

OSCAR OEDING B, MD is an orthopedicsurgeon at the Hospital Clinica Biblica inCosta Rica

New York Health Crisis

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

28 DECEMBER 2007

By DR ELLIOTT GARITA JIMENEZCardio-Vascular Surgeon, Hospital Clínica Bíblica

As the world becomes more globalized and traveling becomes easilyaccessible to most people, we face diseases that may result from travel.Deep Venous Thrombosis (DVT), also referred to as VenousThromboembolism (VTE), is undoubtedly a disease that can be deadly foran individual. It is therefore important for patients intending to travelabroad and medical tourism companies assisting patients abroad tounderstand the risks and take measures to prevent them.

DVT results from many factors that can easily occur in travelers duringflights lasting longer than 3 hours. Although the risk of DVT is not veryhigh, occurring generally in about one in every six thousand people,risk factors such as age, obesity, pregnancy, smokers or people who havehad certain surgical procedures like hip or knee replacements, orabdominal surgeries may increase the risks of DVT. Some cancers such aslung, ovarian and breast cancers have been shown to increase the risks aswell as anyone having undergone chemotherapy. Certain heartconditions, high blood pressure or cardiovascular disease, boweldiseases and other gastrointestinal conditions can increase the risk as well.

A prime candidate for DVT might be also be a person with varicose veinswho takes a flight longer than 3 hours in an air-conditionedenvironment that causes dehydration, who failed to ingest liquids, therebyavoiding frequent bathroom visits.

DVT results from a blood clot in the deep veins of the lower extremities,producing intense pain in the calves and extreme swelling in the limbs.This swelling may progress from the feet up to the thighs. This phenom-enon may not appear for up to 48 hours after a trip. Although there is animmediate concern of pain and swelling, blood clots are not the real causesof concern per se. However, if a clot in a vein breaks off and travels to thearteries of the lung in the form of a pulmonary embolism, this may quicklylead to death or may result in many serious complications that requireimmediate hospitalization in the Intensive Care Unit.

Preventing this and many other diseases is much more effective andeconomical than treatment. The following recommendations arespecifically designed to prevent DVT:


Deep Venous ThrombosisThe Traveler’s Disease

32 DECEMBER 2007

The day before traveling:

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

� Do not forget to take the medications you usually take.

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

� Take a lot of fluids 24 hours before the trip.

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

The day of travel:

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

� Avoid using high-heeled shoes to prevent swollen feet.

� Make sure you take liquids throughout the day so your bloodstream canbecome thinner, forcing you to get up and walk to the bathroom during theflight.

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

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

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

� Stretching exercises are recommended, such as standing on your heels ortoes.

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

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

Illegal Practices in Australia

The Sydney Morning Herald reported that the New South Wales MedicalBoard is trying to crack down on medical tourism companies that areperforming illegal practices of paying Malaysian and Thai doctors to cometo Australia to provide consultations in hotels. Thus far, the only report ofsuch events comes against Gorgeous Getaways which advertised on itswebsite for free consultations in Australia with overseas doctors beforesurgery. The Medical Practice Act, Section 105, states that “It is an offensefor a person who is not a registered medical practitioner to advertise or holdthemselves out to be qualified…or to give surgical advice and service.”Therefore the surgeons flying to Australia and giving consultations topatients in New South Wales are in violation of the Medical Practice Act.The NSW Medical Board threatened action against Gorgeous Getaways,but they are still promoting the service. What is the experience of some ofthese medical tourism companies? In some cases, none. One company isrun by a former carpet cleaner, and many have no medical background orexperience. It is very important to research the medical tourism operatorand assure that you are not being misled by false promises.

DECEMBER 2 0 0 7 33

Got a Passport?Get a smile!

By EUGENIO J. BRENES, DDS & JAVIER QUIROS, DDS

There is currently a trend in the UnitedStates, where more and more Americans travelabroad for various medical and dentalprocedures offered by specialists around theglobe.

It is not a secret that a great number ofAmericans are not covered by dentalinsurance. For those who have dentalinsurance, their insurance generally does notcover cosmetic or aesthetic procedures, suchas veneers, crowns, bleaching or dentalimplants. Even though these procedures offersuperior treatment results, and providepatients with an improvement in their qualityof life, insurance companies do not considerthem basic dental treatments, and usuallyreject any claims filed by the patients.

The only solution for some patients is topay out of pocket for dental treatments attypically very high prices. The underlyingfactors creating the high cost of dentalprocedures in the U.S. include the high cost ofmaterials that are used, unusually high cost ofmalpractice insurance, overpriced labor and theunaffordable cost of living in the U.S.Additionally, the number of years of training

that are required by the dental doctorsproviding these types of procedures is veryhigh in order to provide their patients withpredictable and successful treatments.

People often may ask themselves why travelabroad? Which procedures can be done inforeign countries? How does one choose theright Doctor? How does one contact theseprofessionals?

In order to answer these questions, it isimportant to understand that a veryimportant factor that drives people to traveloutside the U.S. for dental treatment isfinances. As emphasized, dental treatmentsin the U.S. can be extremely expensive,leaving most procedures out of reach for agreat percentage of the population.

As a result, Americans are traveling abroadseeking more affordable dental care. One ofthe countries that is fast becoming a Meccafor dental treatments is Costa Rica. Costa Ricahas a large number of dental specialists, manyof whom are trained in the U.S. at the highestlevels and standards, and they provide dentaltreatment at a fraction of the cost in the U.S.

In my case, I had five years of dentaltraining in Costa Rica, followed by four yearsof post graduate training and residency inaesthetics, restorative, and prosthodonticsprocedures at Loma Linda University, inCalifornia. Dr Quiros on the other hand,studied in Costa Rica for six years andcontinued his post graduate education inDallas, Texas with a Fellowship of two yearsin Esthetic Dentistry, and a three yearResidency in Advanced Prosthodontics.We both speak perfect English and performthe same treatments that are performed in theU.S. We both decided to return to ourcountry and open our practice using all theknowledge and experience we gained, trainingat some of the top ranked dental schools inthe U.S., to help the people in our country.

One may wonder how U.S. trainedspecialists in Costa Rica can charge a third ofwhat a U.S. based specialist will charge.

There are a number of reasons for this. First,Costa Rica has a lower cost of labor and feescharged by dental labs (labs that custom makecrowns, veneers, dentures, etc.). Costa Ricandental labs provide excellent quality of work


34 DECEMBER 2007

and some of the biggest American commercial dental labs outsource a greatpercentage of their U.S. business to Costa Rica. That means that a lot ofcrowns, veneers, and partial dentures, and all sort of dental work used byU.S. doctors in the United States, are manufactured in Costa Rica.

Another factor is that the cost of living in Costa Rica is almost one thirdof what it is in the U.S. When one considers states such as California andFlorida, Costa Rica is about one fourth less expensive, and this shows inthe final price of the dental treatments.

Some people wonder about thequality of the materials used in dentalclinics in Costa Rica. Most of thematerials used in Costa Rica aremanufactured by multinationalcorporations that sell the sameproducts in the U.S. Thesemanufacturers distribute their productsworldwide, but they have variablepricing in order to be competitive indifferent markets. Our clinics in CostaRica use state of the art equipment andthe highest quality in all of our clinicaland laboratory materials. This gives usthe certainty that the final results andtreatments are at the same level as thoseperformed in the best clinics anywherein the world.

Another question commonly asked is which dental treatments can bedone in foreign countries. Well, this is a question that is closely related withthe question of how to choose the right dentist. In the U.S., the associationthat regulates dentistry is the American Dental Association (www.ADA.org).It recognizes Prosthodontics as the only specialty in dentistry that dealswith aesthetics, function, and oral rehabilitations. In other words, the nameof the specialty that deals in full detail with the appearance of your smile iscalled Prosthodontics.

How do I know if my dentist is a Prosthodontist? The easiest way isasking them directly, or by doing a little research on your own. TheAmerican Association that certifies dentists with the proper training tobecome a Prosthodontist is called the American College of Prosthodontics(www.Prosthodontics.org). On their webpage, you can find Prosthodontistsin specific areas, both in the U.S. and other countries.

It is important to do your research because the Prosthodontist is trainedas “a quarterback of dental treatments.” He is the best person to coordinatea treatment plan, he knows about the results and outcomes of the differentdental specialties and their procedures such as periodontics, endodontics,orthodontics, oral surgery, and he can guide you in order to achieve your

goals, and expectations regarding your smile.

Dental treatments that are done and supervised by a Prosthodontist cango from aesthetic concerns, crooked teeth, missing teeth due to differentfactors such as accidents, congenital oral defects, or other reasons, to help-ing you improve your quality of life by having a healthy, functional andbeautiful smile.

Why choose Costa Rica and not another country? Besides having worldclass professionals and state of theart hospitals and clinics, Costa Ricahas become one of the most soughtafter places for travel. Costa Ricahas luscious jungles, breathtakingbeaches, amazing volcanoes andeverything in between. Visitors toCosta Rica have increased form784,610, in 1995 to 1,452,926 in2004. Along with the increase inthe number of tourists, is thedevelopment of touristinfrastructure. Another factor is thesocial and economic stability of thecountry. Since abolishing its armyover fifty years ago, Costa Rica hasbecome one of the most developedcountries in Latin America, having

redirected previously budgeted military funds to furthering education. It isknown for its high rates of literacy and the warmth of its people and theirlove for their country. As an independent country, Costa Rica has excellenteconomic and diplomatic relationships with the U.S. Costa Rica is veryAmerican friendly, and is a preferred country for American expatriates,with over 8,000 Americans permanently living in Costa Rica, making it thecountry with the most U.S. citizens per capita in Latin America.

And finally, you might wonder how to get in contact with the rightprofessionals. A good way of getting appointments set and proceduresdone are by solid institutions, and always look for the right accreditationsof such establishments. Look to the top hospitals first for their specializeddental departments to find the right professional for you.

Eugenio J. Brenes, DDS, Advanced Prosthodontics, certified atLoma Linda University, School of Dentistry, Loma Linda, CA.,and Javier Quiros, D.D.S, Advanced Prosthodontics, certified atBaylor College of Dentistry, Dallas, TX are both Prosthodontistsat Hospital Clinica Biblica, San Jose, Costa Rica.

It is important to do your researchbecause the Prosthodontist is trained as“a quarterback of dental treatments.” He is the best person to coordinate a treatmentplan, he knows about the results andoutcomes of the different dentalspecialties and their procedures...

DECEMBER 2 0 0 7 35

CLINICA BIBLICA STYLE


Processing the Patient

We interviewed Brad Cook,

Managing Director of the

International Department of

Clinica Biblica Hospital in

Costa Rica to find out just

what it is like to be a patient

looking for medical treatment at

their hospital and what a patient

might expect from beginning to end.

Generally most patients looking forhealthcare overseas start their search on theInternet. Milling through the web pages, somein English, some not, performing your own duediligence can be very wearing. In an effort tomake this process easier, Clinica Biblica Hospitalestablished an international patient departmentspecifically dedicated to making life a little easierfor the foreign patient. We interviewed BradCook, Managing Director of this Departmentto learn a little more about what their role is inthe lives of their patients.

“We receive a call or Web form from theprospective patient and based on theinformation received, we then put together aprice estimate for the requested proceduretogether with a brief description of theprocedure, details concerning recommendedarrival date, length of the procedure, inpatientor outpatient, and how many days are

recommended for recovery,” says Cook. “Wealso request additional information such asphotos, medical records and require the patientto complete a detailed medical questionnaire.”

Cook went on to explain, “The schedulingprocess includes a pre-operative consultationwith the physician and the procedure itself, withfollow-up care, if required.” Generally,scheduling of these appointments may be madeon the day the patient first contacts theinternational department, depending on theavailability of medical records and the particularhealth conditions of the patient. Wait times arealmost non-existent at Clinica Biblica as theyrun a tight ship. “It is not unheard of for apatient to contact us on Monday and schedulehis or her surgery for Thursday,” says Cook.

However, most patients have a long list ofquestions and are usually not so quick to committo the surgery on such short notice. They

CLINICA BIBLICA STYLE

By RENÉE-MARIE STEPHANO

36 DECEMBER 2007

Brad Cook, is founder and director of Medical Tours Costa

Rica and Segrupex S.A. Brad has more than 13 years experience

coordinating medical services for international patients at

Clinica Biblica Hospital in Costa Rica where his company runs

the International Department for the hospital.

Under his direction, the International Department has been

instrumental in forging relationships with insurance companies

throughout the world positioning Clinica Biblica Hospital as a

premier destination for international travelers. Mr. Cook is

frequently contacted by local hospitals and international billing

agencies for assistance and services in regards to international

insurance billing.

Mr. Cook launched the Medical Tourism initiative for Clinica

Biblica Hospital orchestrating an aggressive service oriented

model that has helped position Clinica Biblica Hospital as one

of the premiere destinations in the region for medical services.

His marketing efforts have been successful in attracting local

and international media outlets for segments and stories

regarding Medical Tourism. He has also been proactive

contracting with and hosting medical tourism companies from

around the world.

typically have questions they would like answered by the physiciansusually relating to the doctor’s qualifications, questions about thehospital, the type of pre-op tests involved, accommodation issues,and what the price estimate involves. “We are seeing patients taking amuch more proactive approach to their medical care and performingtheir due diligence since they are traveling out of their comfort zone,”says Cook. “Patients traveling abroad for healthcare are in some casesasking more questions and doing more research on their physiciansthan they would actually do at hospitals in the U.S. and this is a verygood thing, as they are taking control of their healthcare,” he addedOver the course of several days many emails and calls are exchangedbetween the international department staff of Clinica Biblica in orderto make the patient feel completely at ease about the decision. Thestaff generally will make arrangements for the doctor to speak with thepatient by phone or by web cam from their office.

Once the decision to travel to Costa Rica for the surgery has beenmade, the staff sends the patient a formal itinerary confirming all medicalservices. If the patient desires, staff will meet the patient and anycompanions at the airport and assist them through Customs. Fromthere, air-conditioned vans driven by bilingual guides deliver the patientto their prearranged hotel accommodations.

“On the day of the pre-operative consultation we arrange for patientpick-up and transfer to the hospital and personally assist the patientevery step of the way,” affirms Cook. A staff member escorts thepatient through pre-operative tests and doctor’s appointments, assistingwith translation if required. The international staff generally matchesa prospective patient with an English speaking physician, unless, ofcourse, the patient requests a specific surgeon based upon referral,specific experience of qualifications for a certain procedure, or if thepatient is bilingual. Costa Rica receives a large number of Spanishspeaking patients from the United States.

On the day of the surgery the patient is picked up and transported tothe hospital where our staff meets the patient for admission. After thesurgery, staff periodically visit the patient to assure all needs are beingmet and will then transport the patient to a hotel with a bilingualregistered nurse escort. This registered nurse will then continue to visitthe patient periodically over the next few days to assist with bandagesor injections if required, administer medications, and to monitor thepatient’s recovery process.

A day or so before the intended departure, the patient is escorted tothe hospital for final evaluation before returning home. A completemedical examination is performed to assure the patient is ready totravel. Then, on the day of departure, the patient is transported to theairport where the staff assists with procuring a wheel chair, if needed.

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

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

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

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

medical procedure and the health condition of the patient,” states Cook.“We recommend the following general guidelines which may be adjustedaccording to each patient health situation. Cosmetic surgery may take7-14 days, Bariatric surgery 5-7 days, Orthopedics 7-10 days, dentalprocedures require usually no more than 24 hours,” he added.

Does this mean you can get a new smile in less than two days?“Definitely,” says Cook.

DECEMBER 2 0 0 7 37

Big Tr ip , L i t t le Country

By RENÉE-MARIE STEPHANO

In the heart of Central America, bridging the gap between the Pacific and Caribbean Seas,Costa Rica provides an ecotourism for anyone, just a two and a half hour flight from Miami.From die hard backpackers to patients coming for facelifts and lap band procedures, Ticos (asthe locals are called) have their thumb on the pulse of attracting Americans. People can get ataste of their days of adventure without going too far or spending too much money.

The only problem you might have in Costa Rica is that you might strain yourself trying to doit all before tucking yourself into a hospital bed for a medical procedure. To get the best bangfor your buck, you should consider for your trip a series of a few shorter diversions from thejungle covered volcanoes to the cactus hills of Guanacaste. The important thing to rememberis that you can take the perfect trip to Costa Rica in about a week and then allow yourselfample time to recover from whatever procedure you might be having. What’s more, with therelatively small size of Costa Rica, the rest of your family can continue to explore while youare recovering.

The President of the Medical Tourism Association, Jonathan Edelheit and I planned a trip tovisit some of the hospitals in Costa Rica for our research and for this issue of the magazine. Wewanted something different, something exciting during our trip to Costa Rica. We wanted anadventure trip since this was my first time to the ecotourism paradise, and that is just what wedid. We stayed at two eco-friendly lodges with toucans, monkeys and hummingbirds.

Downtown Reality

We arranged for a several day tour of Hospital Clinica Biblica through their special internationalpatient department. Managers Brad Cook and Bill Cook, and their staff took care of all the

Decades ago, Costa Ricawas a pioneer in ecotourism.Now it is also a pioneer inmedical tourism. Oh how farit has come.

Costa Rica

38 DECEMBER 2007


DECEMBER 2 0 0 7 39

Okay, so they did tell us to travel light for the one night stay and I thoughtthat was just to prevent you from bringing your valuables and extra yournecessities. What I failed to realize was that our luggage was going to be drybagged and then rafted down by another brave soul with two paddles in anoversized raft. Fitted up in life preservers, helmets and a paddle, we wereinstructed to get in the Pacuare River and learn how to swim towards the raftin the event we were tossed out. This was the adventure we were looking for!

The raft ride into the Pacuare Lodge was not that intense, only Class 3 and4 Rapids I was told. Not bad at all. With six people and a guide, the raft wascomfortable and the company was terrific with Tito also as our river guide,pointing out natural flora and fauna, wildlife and waterfalls, when spotted.The ice cold water quickly dissipated with the heat of the sun and I foundmyself curiously comfortable in my Florida-thin skin. We stopped for lunchon the river bank, which was prepared by the rafting guides as well. They raftand they prepare food? You cannot ask for more than that!

We were warned about the frequent rains in the rainforest, where the riverwas guiding us, and fortunately we just barely missed the downpour thatcame through just after we arrived at the Pacuare Lodge(www.pacuarelodge.com).

The Lodge itself is environmentally responsible inasmuch as there is noelectricity, no lights and you do not flush toilet paper. We were greeted bythe staff and led to our bungalows by our river tour guides. Tito carried ourluggage to our new home away from home and told us dinner was to be servedin about an hour. This was like no other bungalow I had stayed in. The placewas huge, private and definitely romantic. Minimalist but largeaccommodations featured a large main bedroom with a small step down hallwayand inspired bathroom with rainforest water showers. Our friends were stayingin the honeymoon suite, which was worth the long hike to view its privacy,its own swimming pool, magnificent view and outside porch with hammocks.

Dinner consisted of five star dining, tables located in the main lodge areawhere you can sit with anyone staying at the lodge. We ended up sharing ourmeals with the same people on our raft. After all, we were devoted to savingeach others lives out there on the rapids. Interestingly, Tito was also ourserver and the raft guides were the chefs of our meal. We were able to relaxand kickback with backgammon and cocktails under the candle chandeliersuntil dark. I even indulged myself in an in-bungalow massage.

arrangements. Getting off the plane and going through customs, wewere lured into excitement by the large flat screens depicting exoticphotographs of volcanoes, toucans and poison dart frogs. Soon thereafter,we were greeted by a nice woman with our names on a sign showing uswhere to get our baggage and where we should go to meet Luis, ofTropical Expeditions (www.tropicalexpeditions.com). Luis took us ona driving tour of downtown San Jose, the capital city of Costa Rica,pointing out some of the notable monuments, art centers, museums andof course, the international icons of McDonalds and Taco Bell. Themajority of the population speaks Spanish, but then again, living onlyone and a half hours from Miami, I felt right at home.

We finally ended at our destination, the Holiday Inn – Aurora, ownedby the Intercontinental Group. This had to be one of the nicest HolidayInns I had ever stayed in. We met Bill and Brad Cook for dinner in therestaurant of the hotel to discuss our upcoming tour of their hospital andalso our prearranged ecotour. The upscale dining and pianoaccompaniment was a relaxing way to end our first day in this exoticcountry. The next few days were spent touring the city and the hospitalfacilities.

Rafting the Pacuare River

Following our desire to be adventurous, the Cooks arranged an overnightrafting tour through Tropical expeditions and the Pacuare Lodge. Classfour to five rapids we were told…the adventure was on. We were pickedup by shuttle that made several stops at other hotels to pick up someAmericans and some British folk, one couple on their honeymoon, afather and son seeking bonding time and another couple on a one monthvacation through Central America. Clearly, we had very little concernthat our Spanish was not up to par.

Our tour guide was a lively fellow named Tito, employed by the PacuareLodge, our ultimate destination. During the one and a half hour shuttletour through some of the most exhilarating and picturesque countryside,Tito gave us a detailed history of Costa Rica, its people, towns, folklure, architecture and personal stories about his experience working inthe coffee fields. Surely, he must have been handpicked for our tour. Hischarisma and sense of humor made the long journey at such an early hourvery invigorating. We made a stop for breakfast, where we were servedlocal foods at a restaurant located at the top of a hill overlooking thevalley. It was a nice break and great photo taking opportunity, not tomention the last toilet break for the whole rafting trip, we were told.

The next day, we all took a wonderful, yet intimidatinghike up the mountain terrain to get to the start of thezip-line tour. Capped in hardhats and lining harnesses,we zipped from one tree to another, overlooking therainforest and all of the beauty Costa Rica has to offer.When you take a zip-line tour, you’re basically as highas the clouds. You go along the top part of the rainforest, also known as a canopy. It is terrifying, yetincredible. There’s only a wire hanging between two treesand you are really high. The natural American in meleads me to think, “Who inspected these things?” Ourguide Alex, also a rafting guide assured me that I was notthe first person to stop myself just a little bit short ofthe end so I had to sort of monkey-crawl to finish.

Once landed back at the lodge, we prepared ourselvesfor the big day. Today we would raft on Class 4 andClass 5 rapids. Would we flow through this one like wedid the day before? Tito retaught the method of “gettingdown” in the raft during certain rapid areas, presumablyso we would not go flying out of the raft. No problem

there, as I was more than willing to be the first down in the raft. Surprisingly, the words ofmy mentor Tito rang in my ear before each rapid, “okay good position now…get down getdown!” This was a piece of cake. After each pass through conceivably deadly rapids, Titoencouraged us with the tapping of our paddles in the air yelling “Pura Vida!” I had developeda strange and deep confidence in this person who had taught me to raft, housed me, fed meand directed me each step of the way. Overall, we only had one person fall out of the raftduring the whole trip. He fell over twice, but….we did not hold that against him. Afterspending the whole day on the water fighting the rapids, we were ready to hit land. The tripoverall was unforgettable.

After two days of intense physical workout, we decided to spend a couple of days at aplace called Peace Lodge. Who could have a bad time at a place called the “Peace Lodge?”The drive to get there was picturesque with views of the coffee fields and volcano rainforest.When we arrived it was raining, but it did not taint the exotic flair of the Peace Lodge with itsrooms named after butterflies. The Peace Lodge has established a fantastic series of walkways,hiking paths and stairs that weave you in and around the volcano area to expose three of themost powerful waterfalls I have ever seen this close up.

It would seem that the Peace Lodge must have its sufficient share of guests since they didnot respond to our request for photos for the Magazine, however, we have included some ofour own. Some of the unique charm of the peace lodge is the privacy and the unique caretaken to create the rooms, which are very large. Each room has a fireplace, as the rainforestand the elevation makes for chilly evenings. The large bathrooms include a tub with awaterfall backdrop and even a natural rainfall shower that seems to emanate from the walland ceiling. The stained glass separating from the bathroom and the main bedroom emanatesromanticism and who does not appreciate a balcony with a hot tub and its own hummingbirdfeeder? Although I must say, watch your eyes, those hummingbirds mean business.

Costa Rica is truly an amazing and beautiful country. It’s people are friendly, it’s medicalfacilities state of the art, and it gives medical tourists a wide range of activities to choosefrom. Even if you don’t choose an eco-adventure, it is still a beautiful country to go to.

TAIWAN TRIAD

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

40 DECEMBER 2007



AmericanHealthcare

System

Understanding the

AmericanHealthcare

SystemUnderstanding the American Health CareSystem is a four part series with a focus onwhich aspects of the American Health CareSystem will readily access overseas medicalcare.

The most common question asked when you explain the conceptof medical tourism is, “What kinds of Americans are going to get ontoa plane to travel to a foreign country for healthcare?” Surprisingly,most overseas hospitals have very little idea about what segment of thepopulation their future health care clients come from. Therefore,hospitals seeking to attract medical tourists to their country have noidea who their audience or core market is, providing for futile marketingefforts.

If international hospitals are to succeed in attracting Americans theyfirst need to succeed in narrowing their marketing efforts to thosewhere they will generate the greatest returns. Just as many hospitalshave been misled into believing Medicare will soon be approvingoverseas medical treatment, still more hospitals are misled about thetypes of American patients that will be traveling overseas for healthcare.

Many international hospitals and medical tourism companies arethrilled about the possibility of fully insured health carriers such asBlue Cross Blue Shield, Aetna, CIGNA, Humana, United HealthCareand other insurance carriers affording their fully insured members theopportunity to go overseas for health care rather than receiving caredomestically in the United States. In fact, many hospitals have beentold that the fully insured American health insurance carriers are aboutto approve medical tourism, opening the flood gates to swarms ofAmericans going overseas.

Here is a reality check. It’s not going to happen, but if it does, it is notgoing to happen anytime soon.

If an American can go to their local U.S. hospital for the same costthat they can go to an overseas hospital, why would the American gooverseas for surgery? Especially if by going overseas the Americanwould incur travel costs, such as airfare, hotel, meals, etc., and having

to spend a good amount of time far away from home. Many people inthe industry are keeping the myth alive that these Americans willmagically appear abroad. This is simply not true.

And then you hear another rumor. Okay, maybe regular fully insuredmembers won’t go, but what about Americans on high deductible plans?Even if someone has a $10,000 deductible on their U.S. health insurancepolicy, for most procedures worth going overseas, the cost for theAmerican patient could be the same or comparable to the total costs forhaving the procedure performed here in the US. For example, if a heartprocedure is almost 80% less overseas at a cost of about $9,000, if you


Part I:The Fully Insured American Patient

~ Dispelling the Myth

42 DECEMBER 2007

factor in medical expenses, plus the cost of travelfor you and a companion or family, hotel and/orrecovery center, meals and entertainment, lostwages, possibly child care or missed opportunityin some cases, there may be no savings for theAmerican patient to going overseas, and insteadhigher costs.

So, why would an American with a fully insuredhealth policy decide to go overseas for treatmentversus getting it done domestically here in the U.S.?Certainly the average patient has very little interestin saving the insurance carrier any money after thepatient has paid the ridiculously high and ever-increasing insurance premiums. Moreover, theinnate concerns about safety, quality of care andinconvenience are not going to be easily dispelledwhen the fully insured patient could just as easilybe treated domestically for similar out of pocketcosts to that patient.

Then why would a fully insured patient gooverseas for care? Here are two possible reasons.First, the fully insured carrier is going to giveincentives to an insured, such as waiving adeductible or coinsurance, and in some cases, pickingup travel expenses. Some may go so far as to givecash incentives. If an insured had a $5,000deductible or a Health Savings Account in the UnitedStates, but no deductible overseas, all travelexpenses paid, plus a cash incentive of severalthousands of dollars, American patients wouldblink, and clearly would look into the option ofgetting treatment overseas. Currently, no U.S. healthinsurance carrier is offering cash incentives for aninsured to go overseas. Many health insurers arestill focusing on the evaluation of liability anddetermination of risk involved in sending patientsoverseas, and especially the risk involved inproviding incentives to do so.

The second reason a fully insured patient wouldgo overseas would be quality of care. At this time,it is very difficult to determine and compare thequality of care overseas. Several of the largesthealth insurance carriers in the U.S. have said theyare not comfortable with being able to evaluate anddeterminate the level of quality of care. Many ofthe fully insured carriers feel there needs to be anextremely high standard for overseas hospitals.

Some have off the record even stated that they feel JCI, the most well-known and sought afteraccreditation system for the larger overseas hospitals isn’t good enough for them and they wish tosee a higher standard, however they just don’t know what that is right now. And until they knowwhat they want and what they are comfortable with, these U.S. insurers are not going to moveforward with sending Americans overseas.

A real problem with determining the quality of medical care overseas, especially for fully insuredhealth carriers, but more particularly for patients, is obtaining full disclosure of accurate and detailedinformation on quality of care and outcomes. As long as hospitals hold this information tight to theirchest, American companies will be hesitant to look overseas for health care. Those hospitals willingto progressively move towards transparency, allowing full disclosure of quality of care and outcomedata will be more readily embraced by the U.S. health care system.

In conclusion, it is extremely important for international hospitals seeking to expand their facilitiesin the area of medical tourism to realize who their target audience is. Before spending thousands ofmarketing dollars to attract the insurance carriers and fully insured patients, international hospitalsshould focus on globalizing their data to allow for full disclosure of quality of care and outcome data.Hospitals need to understand that fully insured carriers will not be sending many patients overseasuntil quality of care can be confirmed in a way they are comfortable with.

DECEMBER 2 0 0 7 43


Change is the only constant. And because it is often accompanied bystressful and sometimes difficult adjustments and decisions, we often goto greater lengths to resist rather than embrace change. So how does onemake change a little easier? Oftentimes having choices and options makesthe transition bearable, and even rewarding.

The challenges we face in health care today are certainly no exception. Asleaders and employers address the need to manage the rising costs of carein the U.S., consumers have more options than ever. From multiple offeringsof plan options, Health Savings Accounts (HSAs) and Flexible SpendingAccounts (FSAs) to seeking medical treatment abroad, both insured anduninsured health care consumers now need to research how to spend theirown resources. One such option is medical tourism, or as the quality-conscious refer to it, medical travel – traveling abroad expressly for highquality medical care at a lower cost.

Traveling to another country for medical care, however, is not withoutsome significant challenges of its own. One of particular importance isexactly how to involve your local physician and ensure that they will haveaccess to the necessary resources when you return home. Medical travelwill be more successful with the support of physicians and ancillaryproviders once back in the United States. A critical component in thesuccess of one’s treatment is the availability and coordination of follow-up care with the patient’s domestic physician.

The consensus among many U.S. physicians is that this is fast becominga reality of today’s health care market and more and more patients willhave choices when it comes to deciding where to seek care – especially formore complex, high-cost treatments and procedures. There are severalrecommendations you can follow to help smooth out the transition fromtreatment abroad to after-care at home.

First, and most important, locate a provider and physician that supportand encourage collaboration with the primary physician in the U.S. andvice versa. This should be viewed as a partnership between your doctor athome and the clinician abroad. It’s not enough to simply discuss the planof treatment with your attending physician at home, but encourage themand the destination specialist to communicate. Effective communicationbetween all individuals, services, programs and organizations will likelyimprove the quality of care and level of functioning. According to theMarch 31, 2007 sentinel event statistics published by The Joint

Engaging Your Family Physician in

Medical TravelBy THOMAS C. JOHNSRUD,

Medical Travel Consultant, Parkway Hospital

Locate a provider andphysician that support and

encourage collaborationwith the primary physicianin the U.S., and vice versa

Commission, communication was cited as the root cause of the event innearly 70% of the reported cases.

Also, share ALL of your medical history, medications, allergies and anyother relevant indications that you and your physician deem important toshare. If you are working through a medical travel agent, they should beable to facilitate the transfer of appropriate medical records includingcurrent x-rays, diagnostics, etc. In fact, some agents have access to web-based repositories that enable medical records and documentation to beeasily shared between authorized providers. Contrary to the more familiarreferral process, this is a more complex partnership that requires all involvedphysicians to work together for the patient to receive the best and safestcare.

The total plan of care also should include ensuring that the potentialresources needed after the initial treatments are available upon your return.Although the acute portion of the recovery may occur at the treatmentdestination, medical travelers may require the need for several weeks ofrehabilitation at home post-treatment. Make sure you and both physiciansare aware of what these requirements are before completing your travelplans.

The collaborative link between the physicians facilitates a much morecomprehensive treatment plan to follow you through your recovery andhelps to ensure a better outcome. Medical treatment overseas serves as acomplement to, not a replacement for, health care in the U.S.

44 DECEMBER 2007

JOIN

THE MEDICAL TOURISM ASSOCIATION

[email protected]


In recent years medical tourism has becomesomewhat of a buzzword in the USA – it mighteven be worth calling it a bubble, given both itslinks and likeness to the dot-com investmentbubble. Although one could view this evolvingindustry as a manifestation of globalization andmore liberal trade common in all sectors of theeconomy, some have attempted to classify thisas a unique phenomenon – often considering ita “disruptive” technology that couldrevolutionize health care, both here and abroad.Others paint a more sinister picture, claimingthat healthcare tourists are “refugees” escapingthe high prices of the U.S., displaced from thecomfort and quality of American health caresystems in order to afford care (with the naturalextension that they are sacrificing both comfortand quality by doing so).

In reality, the U.S. plays a minor role in theinternational market for healthcare tourism.The American market is dominated by theAsian market, and both Asia and the Americasare minuscule compared to the size of theEuropean market. This disparity is in part

This disparity is in part due

to the misconceived

definition of “health tourist,”

which focuses on national

borders rather than

state borders.

Psychological

barriers to

understanding

the market for

due to the misconceived definition of “healthtourist,” which focuses on national bordersrather than state borders. If we focused on theE.U. and just looked at its collective exteriorborder, much of the internal trade amongst itsmember countries would be omitted. Similarly,if the focus in the U.S. were to shift to patientscrossing state borders for healthcare, thenumbers would be much higher. In fact,Americans cross state borders for healthcareevery day in search of better quality of care,better physicians, greater convenience ofscheduling and even better pricing. What issurprising about the American market is thatmost of the current discussions focus onexporting patients to other nations, rather thanthe traditional market of attracting wealthyforeigners to our elite hospitals systems. It isclear, however, that the debate on healthtourism is being manipulated for politicalmeans (e.g. healthcare reform in the USA ishard to sell if you focus on the positiveelements) and such manipulation is being madepossible by a lack of data on health care

Psychological

barriers to

understanding

the market for

Medical TourismBy JOHN F.P. BRIDGES, Ph.D.

46 DECEMBER 2007

John FP Bridges Ph. D. ~ John is an Assistant Professor in the

Department of Health Policy and Management at Johns Hopkins

Bloomberg School of Public Health (www.jhsph.edu/dept/hpm)

and a Senior Fellow at the Center for Medicine in the Public

Interest (www.cmpi.org). He is an advocate for the scientific

study of patient preference in the area of Pharmacoeconomics,

Outcomes Research and Technology assessment and is the found-

ing editor of a new journal titled “The Patient – Patient Centered

Outcomes Research.” He is also a co-author (with Percivil

Carrera) of a study titled “Globalization and Health care: Un-

derstanding health and medical tourism,” published in the Expert

Revue of Pharmacoeconomics Outcomes Research

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

[email protected].

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

If we are going to truly understand healthcare tourism in America,then there are at least three barriers that we have to overcome.Unlike most trade barriers, these barriers are in many respectspsychological ones or relate to historical biases or have been generatedby misinformed media coverage of the issue. Like many trade issues,there are vested interests looking at the market for medical tourismeither as an opportunity, (particularly those that want a quick buckout of exploiting this market), or a threat to the status quo. To date,there has not been a rigorous discussion concerning the potentialgains from trade associated with the internationalization of healthcare services.

The first barrier to understanding health tourism is realizing that itis not dominated by flows of patients from the developed to thedeveloping world per se. Many health care tourists come fromdeveloping countries that lack specialist care or infrastructure. Forexample, many health care tourists in Singapore come from Indonesia.In fact, when one assesses international trends, two assertions canbe made. Generally, patients travel to countries with relative similarlevels of development and patients normally seek care in their ownregion. Of course, many exceptions can be found to these rules, butit is important to note them as exceptions.

The second barrier to understanding the market relates to the pushand pull of patients. In the U.S. we need to stop focusing on thepush factors that are leading people to consider healthcare tourismand focus on mechanisms to pull patients towards our facilities.This will be difficult as the notion of push is so engrained into theAmerican health care system. (When has your surgeon ever said,“Let’s schedule the surgery when it is best for you?”) Managed careengrained the notion of push, and pay-for-performance will do littleto make care more patient-centered. In reality, many Americanschoose foreign providers because they are attracted by the qualityof facilities, customer service and a holistic approach to care.

Finally, to understand healthcare tourism one has to realize that itis more than just travel for medical procedures, rather, it incorporatesa broad range of lifestyle and wellness factors. While many hospitalsin the U.S. are venturing into the realm of complementary andalternative medicine, the environment of the typical aging hospitalinfrastructure of the U.S. might negate some of the benefits of thesetherapies. An example of how medical tourism enhances wellnessrelates to dedicated recovery time. In the U.S., it is common for apatient to return to work or return to their day to day grind before

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

Patient with chronic back pain given life back

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

DECEMBER 2 0 0 7 47


It killed Manufacturing, put Software on life

support and is now infecting U.S. Healthcare

Ebola

By MICHAEL BINA

PART - 1

According to experts at Harvard, JohnsHopkins and Mercer, the US System is sick;its prognosis, poor.” We’re reaching the outerlimits of affordability,” said Arnold Milstein,MD, Medical Director of Pacific BusinessGroup on Health (PBGH) and ChiefPhysician at Mercer Human ResourceConsulting (MHRC). Milstein wasaddressing an international conference ofproviders, educators, brokers and facilitatorson Global Health when he said, “We’reseeing an upward spread of the‘Unaffordability Ebola’.”

What Happens in Vegas...

At the first International Medical TourismConference in Las Vegas this year, Milsteinwas one of the prominent canaries singing anearly warning of a virus attacking theseemingly immune U.S. Healthcare System– (formerly known as “The Best System inthe World”). The Canaries were singing atall venues in ‘Vegas, but it WON’T stay in

Driven by “The Number One

Concern of Adults and

Businesses in the U.S.,”

an insatiable and immutable

‘Unaffordability Ebola’ is

attacking another compliant

U.S. host: The U.S.

Healthcare System.

Vegas. The Ebola is spreading across a FlatWorld faster than people will admit...

500,000 U.S. Patients Abroad

The National Coalition of Healthcareestimates 500,000 people left the US fortreatments last year; 500,000 internationalpatients will visit India this year infusing $2.2Billion into its economy; 200,000 patientsvisited Singapore in 2005; 100,000 visitedMalaysia that same year. It’s a $60 BillionGlobal Business that’s growing 20% a year.

At a presentation titled: “Leveling theGlobal Healthcare Playing Field,” HarvardMedical International President and CEO,Dr Robert Crone argued: 1.) Regional HealthSystems have achieved quality services atlower cost than U.S. systems; 2.) GlobalStandards and Benchmarks of quality areemerging; 3.) Medical Tourism is growing,and global insurers will participate. Privately,he said, “They’re going to eat our lunch.”

Unaffordability

48 DECEMBER 2007

How interested would

you be in traveling to

another country for a

routine procedure (e.g.

your Executive Physical)

if you knew the cost

would be considerably

less - and the care would

be equally good?

Bark and Bite!

Dr Crone knows what’s going on. He has thecredentials one would expect of a guy who’s atthe top of the food chain at Harvard Medical.He’s lectured and implemented health educationand delivery system programs in more countriesthan the average American could name, spell orfind on a map! A Top Dog in global healthcare,Crone has the bedside manner of a Junk YardDog: both the bark and the bite hurt!

”In the Flat Medicine World, US facilities maybe seriously disadvantaged; adversely impactedin the global marketplace. “Oh well,” he saidsmugly, “we had our Century.”

Crone rattled off the maladies running rampantthroughout the system today, then piled onseveral scary scenarios ahead. It was a forebodingmessage for anyone planning to access USHealthcare today, or tomorrow.. (Meaningeveryone; every single American; rich, poor,healthy, sick!)

Like other industries, healthcare has globalizedand the new, uber competitive marketplace isintroducing unimagined (some say impossible)features and benefits to consumers of healthcare:Cheap; Comparable Outcomes; OutstandingCustomer Service…What’s not to like?

Let’s say you’re uninsured and need a newknee? What if you needed something less invasivelike your annual physical? What if you wanteda face lift; breast reduction; tummy tuck or, sexchange? Since you’re responsible for the fullprice on these latter procedures, you’reprobably going to shop around, (after you’veself-diagnosed your problem, of course.)

As you’re shopping, you’re probably tryingto find other important things to look at andmeasure. Unfortunately, there is little accessible,comparable consumer information on cost,quality and care in the U.S.! As a result, eventhe most unsophisticated buyer of healthcare isdrawn to the international healthcare bizarre onthe internet – and a sale is made half way ‘roundthe earth, in the dead of night.

Joe Sixpack

Let’s say you’re a self insured employer –responsible for the first $50,000 or so on eachemployee. Would you consider recommendingOld Joe from Sales to contemplate an awake,beating heart coronary artery bypass grafting ata superspeciality hospital in India - instead ofat a local provider? Would you ask/beg Joe to gohalfway around the world for a couple monthsof cancer treatments for the good of thecompany? Would you rewrite your plandocument to take advantage of global pricing?

Would you consider Singapore as your PreferredProvider Network?

And what about taxpayers? Should the U.S.Government send Medicaid patients packing?What about Medicare? Should taxpayers shellout $50,000 for grandma’s new hip when shecan get one of those innovative, high tech hipresurfacing jobs for about $10,000 bucks or soin India or Thailand?

How about all those new, high deductible healthplans being sold by the carriers - where yourbest interest (maybe your only interest) is findingand buying the most cost-effective care you canafford?

Would you fly 10,000 miles for a couple newcrowns - plus a week on the beach - if you’dsave $1,000? A TIME Magazine poll in May2006 found that 45% of uninsured people saidthey would; 19% of insured people said theywould, too. When asked if they could save$5000, 61% of the uninsured and 40% of insuredssaid they would travel 10,000 miles for anelective procedure.

Hold the Mayo

Imagine your Executive Physical at a Mayo vs.Maya? (Come on, guys, wouldn’t you be moreinclined to actually have an annual physical –even with a colonoscopy – if it included a weekon the beach with a martini and a massage forless than you’d spend for three days inRochester, Minnesota?)

Medical Tourism is Hot. (Some call it:“Medical Value Travel;” others:“ConsumerDriven Healthcare at its most driven level.”)Whatever YOU call it, it’s economics applied tohealthcare for the first time in 50 years.

Medical Value Travel has been going on in theworld for a long time, but most tourism has beeninbound to the Mayos and the Cleveland Clinicsof the world. Since 911, however, inboundMedical Travel has all but dried up; outboundtourism is growing by leaps and bounds. Insteadof Cleveland, it’s Chennai; instead of Mayo, it’sMumbai.

What’s a CEO to do?

Nicolet Bank Business Pulse© is a quarterlyeconomic and business study of CEOs, O&Osand GMs in 10 Northeastern Wisconsincounties. (Businesses from all sectors and allsizes are represented in the sample.) In January,Nicolet Bank posed several questions aboutMedical Tourism: 52% of the CEOs, O&Os andGMs never heard of Medical Tourism; 23%heard of it, but didn’t know much about it; 17%were somewhat familiar; 9% very familiar.

The Nicolet Bank Business Pulse© also asked:“How interested would you be in traveling toanother country for a routine procedure (e.g.your Executive Physical) if you knew the costwould be considerably less - and the care wouldbe equally good?”

“Nearly a third said they’d be interested,” saidDr David Wegge, president of IntellectualMarketing, LLC – the firm that conducts thestudies for Nicolet Bank of Green Bay. “I don’tknow how this compares to national CEO data;I suspect we’re the first to ask.”

Wegge was surprised that a third of the CEOswould be interested, “especially among CEOswho probably have health insurance and fewerfinancial worries.” 30% were definitely notinterested; 23% were probably not interested;19% said, “It depends on the country.” (Of thecountries listed, Canada was the overall preferredprovider; Russia was dead last – definitely anOUT of network provider!)

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

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

*Contact Wegge for detailed analysis:920 217 7738

Britons Taking Up Private Medical Plans

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

y

DECEMBER 2 0 0 7 49

Why pay for performance?

Pay for performance ( P4P ), is a new trend inreimbursement that is gaining momentum in theUnited States. Traditional payments tohospitals and doctors were based on diagnosis~ the government or managed care companieswould pay a specific fee to doctors and hospitalsbased on these diagnosis, regardless of outcome,complications, patient satisfaction, or errors.Today, many large insurance companies and thefederal government (CMS) are incentivizing, orpaying bonuses to doctors and hospitals thatfollow specific guidelines set out as “quality”by these reimbursing entities. These may includeusing certain medications, timeliness of care, orcomplication rates. These guidelines are mostoften clinical, but some also include measuresof cost effectiveness as well.

Today there are only a few system-wideimplementations of the pay for performanceplan and most projects are still pilots. Med-Vantage and The Leap Frog Group projectedthere will be 155 Pay for Performance programsin place this year compared to a mere 39 in2003. The metrics are still being hotly debatedby providers, payors and regulatory agencies.

Costs of P4P

Opponents of Pay for Performance argue thatP4P increases administrative costs. Manyprivate payors are piloting new P4P projectsthat involve penalties. Although only fewpenalties have been enacted, different structures


Pay for Performance:Here today…..here tomorrow?

Quality Indicators

� Patient Satisfaction

� Mortality Rates

� Rehospitalization within 72 hours

Operational Indicators

� Average Length of Stay

� Cost per Discharge

� FTE’s per Occupied Bed

P4P already indirectly rewards OperationalEfficiency by generating increased profitabilitydue to lower costs as a percentage of charges,but what if P4P were applied to youroperations? A higher than average percentage ofspending on administration implicitly means thatyour organization is spending LESS (as apercentage of revenue) on patient care.Philanthropic organizations are already measuredand rated based on their percentage ofadministrative cost. (www.charitynavigator.org)

Source: National Center for Health Statistics

Is the US Healthcare System broken?

It is no secret that employers are droppinginsurance plans and cost shifting to employees.In some cases, it takes 18-30 months forcoverage to take effect. What about the qualityof care received in the US? It is estimated thatonly 55% of medical care received is actually

are being discussed, some of which include areduction in base reimbursement as incentivesincrease. These same payors are also placingmore of the burden of measurement and reportingon providers in order for them to obtain Pay forPerformance incentives and thereby increasingprovider administrative costs. Lowerperforming providers are improving the fastest,but receiving the smallest allocation of P4Preturns. (JAMA October 12, 2005)

Operational Efficiency

Pay for Performance revenue less operationalefficiency (OE) are the two factors that aredirectly correlated to organizational profitability.Where 80th percentile Pay for Performance withonly a 10th percentile OE may net out at a levelwell below the national average industryprofitability, this factor is critical. Pay forPerformance cannot be evaluated withoutassessing the impact of OE. To improveprofitability in future P4P environments, weneed to increase quality or operational indicatorswhile holding the other constant. But to movethe curve in the future P4P environment,quality improvements will need to increase OEor vice versa.

Operational Efficiencies

Financial Indicators

� Operating Margin

� Contribution Margin

We all recognize that there is no perfect payment system. The historical “fee for service”method does not align quality of treatment and treatment results with reimbursement ~ butrather with volume of treatment. Financial incentives have been demonstrated to changebehavior. The current “Pay for Performance” method established by many insurancecarriers is intended to reward providers for achieving certain performance measures forclinical quality and efficiency. So the theory is that high quality should be rewarded andthat better care will lead to better outcomes. The question is…is it working?

By DAN BONK

50 DECEMBER 2007

the correct care for patients’ conditions. There is an average of 98,000deaths per year directly related to medical errors. With 46 millionAmericans uninsured, and although healthcare is always on the politicalagendas at the national and local levels, there does not appear to beany immediate solution in sight. Needless to say, one of the greatestAmerican myths is that we have the best healthcare system in theworld.

A crisis in need of P4P

Healthcare’s share of the economy continues to grow and is projectedto reach 19.6% BY 2016. US healthcare spending far exceeds that ofother “developed” countries both in terms of per capita spending andpercent of GDP.

Physician Compensation and the Delivery of Quality HealthCare

We all recognize that there is no perfect payment system. In fact,financial incentives have been demonstrated to change behavior. Thefee for service/volume system can encourage over utilization whileprepayment or capitation risk models encourage wider utilizationeven when prevention is encouraged. Salary systems withoutincentives can discourage effort and innovation. Peter Lee, CEO ofThe Pacific Business Group on Health said, “We pay even if doctorsmake mistakes, run unnecessary tests and have to redo their work.”

Today there is no national set of performance standards againstwhich physicians are measured. The CMS pilot project may be thefirst effort announced in 2003. CMS administrator Tom Scully hascriticized the current system for paying every healthcare provider“the same rate, whether they are the best or the worst” (New YorkTimes, July 11, 2003). Under the P4P program, medical groups submitdata toward a common scorecard that grades them on patient

15%

5%

3%

2%

Healthcare

Airlines

Retail

Hotel

Percentage of Revenue Spent on Administration

Per Capita

$ 2,094$ 2,467 $ 2,508

$ 2,825$ 3,043 $ 3,120 $ 3,159 $ 3,165

$ 4,077

$ 8,000

$ 7,000

$6,000

$5,000

$4,000

$3,000

$2,000

$1,000

$0Spain Italy UK Sweden Germany Australia France Canada Switzerland USA

% of GDP

18%

16%

14%

12%

10%

8%

6%

4%

2%

0%

$ 6,102

8.1% 8.7% 8.1% 9.1% 10.6% 9.6% 10.5% 9.9% 11.6% 15.3%

Health Care Spendingin Selected Developed Countries, 2004

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

DECEMBER 2 0 0 7 51

satisfaction, clinical treatment, and investment in informationtechnology.

Some substantial payments are being made. In addition, on August24 Blue Cross of California, a subsidiary of WellPoint, announcedthat is was rewarding 126 physician groups a total of $69 million inbonuses for performance in 2006. About a week earlier, Blue Shieldof California announced that it distributed $31 million in bonusmoney.

What do Physician Groups Fear about P4P?

� Getting used in a “shell game” manipulated by the payors

� To date there is no long term commitment to P4P by payors

� Measures are not geographically or socio-economically fairor reliable

� P4P compliance is too burdensome and expensive

� Public reporting can increase liability

� Cost controls will masquerade as quality and initiatives

Physicians have embraced some P4P models over the last severalyears such as the one Beckman developed for physician stages ofchange P4P (see illustration below).

REGULATORY & LEGAL ISSUES

The issue of increased liability for P4P participation raises severallegal and regulatory issues – yet to be resolved. These includePhysician Anti-Self-Referral Law (the “Stark” law), Anti-KickbackStatute, Civil Monetary Penalties Act, Antitrust, Defamation,Malpractice and Privacy.

Physician Self-Referrals

The Stark Law prohibits a physician from referring Medicare andMedicaid patients for designated health service to entities with which thephysician (or an immediate family member) has a financial relationship. AP4P arrangement may be exempted from the Stark prohibitions by meetingone of the following exceptions: personal services exception, fair marketvalue compensation exception, electronic items and services exception. Inthe hospital/physician model, a hospital may become involved in a P4P orgainsharing program by contributing funds as part of the program. If thisis the case, a financial relationship with the participating physicians willbe created, and the financial relationship must satisfy each element of aStark exception.

Anti-Kickback Statute

The Anti-Kickback statute prohibits the solicitation of, offering of, orpayment of any type of remuneration (directly or indirectly, in cash or inkind) in exchange for referrals or the arranging for the furnishing of healthcare that is paid for by federal health care programs. A P4P arrangementmay be immune from Anti-Kickback liability if it meets one of the followingSafe Harbors: investment interest, personal services and managementcontracts, electronic items and services.

Civil Monetary Penalties Act

This Act prohibits a hospital from making a payment directly or indirectlyto a physician as an inducement to reduce or limit services to Medicare orMedicaid beneficiaries under the physician’s care. This is the major issuefor gainsharing programs.

Antitrust

To avoid a price fixing charge, an arrangement should indicate financial andclinical integration.


52 DECEMBER 2007

Defamation

If a report questions the quality of care administered by a physician, would thepeer review privilege apply? Are the network decisions regarding credentialingand termination protected from discovery? Are patient surveys subject todiscovery?

Malpractice

Do reported quality indicators make physicians more susceptible to malpracticeclaims? Will quality rankings be admissible in a malpractice lawsuit?

Privacy

P4P arrangement may involve the sharing of patient information, which wouldtrigger applicable privacy laws. HIPPA concerns will need to be addressed orprovider confidence will be an issue.

Also, in the future, medical staff by laws, and rules and regulations need to bereviewed and possibly revised. Medical staff policies need to be reviewed andpossibly revised to address a provider’s performance. Both the hospital and themedical staff should consider establishing loss control/loss mitigation strategiesrelated to outcome data use.

Is P4P Here to stay?

As reported in Health Leaders News on August 1, 2006, “100 healthcare leadersfrom hospital, physician, supply chain and policy sectors were asked to rank thetop 10 most important issues that are transforming US healthcare. Pay-for-performance programs were ranked #1.”

Paul Danello, former counsel DHHS, OIG wrote recently, “This is the beginningof the third wave of reimbursement, not some fad.”

Mark McClellan, 2005 in “Quality, Safety, and Transparency: A Rising TideFloats all Boats” wrote, “During the next 5 to 10 years, P4P could account for20% to 30% of what federal government pays providers.” While Leslie Norwalk,CMS wrote : “The Premier Hospital Demonstration is showing that even limitedadditional payments, focused on supporting evidence-based quality measures,can drive across-the-board: improvements in quality, fewer complications andreduced costs.”

Another CMS leader was overheard comparing the CMS P4P pilot to the studyof a new drug. His analogy compared P4P to a new drug, and our current paymentmechanism to the placebo. His analogy was that P4P was curing patients whilethe placebo group was remaining ill. He joked that possibly we should call offthe study, throw away the placebo, and “cure everyone” by implementing P4P!

Overall, it looks like Pay for Performance has the right idea to at least improvingthe quality of care for patients. Although the providers find the program to becostly and unfair, it would appear that at least the patients are reaping thebenefits of a better quality of care.

Dan Bonk is the Executive

Vice-President, Central Region of

Aurora Healthcare, a successful

senior healthcare leader for over

25 years. He is also an Advisory

Board Member of the Medical

Tourism Association.



What is Self-funded Healthcare

Amazingly many overseas hospitals don’tknow what self funded health care is (sometimesreferred to as Self Funding). Every hospitalshould, because self funded healthcare is one ofthe few ways for hospitals to tap into thepatient pool for Americans that already havehealth insurance coverage, but may choose togo overseas for healthcare rather than receive itdomestically in the U.S. Understanding howSelf Funded Health Care fits into MedicalTourism is a key factor in the growth of thisindustry.

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

What is a Self-Funded / Self-InsuredPlan?

A partially self-insured, or self-funded plan,is one in which the employer assumes a portionof the financial risk in providing health carebenefits to it’s employees. The employerchooses a plan of benefits, which may be similarto or identical to the employer’s current fullyinsured plan. Rather than obtain medicalcoverage from an insurance carrier (such asBCBS or Aetna), the employer elects to fundthe risk of medical claims up to a certain levelwhere a Reinsurance or Stop Loss Insurancecarrier is brought in. For larger employers, noreinsurance or stop loss insurance is brought inand the employer is fully 100% at risk for allmedical claims.

Stop Loss or Reinsurance is designed to limitthe employer’s risk of self funding theirhealthcare and limits the losses for medicalclaims to a specified amount, to ensure thatlarge, or unanticipated claims, do not upset thefinancial integrity of the self-funded plan. Thelevel of risk an employer takes on with selffunding and the point at which a reinsurance orstop loss insurance kicks in is in direct relationto the employer’s size, nature of their business,past medical claims experience and tolerancefor risk.

Normally, in self funded arrangements, a Thirdparty administrator (TPA) administers the plan.A TPA performs the same functions that a fullyinsured carrier would. A TPA’s responsibilityincludes maintaining eligibility, customerservice, managing a network of contractedproviders, adjudicating and paying claims,managing and negotiating claims, preparingclaim reports, plus arranging for managed careservices such as network access and casemanagement.

Self Funding – A Comparison to FullyInsured Plans

Everything that is provided in a fully insuredhealth plan is duplicated in the self funded healthplan. (Everything that the fully insured carrieroffers in a fully insured plan, is offered in theself funded plan – from PPO networks tobenefits, such a co-pays, deductibles andcoinsurance.)

The difference is that with the partially selffunded plan the employer holds the cash neededto fund benefits (claims from providers), andinstead of sending the fully conventionalpremium to the insurance company (such as

BCBS or Aetna), only a small fraction of theconventional premium is sent in to thereinsurance carrier and a small amount to theTPA. The employer purchases reinsurance forprotection, holds the remainder of theconventional funds (claim funds), invests them,segregates them if desired, or utilizes them forgeneral business purposes until they are neededfor the funding of medical claims. The employerretains and keeps the funds when claims do notmaterialize, hence realizing further profit. So,if an employer was paying BCBS or Aetna$5,000,000 a year in premiums, and theemployer’s employee claims were only around$2.5 million, then it is possible for the fullyinsured carrier to walk away with close to $2.5million in profits. If the employer self funds,the employer is the one who walks away withthe $2.5 million dollars in savings at the end ofthe year.

Example A: (Fully Insured Example)

Acme Company is fully insured with a FullyInsured Carrier and pays a premium of$1,500,000.00 annually for their healthinsurance plan. Claims experience shows thatAcme Company only had $1,000,000 in claimsand administration expenses. The fully InsuredCarrier keeps the $500,000 in profits.

The advantages of self-funding are many.There is tremendous flexibility in the benefitplan design. You can decide what you want tocover and what you don’t, whether it’s certainvaccinations, chiropractors, injectibles, obesity,or infertility. Another major advantage, isportability from one carrier to another. There’sno disruption in plan when you shift betweenreinsurance carriers. You don’t have to start allover again with new I.D. cards, booklets and

How does Medical Tourism fit into it?&

54 DECEMBER 2007

doctors, the way you do with the fully-fundedplans. Also, for employers with more than oneoffice, it is possible to offer the same plan toeveryone in every location. This makes it somuch more administratively efficient. By SelfFunding an employer can utilize onenational PPO network or multiple local PPOnetworks with the same benefit plans. But thebottom line, is cost savings.

Example B: (Partially Self FundedExample)

Acme Company’s group health insurance isself funded with a Third Party Administratorwith reinsurance. Acme Company’s potentialworst case scenario for the year is $1,600,000annually (what they would have paid to a fullyinsured carrier). Acme Company pays $20,000a month in fixed premium costs and holds inclaims reserves $1,360,000 for potential claims.The $1,360,000 is retained by Acme Companyand it is theirs to utilize as they see fit untilclaims materialize. At the end of the year AcmeCompany’s claims are $1,000,000. Their fixedpremiums were $240,000 for a total of $1.24million. Acme Company retains the $360,000it reserved in a worst case scenario. AcmeCompany realizes a $360,000 savings by goingSelf Funded versus Fully insured.

ClaimsExperience—ImmediateRealization of Hard Dollar Savings

Under a fully insured program, if anemployer’s experience is “better than expected,”the insurance company gains financially andmakes an unexpected profit. The insurancecarrier does not refund the excess profit to theemployer. Even if an employer has good claimsexperience, the insurance company will stillpass on a renewal based upon the insurancecompanies’ pool of thousands of groups.Employers are not truly rated based upon theemployer’s claims experience and can be treatedunfairly. With Self Funding your renewals arebased on “YOUR” company’s claimsexperience, and it is not based on thousands ofother companies that have no relation to yourcompany or industry. You, the Employer, notthe insurance company enjoy the advantage offavorable claims experience. You, the Employer,keep the savings, not the fully insured carrier.

How Does Medical Tourism fit intoSelf Funding?

Most Self Funded plans have reinsurance,which is a form of insurance that protectsemployers from catastrophic losses. So, theemployer funds the base of the plan, with areinsurer taking care of catastrophic losses.One form of this insurance is Specific StopLoss Reinsurance. Specific Stop Loss -Reinsurance (also known as Individual StopLoss or Specific Deductible) protects a self-funded employer from large claims from anyone individual or dependent. If any oneindividual’s claims hits the Specific Deductible/Individual Stop Loss Level (a specific dollaramount) the employer’s liability ceases andthe reinsurance carrier takes on the liabilityand the claims. The Stop Loss Carrier willthen reimburse the employer for all claims inexcess of the specific deductible for the rest ofthe plan year. The Specific Stop LossDeductible is determined by the followingdemographics of the employer: number ofemployees, age, sex, claims experience, etc..

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

$99,999.99 in a self funded health care plan.If the employer can implement medical tourismand convince an employee to go overseas forhealthcare, and the employee goes to Asia forexample, then the cost for the surgery mayonly be $9,000. That means the employer justsaved $91,000 “hard” cash. By the U.S.employer utilizing Medical Tourism they justcut their health care expenses for majorsurgeries by up to 90%!

A creative method some Third PartyAdministrators and employers are doing iscreating incentives for employees. Theseincentives could be from paying for the memberand a loved one’s airfare to the foreign country,plus picking up all expenses, hotel, food, etc.Some companies are even offering cashincentives on top of an all expense paid trip/vacation, allowing employees to take avacation they otherwise couldn’t afford andstill have cash in their pocket. For a $100,000surgery in America that would cost $9,000 inthe U.S., if the employer waived a $2,000deductible, paid for airfare for the member anda loved one, plus all expenses and a $5,000cash incentive, the employer could walk awayspending less than $20,000 for the surgery.Which is still a $80,000 savings (80%) overgetting the surgery done in the United States.Don’t forget, with self funding, this is theemployer’s money that’s being saved, not theinsurance carrier..

The most important part for the Third PartyAdministrator and Employer is partneringwith a quality hospital and ensuring theemployee or participant has an amazing healthcare experience. Next month we will addresshow employers should approach medicaltourism with their employees and how it canchange the corporate culture.

Malaysia

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

Jonathan Edelheit is Presidentof the Medical TourismAssociation with a long historyin the healthcare industry,providing third party administra-tion services for fully insured,self-funded and mini-medicalplans to large employers groups.

Medical Tourism is the onlyreal solution in health caretoday where employers areguaranteed to save money.

DECEMBER 2 0 0 7 55


PLANNING YOUR

MEDICAL TRIP ABROAD

Recovery Retreat or Hotel:An Interview with Jim Follett of

International Hotel Group

As the amount of US patients

traveling abroad for elective care

continues to increase, where to stay

when arriving at a destination

country is becoming big business.

By LOURDES GASPARONI

The needs of the “Medical Tourist” are muchdifferent than those of someone traveling on businessor vacation. Historically, for a medical tourist, stayingat a traditional hotel comes with much apprehension.While a hotel may be very appropriate for someonehaving dental work done, it may not be very suitablefor someone having a cosmetic or bariatric procedurefor example. Challenges include: the lack of privacyafter the procedure, rooms often times not properlyequipped to handle post-surgical issues, medical needs,such as nurse care and massage therapy, are not readilyavailable. This may cause frequent trips to a medicalfacility for post-operative care and follow up.

Many hotels are trying to make the adjustments. JimFollett of International Hotel Group, based in Dallas,TX says, “As the hotel company with more guest roomsthan any other company in the world, we are focusingon the individual traveling internationally for variousmedical treatments.”

Jim is the Director of Global Sales in Latin Americaand has spent much time in Central and South America.“Our research found these individuals have specialrequirements at the facilities they select for theirrecovery period. Our brands InterContinental, CrownePlaza, Holiday Inn, Holiday Inn Express, and StaybridgeSuites are committed to satisfying the unique needs ofthese guests.”

“The initial markets where we are developing programsfor these guests include San Jose Costa Rica, MonterreyMexico and Sao Paulo Brazil. Each city has multipleIHG brands which will satisfy the different budgets ofthe travelers. The Real InterContinental San Jose forexample offers 24 hour room service, health club andbusiness center which is very important to many ofthese guests. The newly renovated Holiday Inn San

56 DECEMBER 2007

Jose-Aurora located in the city center offers walkingaccess for the guest to the city - a plus for individualsinterested in exploring the city as they recover.”

“The hotels will have specifically designed programsfor the medical tourist. Their recovery needs will varybased on the various medical procedures. Staying withinternationally recognized brands will reduce some ofthe anxiety these patients experience. Additionalservices such as daily transfer to the facility, specialdietary offers and free local phone calls to their doctorswill include some of the services these guests willexperience with IHG brands. A web site has beenestablished for the industry, specifically for the medicaltourism providers in the USA and Canada. Weanticipate working in concert with these professionalsto insure a quality experience for the guests.”

Outside of hotels, many countries in Latin Americacatering to medical tourists, have left it to thephysicians and hospitals to come up with solutionsto this need. A plastic surgeon or hospital, for example,may offer an apartment that is nearby to the medicalfacility with 24 hour nurse care.

Some countries such as Costa Rica, however, havebeen quick to identify a medical tourist’s needs andhave made adjustments accordingly.

“There are over 15 recovery-type retreats in SanJose alone,” said Raul Cossio, Owner of the ParadiseCosmetic Inn. “Hotels are not medically equipped tohandle surgical patients, in fact, many of the localhotels will tell people to contact us instead.” Hebelieves the biggest difference is the 24 hour nurseattention and “the fact that you are among peoplethat you have a lot in common with and can shareyour experience, is a big factor.” “It’s like a big pajamaparty, everyone is comfortable, it’s the perfectatmosphere for relaxing and recharging, whichfacilitates the healing process.” “By the time thepeople leave, everyone feels like one big happy familyplanning a reunion at Paradise.”

Like hotels, there are some challenges to the RecoveryRetreat for a Medical Tourist. The issues that theyrun up against involve the limitations on what isavailable at the facility. This is particularly an issuefor those Medical Tourists that bring a spouse orcompanion. Meal selection and entertainment can belimited and the costs for extra services that may beincluded in the price at a hotel, needs to be evaluatedby the Medical Tourist. Also, after the required periodof recovery in which the Medical Tourist needs dailymedical attention for Post-operative care, they may“outgrow” the facility. Consideration to changingvenues for the remainder of the stay may be a goodoption.

Consulting the doctor, who is carrying out theprocedure is very helpful in deciding how and whereto stay. Based on their experience, they will be able toprovide you with what your expected recovery timeshould be and how long a recovery retreat would bebeneficial.

Both the recovery retreat and a traditional hotel havetheir advantages. Doing your homework and researchto determine what is best for you, the medical tourist,will help make your experience a very positive one.

Lourdes Gasparoni is a proprietor ofPremier MedEscape in Palm BeachGardens, Florida and may be reached [email protected].

DECEMBER 2 0 0 7 57

What is Your Country’s

As the healthcare crisis in the UScontinues to grow and Americans arelooking to overseas alternatives fortreatment, many people are lookingback to the World Health Report fromthe year 2000 that focuses on theperformance of health systems worldwide. It assesses health systems andthe 35 million or more people theyemploy. The report notes that thewell-being of billions of peoplearound the world, the quality, andlength of their lives, depends on theperformance of the health systems.

The WHO report came out as the first ever analysis of the performance of the healthsystems of WHO’s 191 Member States. The performance assessment of health systems isbased on many country variables such as: socio-economic, political and technological.WHO rankings show that even countries with the same levels of income can have verydifferent healthy life expectancies while many countries fall short of their potential forperformance.

According to Dr Uton Muchtar Rafei, WHO’s Regional Director for South-East Asia,“This Report will hopefully provide a framework for the review of health sector reform inthese countries, and will enable them to adopt various policy options in order to obtainhigher levels of health.”

According to Dr Uton, “Choosing the right interventions and providing incentives to theproviders is one way to improve the performance of the health system. WHO calls for anew ‘universalism’ - which means providing the simplest and most basic quality care forall, including the poor. Developing countries should rationalize their investment in human,physical and technological resources. The health ministries need to play a strong stewardshiprole, and should invite and regulate investment by other sectors, including the privatesector into health.”

R ank ing?


58 DECEMBER 2007

1 France2 Italy3 San Marino4 Andorra5 Malta6 Singapore7 Spain8 Oman9 Austria10 Japan11 Norway12 Portugal13 Monaco14 Greece15 Iceland16 Luxembourg17 Netherlands18 United Kingdom19 Ireland20 Switzerland21 Belgium22 Colombia23 Sweden24 Cyprus25 Germany26 Saudi Arabia27 United Arab Emirates28 Israel29 Morocco30 Canada31 Finland32 Australia33 Chile34 Denmark35 Dominica36 Costa Rica37 United States of America38 Slovenia39 Cuba40 Brunei41 New Zealand42 Bahrain43 Croatia44 Qatar45 Kuwait46 Barbados47 Thailand48 Czech Republic49 Malaysia50 Poland51 Dominican Republic52 Tunisia53 Jamaica54 Venezuela55 Albania56 Seychelles57 Paraguay58 South Korea59 Senegal60 Philippines61 Mexico62 Slovakia63 Egypt64 Kazakhstan

65 Uruguay66 Hungary67 Trinidad and Tobago68 Saint Lucia69 Belize70 Turkey71 Nicaragua72 Belarus73 Lithuania74 Saint Vincent and the Grenadines75 Argentina76 Sri Lanka77 Estonia78 Guatemala79 Ukraine80 Solomon Islands81 Algeria82 Palau83 Jordan84 Mauritius85 Grenada86 Antigua and Barbuda87 Libya88 Bangladesh89 Macedonia90 Bosnia-Herzegovina91 Lebanon92 Indonesia93 Iran94 Bahamas95 Panama96 Fiji97 Benin98 Nauru99 Romania100 Saint Kitts and Nevis101 Moldova102 Bulgaria103 Iraq104 Armenia105 Latvia106 Yugoslavia107 Cook Islands108 Syria109 Azerbaijan110 Suriname111 Ecuador112 India113 Cape Verde114 Georgia115 El Salvador116 Tonga117 Uzbekistan118 Comoros119 Samoa120 Yemen121 Niue122 Pakistan123 Micronesia124 Bhutan125 Brazil126 Bolivia127 Vanuatu128 Guyana

129 Peru130 Russia131 Honduras132 Burkina Faso133 Sao Tome and Principe134 Sudan135 Ghana136 Tuvalu137 Ivory Coast138 Haiti139 Gabon140 Kenya141 Marshall Islands142 Kiribati143 Burundi144 China145 Mongolia146 Gambia147 Maldives148 Papua New Guinea149 Uganda150 Nepal151 Kyrgystan152 Togo153 Turkmenistan154 Tajikistan155 Zimbabwe156 Tanzania157 Djibouti158 Eritrea159 Madagascar160 Vietnam161 Guinea162 Mauritania163 Mali164 Cameroon165 Laos166 Congo167 North Korea168 Namibia169 Botswana170 Niger171 Equatorial Guinea172 Rwanda173 Afghanistan174 Cambodia175 South Africa176 Guinea-Bissau177 Swaziland178 Chad179 Somalia180 Ethiopia181 Angola182 Zambia183 Lesotho184 Mozambique185 Malawi186 Liberia187 Nigeria188 Democratic Republic of the Congo189 CentralAfrican Republic190 Myanmar

The following is the list provided in that report. Where does your country rank? Surprised?

DECEMBER 2 0 0 7 59

The Boomers are Coming!The Boomers are Coming!


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

THE BABY BOOMER BULGE,A PIG GOING THROUGH A PYTHON

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

The Baby Boomers are the generation of Americans born between1946 and 1964, after World War II. The leading edge of this generationturned 60 years old this year and by the year 2030, the entire babyboom generation will be 65 or over. Currently baby-boomers makeup approximately 27% of the total population, or nearly 77 millionpeople, representing a peak in the overall population of our nation.Charting the baby-boomers on a horizontal graph would representthem as a bulge, referred to by aging expert and authorDr Ken Dychtwald, as “a pig going through a python.” Every day,almost 11,000 boomers turn 50 – that is one every eight seconds.

Aging of the Baby Boomers

2000 2010 2020 2030Age 36-54 Age 46-64 Age 56-74 Age 66-8478 Million 75 Million 70 Million 58 Million

This bulge works its way through time and has had significant effects ateach point in time. The baby boomers put stress on the educational systemwhen they were coming through their K-12 years. They helped bring abouta surge in the housing market when they reached middle age and, in the nearfuture, they are going to put incredible pressure on American health carefor generations to come.

While the boomers alone will create a notable rise in demand for healthcareservices, the demand will continue to rise, rather than drop, as the boomerpopulation decreases because everyone including the members ofGenerations X and Y are living longer.

ELDER BOOMERS ARE THE NEW AGE WAVE

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

What next? Ken Dychtwald answers, “For starters, they are no longerbaby boomers. They have become a continued demographic force – an “agewave”. As this generation travels along the lifeline, it will profoundlyinduce change in American society, now and for the future. The boomershave broken the rules and exploded the norms at every stage of life theyinhabit. Undoubtedly, they will continue to do so as they turn 60, 70, 80 or100 years old. Imagine a nation not of baby boomers, but elder boomers.It’s coming. Our country is about to be transformed by an age wave thatleaves each stage of life changed forever.”

LIFE EXPECTANCY ~ LIVING 120 TO 180 YEARS

It is not just the shear numbers of baby-boomers that will affect futurehealth care needs and costs; it is also the overall increasing life expectancyin our society. Life expectancy in 1900 was 49 years and by the end of the

By BOB MEISTER

60 DECEMBER 2007

20th Century, it had increased to 77 years. The increase in lifeexpectancy during that period was due primarily to basic improvementin living conditions as well as improved medical technology. Futuristsbelieve that we are again on the verge of making significant improvementsin life expectancy so that in the future we may have life expectancylevels of 110 to 120. In fact, a program held at the World FutureSocieties annual convention in the summer of 2003 was entitled “Living120 to 180 years.”

Life Expectancy at Birth 1900 to 2000

Men Women1900 47.9 50.71920 55.5 57.41940 61.6 65.91960 66.8 73.71980 70.8 77.62000 74.8 79.5

In one sense, increased life expectancy represents a human successstory; America now has the luxury of aging. Or is it really a luxury?Most would agree that it depends on the quality of life we can maintainas our lives are extended years beyond expectations. But that isn’talways a pretty picture.

Take Gertrude from Wisconsin, for example. When she was born in1911, her life expectancy was 53.2 years, yet she lived to almost 92.However, the difficulty was that after age 78, her health problemscompounded. It began with diabetes, then a quadruple heart by-pass,followed in a couple years by a heart-valve transplant, then cancer andfinally a punctured lung, which occurred while getting a pacemakerinstalled. Her quality of life diminished and was dependent on thirteendifferent medications, family assistance, home care, then assisted living,followed by a series of hospital and recuperative nursing home stays.This all too common sequence of events and series of procedurestapped out Gertrude’s personal resources and used up many times theMedicare dollars she contributed during her working years. The pointis that life expectancy often comes at a very high price financially andalso in terms of human comfort.

SKYROCKETING COST OF CARE

The cost of health care has been rising at a rate much higher thaninflation and family incomes. Health care expenditures in Americahave gone from 246 billion in 1980 to just under 1.7 trillion in 2003.The problem is compounded when employers discontinue employeeinsurance, contributing to the rising number of uninsured Americans.

Examples of Health Care costs in the United States

Hartford, CT Fairbanks, AKHome Health Care – Aide $13,130 year $12,558 yearHome Health Care – LPN $22,180 year $34,112 yearAssisted Living $27,888 year $28,550 yearNursing Home – private $99,692 year $153,227 year

Procedures*Heart Bypass Angioplasty Knee Replacement Spinal Fusion$130,000 $57,000 $40,000 $62,000

AMERICANS HAVE SUFFERED AN OVERALL DECREASEDQUALITY OF LIFE

Results of a study that approximates quality of life, published bythe United States Department of Health and Human Services Centersfor Disease Control and Prevention, demonstrate that overall health-related quality of life worsened dramatically in the 12 years between1993 and 2005. While this research does not conclude that the increase

is related to extended life or to baby boomers, it does present a trend worthyof note.

Percentage of people with 14 or more activity limitation days1993 1998 2000 20054.8% 5.6% 5.8% 6.6%

Percentage with 14 or more physically unhealthy days overall1993 1998 2000 20058.6% 9.4% 10.1% 10.7%

BOOMERS WILL RESHAPE THE FUTURE OF HEALTHCARE

In May of this year, First Consulting Group, Long Beach, CA conducted astudy that helps project the effect of the baby boomer generation on futurehealth care in the United States. Following are some results and conclusionsdrawn from “When I am 64.”

“The wave of aging Baby Boomers will reshape the health care systemforever. There will be more people enjoying their later years, but they’ll bemanaging more chronic conditions and therefore utilizing more health careservices by 2030.”

• The over 65 population will nearly triple as a result of the agingBoomers.

• More than six of every 10 Boomers will be managing more than onechronic condition.

• More than 1 out of every 3 Boomers – over 21 million – will beconsidered obese.

• One out of every four Boomers – 14 million – will be living withdiabetes.

• Nearly one out of every two Boomers – more than 26 million – will beliving with arthritis.

• Eight times more knee replacements will be performed than today.

Every day, almost 11,000boomers turn 50 – that isone every eight seconds.

DECEMBER 2 0 0 7 61

Sixty-two percent of 50 to 64 year olds reported they had at leastsix chronic conditions (hypertension, high cholesterol, arthritis,diabetes, heart disease and cancer). As Boomers age, the numberwith multiple chronic conditions is expected to grow from almost8.6 million today (about one out of every 10 Boomers) to almost 37million in 2030. Since the biggest factors influencing medical spendingare chronic illness and a patient’s level of disability, the growingincidence of multiple chronic conditions will put increasing demandson our health care system.

“The confluence of the large Boomer population, increase in chronicconditions and rise of available medical treatments will begin toimpact health care in 2010, when the oldest Boomers turn 65 – whenmore health services typically begin to be used.”

• By 2030, there will be nearly twice as many adult physicianvisits as there were in 2004, and Boomers will account formore than four of every 10 of these visits.

• By 2030, if all Boomers with diabetes receive recommendedcare, they will need 55 million laboratory tests per year – 44million more than today.

• Physician office visits will number more than one billion by2020. Four out of 10 will be Boomers.

• The growing demand of chronic disease will increase theneed for medical sub-specialists.

• The increase in longevity of Boomers – on top of advancesin medications, less invasive treatments and diagnostic testing– will greatly increase the demand for cardiology.


“The severe workforce shortage will challenge the health care system’s abilityto meet this Boomer demand”.

• In 2005 there was a shortage of about 220,000 registered nurses; by 2020that gap will be over one million.

• Even if the number of geriatric specialists remains stable, there will be ashortage of almost 20,000 by 2015.

• Between 2000 and 2020 the supply of orthopedic surgeons will increaseby only 2 percent while the demand will increase 23 percent.

• Between 2000 and 2020, the supply of cardiologists will increase by only5 percent while demand will increase by 33 percent

• The projected gap for primary care physicians will increase as Boomersage.

THE DILEMMA

While the combination of the largest demographic cohort in history and theextended years (provided to us by new drugs, and medical technology andprocedures) may not be a formula for disaster, it does raise a red flag and a fewquestions.

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

payments to overseas providers to help reduce the cost of providinghealth care to baby boomers?

As Boomers age, thenumber with multiplechronic conditions isexpected to grow fromalmost 8.6 million today(about one out of every 10Boomers) to almost 37million in 2030.

Bob Meister is a faculty member at CareQuest University. CQU provides education and certification for professionals in health care planning,financial planning and insurance. Most of Bob’s business experience is in designing and implementing market strategies and concepts as aconsultant to manufacturers, service providers and associations. His focus over the past 12 years has been aging, healthcare and retirement.

References: “The Long-Term Care Challenge”, David Wegge, Care Quest University; Care Options OnLine, NavGate Technologies;www.agewave.com, Ken Dychwald; Aetna; “When I’m 64", FCG; “An Aging World”, US Census Bureau.

*Approximate retail costs, based on HCUP data

62 DECEMBER 2007

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