INTERNATIONAL TRENDS

Medical Tourism Takes Night

With high-quality, low-cost care, overseas hospitals hope to turn a trickle of U.S. patients into a trend
t could be almost any American hospital. The policies and procedures are in line with those at your own medical center. The peer review and medical executive committees are structured like yours, and boardlevel discussions are similar, too. Organizationally, there's very little to distinguish this hospital from the one you run. Then there are the finandals. A CABG at that hospital costs $10,000. RNs make $500 a month. Sorry, Dorothy, this isn't Kansas; it's Bangkok. Bumrungrad International Hospital, the Thai health care provider that has most aggressively pursued the so-called international medical tourism market, is making a playforAmerican patientsyour patientsbased not on how different it is from you, hut on how similar it is. Many of its physidans were trained in the United States, as were its directors of nursing and intoisive care. "Any American hospital CEO could come in and understand what we're doing and how we're doing it immediately," says Curtis Schroeder, BIH's Califomia-hom chief executive.

Suddenly you aren't just competing with the hospital on die other side of the county, Now your competition is on the otlier side of the planet. And you better understand what that means. In an age of skyrocketing health care costs, insurance premiums and deductibles, and more tlian 45 lnillion Americans without health insurance of any kind, medical tourismthe concept of patients traveling overseas to get health care may be poised to take off.

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BY PHILIP DUNN
Illustration by Peter Ferguson
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"I tliink if s inevitable," says Arnold Milstein, M.D., medical director of the Pacific Business Group on Healtli and a physician consultant at Mercer Human Resource Consulting. "Within 10 to 15 years it will he routine that insurance plans will offer an international option." Michael B. McCallister, president and CEO of health benefits company Humana, says the idea "takes the concept of consumer activism to the ultimate limit." The reason? Health care provided overseas is less expensive. Consider Tlie U.S. mean chai^ for a coronary artery bypass graft in 2(K)5 was $97,524, according to Healthcare Costs and Utilization Project statistics maintained by the federal Agency for Healthcare Research and Quality. By contrast, many of the top international hospitals in Asia offer a CABG for $10,000 to $11,000including a stay in a private room. Throw in a few days in a "step-down" room at $100 a nighl, lodging for a ioved one at another $100 a night, $50 a day for meals, and roundtrip airfare at $3,000 to $4,000, and the total cost for care there (billed as first class) is about afifthof what it would be here. Even so. medical tourism currently ejdsts as a mere blip on the health care screen. Haifa million Americans travel overseas each year for

MANY MEDICAL TOURISTS

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COMPETE?

Dw do you gauge the ability of a hospital to compete internationally?

Kamaljeet Gill, general manager for business development for Singapore's National Healthcare Group, has devised four-question survey to determine, in broad terms, how a hospital will fare:

1. Clinical outcome indicators: What kind of public reporting does the hospital do, and how reliable are the numbers?

2. Accreditation: In the intemational market, where cultural standards vary widely, it is critical that an international body grant a hospital its stamp of approval. Joint Commission International accreditation is considered the gold standard; the International Standards Organization is also a player.

3. The "PEST" Test: A test of the country's ability to handle foreign patients. P: National political strength and stability E: National economic strength and stability S; National social behaviorsi.e, whether a country's social norms would make visiting patients and their families fee! welcome T: Technological infrastructure and capability 4. Competitive pricing: Is the hospital able to compete on price as well as on quality? How reliable are quoted prices, and what do they include or exclude? "In all of these areas you have to benchmark, not just against your own goals, but against the world." Gill says. "If you are very good, you should be transparent about it."

PHILIP DUNN

some kind of medical or Over the nott 18 months. dental work, according to Wockliardt expects to the National Coalition on double its total number of Health Care, but that is less hospitals to 20 and beds to than one day's total average 3,000, and is stepping up its recruitment efForts census for American hospiin the United States with the goal of attracting tals. Many medical 130 Indian physiciaJis touiists pursue altemaback to India by 2010. tive treatment, elective One way Wockcosmetic surgeiy or prohardt recruits Indian cedures not yet ap- Foreign governments and health care groups pro- doctors is to appeal to moting medical tourism use price as a way to lure proved by the U.S. Rx)d their homesickness; U.S. patients. Many Web sites promise that prices and Drug Administraanotlier is to offer the tion. It's business that are nearly half of what American hospitals charge. opportunity to perfonn Here's an example from Medical Tourism India, an easts in addition to, not procedures not yet Indian medical travel company: in competition with, allowed in tlie United U.S. hospitalsfor States. Wockhardt and APPfiOXfMATECOST now, at least. other Asian hospitals Procedure U.S. India offered hip resurfacing So Bumrungrad Bone marrow transplant $250,000 $69,200 as a less invasive alterand other top interna- Liver transplant $300,000 $69,350 native to total hip tional hospitals {many Heart surgery $30,000 $8,700 replacement years but not all of which are Orthopedic surgery $20,000 $6,300 before it became availin Asia, particularly SinSource Medical Touiism India. 2007 able here (the FDA gapore, India and Tliaiapproved hip resurfacing as a procedure in May land) aren't putting any U.S. providers out of 2006), and Wockhardt is now pioneering a probusiness, nor is that their intention. A look at cedure called COPCAB, or conscious, off-pump such hospitals does, however, offer a glimpse of coronary arteiy bypassin other words, awake, what could be on the horizon. With aggressive beating-heart cardiac surgery, indicated for pricing, stiff competition and medical advances patients for whom anesthesia might be risky. outpacing those in the United States, it's fair to For such complex procedures, die biggest ask Is tlie Wild West of health care the Far East.^ issue is not how to pay for them, but how to ensure they're safe. Enter Joint Commission A Growth Market Intemational, a division of tlie American accredEven before intemational hospitals attract U.S. itation agency, which applies similar, but not patients in large numbers, they are threatening identical, standards to international hospitals as to affect domestic hospitals in other waysfor those applied domestically. JCI has given its seal instance, the medical workforce. Robert K. Crone, of approval to 125 hospitals intemationaUy. M.D., president and CEO of Harvard Medical Intemational, a subsidiary of Harvard Medical )CI accreditation should not he confused School, estimates that 40,000 nonresident Indi- with Joint Commission accreditation in the Unitans currendy practice medidne in the United ed States, however, says JCI President and CEO States. "Three-quarters of those would prefer to Karen H. Timmons. JCI does not conduct unanlive in India," Crone says. "Many would jump at nounced surveys, and the environment-of-care the chance to practice medicine back home." standards are not the same. ORYX indicators A few already have. Wockhardt Hospitals which link outcomes and other performance Group, a chain of 10 hospitals in India, is engaged data into the acaedltation processare used but in a campaigntolure Indian doctors back home; are voluntaiy. Because ]CI accreditation is wholit has already attracted 28 physiciansfromChica- ly voluntary', tlie process is designed with sensigo, New York and Texas, among other places, tivity to cTjltural issues in mind. according to group CEO Mshal Bali. The major"Our mission is to improve quality and ity of them have at least 15 years of clinical expe- safety of intemational hospitals, not to encourrience, and all are board certified in high-end age medical tourism," Timmons says. clinical specialties or subspecialties, Bali says. Some intemational hospitals are seeking to

Ihe Price is Riylit

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MATTERS
Price isn't the only area where hospitals overseas try to compete; they also boast about strong quality metrics. Singapore's National Healthcare Group, that nation's second largest health care company, includes the following results in its annual report and other marketing materials;

outdo U.S. hospitals in the public reporting of dinical quality measures as a means to assuage concems about quality. Singapore's National Healthcare Group, a conglomeration of acute care and specialty hospitals, regularly publishes results of quality measures to compare its results against intemational standards; it reports a 100 percent rate for dispensing aspirin at discharge for acute myocardial infarction and a 0.6 percent to 2.2 percent 30-day mortality rate for heart failure, among other measures. However, few U.S. patients who travel abroad for care are saeened at homefirstfor coniorbidities. "There is no continuity of care," Harvard Medical International's Crone says. Crone envisions aoss-border parmerships or global networks to mitigate this, but such infrastructiu-e does not exist today. Patients also have few avenues for legal recourse when errors do occur. In many parts of the world, lawsuits for medical malpractice ji e unheard of and even prohibited Some overseas providers say that if complications arise, they vdll cover the cost oftiavelexpenses and added care.

services for Blue Qoss Blue Shield of South Carolina, has done the math. "We've recognized. No, I, tliis is a growing trend in the industry, and. No, 2, that the\TOrld is, infeet,flat,"he says. In other words, globalization allows knowledge and people to aoss intemational borders so easily that traditional boundaries are reduced to mere hurdles to be overcome rather than barriers that cannot be ti-aversed. After visiting Thailand in the summer of 2006 to tour Bumrungrad, Boucher started the South Carolina Blues plan down the road toward facilitating inteniational care when the situation is warranted and desired. The uisurer launched Companion Global Healthcare, a medical concierge subsidiary that helps members set up travel and care management arrangements, induding making sure medical records are sent properly. The company established formal ties vvith Bumrungrad and is looking at other overseas relationships. "We're starting to get some questions. We've received some [requests for proposals] from potential gj'oups wanting to know if we have a global health care option," Boucher says. These are baby steps. The South Carolina Blues does not yet cover trips overseas for medica) procedures, but Boucher easily envisions a day in the not-too-distant future in which his company ofFers an international package for those employers who want it. The concept has doubters. "If I was in the hospital business, I would not lose sleep over this," says Humana's McCallister, who insists that intemationa] medical tourism is "not on my horizon." Even Milstein, who is confident that the concept viill catch on, identifies several details that need to be worked out first, including better information-sharing, reporting oi quality data, fallback arrangements in case things go poorly, and verification of credentials. But he likens the notion to Toyota's entry into the U.S. auto market in the late 1950s with the Corona. "You would look at the Corona and laugh." Milstein says. "You would say, 'Tliis is not a threat." But that's exactly how these disruptive innovatiotis get started,"^Philip Dunn is ajreelance writer based in Chiaigo.

Who's Going to Pay for It?

Forget Medicare, HMOs, PPOs or consumerdirected health plans; Intemational medical tourism is a cash-on!y business. Typically, a patient will seek to prequalify for a standard price, which, depending on the hospital, includes all hospital, nursing and physician fees for a set number of days. Prequalification protects the hospitalfrominairring extra costsfrompatients who might be more likely to suffer expensive complications, Tliis keeps things fairly simple and ensures that the business will remain boutiqueuntil a U.S. payer steps up. Medicare hasn't done so; finding ways to reduce health care spending may be attractive to taxpayers, but critics would have afieldday with what tiiey migfit term "offshodng our medicine." "Ifs a no-brainerfinancially,but politically, who's going to touch itfirst?"says Sparrow Mahoney, CEO ofMedicalTourism.com, which connects U.S. patients with intemational hospitals. On the commercial payer side, David Boucher, assistant vice president of health care

UJDICATOR RATE Heart attack (aspirin at dischargel Heart attack (beta blxker at disctiarge) Heart failure PO-day mortalityl Ventilator-associated pneumonia 100% 91 7-100% 0,8-2.2% 1,54% per 1,000 ventilator days 4%

NATIONAL RATE

63.24% 63,91% 10% 5.4% per 1.000 ventilator days 10%

Neurology (inpatient stroke mortalityl

Source: National Healiticare Group, ZQ05

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