Medical Tourism: Global Competition in Health Care

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1 Nationa Center for Poicy Anaysis Medica Tourism: Goba Competition in Heath Care by Devon M. Herrick NCPA Poicy Report No. 304 November 2007 ISBN # Web site: Nationa Center for Poicy Anaysis Coit Rd., Suite 800 Daas, Texas (972)

2 Executive Summary Goba competition is emerging in the heath care industry. Weathy patients from deveoping countries have ong traveed to deveoped countries for high quaity medica care. Now, a growing number of ess-affuent patients from deveoped countries are traveing to regions once characterized as third word. These patients are seeking high quaity medica care at affordabe prices. Reports on the number of patients traveing abroad for heath care are scattered, but a te the same story. An estimated 500,000 Americans traveed abroad for treatment in A majority traveed to Mexico and other Latin American countries; but Americans were aso among the estimated 250,000 foreign patients who sought care in Singapore, the 500,000 in India and as many as 1 miion in Thaiand. The cost savings for patients seeking medica care abroad can be significant. For exampe: Apoo Hospita in New Dehi, India, charges $4,000 for cardiac surgery, compared to about $30,000 in the United States. Hospitas in Argentina, Singapore or Thaiand charge $8,000 to $12,000 for a partia hip repacement one-haf the price charged in Europe or the United States. Hospitas in Singapore charge $18,000 and hospitas in India charge ony $12,000 for a knee repacement that runs $30,000 in the United States. A rhinopasty (nose reconstruction) procedure that costs ony $850 in India woud cost $4,500 in the United States. In 2006, the medica tourism industry grossed about $60 biion wordwide. McKinsey & Company estimates this tota wi rise to $100 biion by Patients who are not famiiar with specific medica faciities abroad can coordinate their treatment through medica trave intermediaries. These services work ike speciaized trave agents. They investigate heath care providers to ensure quaity and screen customers to assess those who are physicay we enough to trave. They often have doctors and nurses on staff to assess the medica efficacy of procedures and hep patients seect physicians and hospitas. Prices for treatment are ower in foreign hospitas for a number of reasons. Labor costs are ower, third parties (insurance and government) are ess invoved or not at a invoved, package pricing with price transparency is norma, there are fewer attempts to shift the cost of charity care to paying patients,

3 there are fewer reguations imiting coaborative arrangements between heath care faciities and physicians, and mapractice itigation costs are ower. How can patients ensure the medica treatment they wi receive wi be of high quaity? Foreign heath care providers often have physicians with internationay respected credentias, many of them with training in the United States, Austraia, Canada or Europe. More than 120 hospitas abroad are accredited by the Joint Commission Internationa (JCI), an arm of the organization that accredits American hospitas participating in Medicare; another 20 are accredited through the Internationa Standards Organization; and some countries are adopting their own accrediting standards. Some foreign hospitas are owned, managed or affiiated with prestigious American universities or heath care systems such as the Ceveand Cinic and Johns Hopkins Internationa. Severa companies are buiding and operating hospitas in Mexico that meet American standards, argey for American (and weathy Mexican) patients. Finay, patients can aso use onine communities to get information on the safety and quaity of medica providers by reading the testimonies of other patients who have had surgery abroad. Medica tourism is ony one aspect of the way gobaization is changing the U.S. heath care system. Apart from patient trave, many medica tasks can be outsourced to skied professionas abroad when the physica presence of a physician is unnecessary. This can incude interpretation of diagnostic tests and ong-distance internationa coaboration, particuary in case management and disease management programs, because of the avaiabiity of information technoogy. If American heath care consumers are to benefit to the fuest extent from goba heath care competition, federa and state poicies must aow them to take advantage of the opportunities. Lega reforms poicymakers shoud consider incude recognizing icenses and board certifications from other states and countries. The federa Stark aws imiting reationships between physicians and hospitas need to be modified to et heath care providers offer integrated medica services, incuding foow-up care for patients returning from treatment abroad. Finay, the federa and state governments shoud ead by exampe by aowing Medicare and Medicaid programs to send wiing patients abroad. Medicare in particuar woud benefit from cost savings due to its arge voume of orthopedic and cardiac procedures.

4 Medica Tourism: Goba Competition in Heath Care Introduction Goba competition is emerging in the heath care industry. Weathy patients from deveoping countries have ong traveed to deveoped countries for high quaity medica care. Now, growing numbers of patients from deveoped countries are traveing for medica reasons to regions once characterized as third word. Many of these medica tourists are not weathy, but are seeking high quaity medica care at affordabe prices. To meet the demand, entrepreneurs are buiding technoogicay advanced faciities outside the United States, using foreign and domestic capita. They are hiring physicians, technicians and nurses trained to American and European standards, and where quaified personne are not avaiabe ocay, they are recruiting expatriates. The Emerging Market for Medica Tourism Medica tourism is growing and diversifying. Estimates vary, but McKinsey & Company and the Confederation of Indian Industry put gross medica tourism revenues at more than $40 biion wordwide in Others estimate the wordwide revenue at about $60 biion in McKinsey & Company projects the tota wi rise to $100 biion by [See Figure I.] FIGURE I Wordwide Medica Tourism Industry (biions of U.S. doars) $100 biion Medica tourists are seeking high quaity medica care at affordabe prices. $40 biion Source: McKinsey & Company and the Confederation of Indian Industry.

5 The Nationa Center for Poicy Anaysis Internationay-known hospitas, such as Bumrungrad in Thaiand and Apoo in India, report revenue growth of about 20 percent to 25 percent annuay. 4 McKinsey & Company estimates that Indian medica tourism aone wi grow to $2.3 biion by Singapore hopes to treat 1 miion foreign patients that year. 6 Reports on the number of patients traveing abroad for heath care over the past few years are scattered, but a te the same story. In 2005: Approximatey 250,000 foreign patients sought care in Singapore, and 500,000 traveed to India for medica care. 7 Thaiand treated as many as 1 miion foreign patients. 8 The foreign patients treated in these countries incuded some of the 500,000 Americans who traveed abroad for medica treatment that year. 9 Medica tourists incude residents of countries with nationa heath insurance, where heath care is rationed. Residents of countries with nationa heath insurance, incuding Canada and the United Kingdom, often trave to other countries, incuding the United States, because they ack timey access to eective procedures due to rationing. In Canada, physicians cannot privatey treat their feow Canadians if those treatments are covered by the government heath pan (Medicare). Aso, nationa heath systems sometimes deny treatment to particuar patients (for exampe, because of age or physica condition), and some treatments may not be avaiabe to any patients (for exampe, because of cost). 10 However, for most medica tourists, incuding those from the United States, the reason for trave is financia. The effect of financia incentives on Americans wiingness to trave for medica care is shown by a recent nationwide survey. Amost no one woud trave a great distance to save $200 or ess. Fewer than 10 percent woud trave to save $500 to $1,000. About one-quarter of uninsured peope, but ony 10 percent of those with heath insurance, woud trave abroad for care if the savings amounted to $1,000 to $2,400. For savings exceeding $10,000 about 38 percent of the uninsured and one-quarter of those with insurance woud trave abroad for care. 11 Some American medica tourists are seeking ower prices for treatments not covered by insurance (such as cosmetic surgery and weight oss surgery). Uninsured patients paying the cost out of their own pocket trave because American hospitas often charge cash-paying, uninsured individuas infated ist prices, which can be much higher than government or private insurers have to pay. 12 Aso, a sma but growing number of insurers are creating heath pans that encourage enroees to shop for better prices among approved vendors in other countries and aow them to share in the savings. There are

6 Most American medica tourists seek treatment in Mexico and other Latin American countries. Medica Tourism: Goba Competition in Heath Care aso potentia savings for insured patients who bear some of the cost through copayments and deductibes. For exampe, if a procedure cost $4,000 ess in another country, a patient required to pay 20 percent of the cost (through a copayment) woud save $800 out of pocket. Where Do Patients Seek Treatment? Most American medica tourists seek treatment in Mexico and other Latin American countries. Cinics in Brazi and Argentina have offered ow-cost cosmetic surgery for years. 13 India and Thaiand are now promoting their high-tech faciities for more serious procedures, incuding hip and knee repacements and cardiac surgery. 14 Other destinations incude Singapore, Begium and South Africa. 15 Many Northern and Western Europeans trave to Centra and Eastern Europe for ow-cost medica and denta services. 16 [See the sidebar, Medica Tourism Destinations. ] Cross-Border Medica Tourism. It may be impractica for sick Americans to trave to faraway paces ike India and Thaiand for major surgery. But many types of medica services are avaiabe nearby in Mexico and esewhere in Latin America. Mexico. Mexican physicians have a thriving business treating American (and Canadian) retirees searching for of ow-cost drugs, denta care and physician services. 17 Prices in Mexico are about 40 percent ower than in the United States. Cash-paying, uninsured Americans can find better deas on procedures in Mexico, incuding price quotes and package prices, which most American hospitas do not offer. 18 Indeed, some Arizona retirement communities have reguar bus tours to take residents across the Mexican border for prescription drugs and denta care. 19 Some heath pans in Southern Caifornia offer ower premiums and copayments to patients who use network providers across the border in Tijuana. 20 Faciities are being buit in Mexican border towns to take advantage of these pans. 21 Daas-based Internationa Hospita Corp. operates four Mexican hospitas, three cose to the U.S. border and one near Mexico City (it has other faciities in Brazi and Costa Rica). 22 A Mexican partnership caed Christus Muguerza is buiding and operating hospitas in Mexico that meet American standards. It has identified 40 communities aong the U.S.-Mexican border where it intends to buid faciities. 23 Some 40,000 to 80,000 American seniors ive in Mexico. In addition to heath care at ower prices (Medicare does not cover care outside the United States), a number of them receive nursing home care at bargain prices. In most areas of the United States, the cost of nursing home care can easiy surpass $60,000 per year. But in Mexico, high quaity ong-term care costs ony about one-fourth as much. For about $1,300 per month, a senior can get a studio apartment that incudes aundry service, ceaning, mea preparation and access to around-the-cock nursing care. 24

7 The Nationa Center for Poicy Anaysis Medica Tourism Destinations Cost and quaity are obviousy the most important factors patients consider in choosing specific destinations for treatment. But many patients aso consider amenities commony found in resorts and hotes. India. Despite the ong trave time invoved, India is a popuar destination for medica tourists. It arguaby has the owest cost and highest quaity of a medica tourism destinations, and Engish is widey spoken. Severa hospitas are accredited by the Joint Commission Internationa (JCI) and staffed by highy trained physicians. Prices can be obtained in advance, and many hospitas bunde services into a package dea that incudes the medica procedure and the cost of treating any compications. 1 Hote accommodations are extra, but hospitas often have hote rooms or can offer discounts for hotes nearby. Thaiand. This popuar destination for medica tourists rivas India in price and quaity. Thaiand s arge tourist industry is one reason it has a better infrastructure and ess noticeabe poverty than India. 2 Prices are typicay not as ow as in India, and Thai hospitas do not offer fixed pricing. However, food and odging during recuperation wi ikey be ess expensive than in India due to Thaiand s competitive tourism industry. 3 Bangkok s Bumrungrad Internationa Hospita is a word-cass private heath care faciity buit for weathy Thais, but foreigners comprise more than one-third of its patients. Singapore. Engish is aso widey spoken in this former British coony, ocated approximatey 1,000 mies south of Bangkok. Singapore has modern, high-quaity hospitas and is home to three hospitas accredited by the JCI. 4 Prices are higher than in Thaiand or India but are much ower than in the United States. Centra and South America. Mexico has been popuar for some time with American patients seeking primary and denta care. But to attract cash-paying American patients for surgica services, heath care systems are buiding hospitas and cinics with the high eve of service and amenities that American patients have come to expect. For instance, Americans expect professiona medica staff and upscae private rooms in cean, modern faciities. They aso expect high-tech equipment that American hospitas woud possess. Other Latin American countries provide services as we: Costa Rica is best known for quaity denta work, with prices one-third to onehaf of those in the United States. 5

8 Medica Tourism: Goba Competition in Heath Care Coombia is a favorite destination for cosmetic surgery. 6 Argentina and Brazi have ong been known for cut-rate pastic surgery, and more advanced treatments are becoming avaiabe. 7 Penitas is a Buenos Aires-based boutique cinic that arranges medica trave. 8 Athough most of the services provided are cosmetic surgeries, it aso offers in vitro fertiization and bariatric (weight oss) surgery. 9 Nine Braziian organizations have estabished a heath care consortium to market Brazi as a medica tourism destination in various countries. 10 Europe. Northern and Western Europeans have numerous opportunities to get ower-cost medica and denta care: Germans favor Szczecin, Poand, ess than 100 mies from Berin, for ow-cost, high-quaity denta work. Sopron, Hungary, ess than an hour s drive from Vienna, Austria, caters to medica tourists. Sopron has more than 200 dentists and 200 optometrists, 10 times as many as woud be expected in a town of 20,000 peope Information from PanetHospita Web site; and Maathy Iyer, India Out to Hea the Word, Times of India, October 26, Conversation with Tom Borta, PanetHospita s vice president cient reations, September India has a shortage of hotes, and its infrastructure is notoriousy poor. See Tourism without infrastructure? December Avaiabe at Access verified June Aso see Shortage of 1.5 Lakh Hote Rooms: Govt, ZeeNews.com, November 30, Avaiabe at Access verified June 22, Information from PanetHospita Web site. 4 Ibid. 5 Jeff Schut, A New Smie (for Haf the Price), Northeast (Hartford Courant), May 23, Avaiabe at Accessed Apri 30, This work was ater expanded into the book by Jeff Schut, Beauty from Afar: A Medica Tourist s Guide to Affordabe and Quaity Cosmetic Care Outside the U.S. (New York: Stewart, Tabori & Chang, 2006). 6 See 7 Oiver Bach Charts the Irresistibe Rise of the Tango-and-Boob-Job Break in Argentina, Guardian Unimited, October 24, Ibid. 9 Web site 10 Marina Sarruf, Brazi Wants to Make Medica Tourism a One-Miion Doar Industry, Brazzi Magazine, February 8, Sharon Reier, Medica Tourism: Border Hopping for Cheaper and Faster Care Gains Converts, Internationa Herad Tribune, Apri 24, 2004.

9 The Nationa Center for Poicy Anaysis Latin America. Costa Rica and Panama are popuar destinations for medica trave. Around 150,000 foreigners sought care in Costa Rica in This is amazing, considering that Costa Rica is a country of ony about 4 miion peope. By contrast, in 2006 just 250,000 foreigners sought care in the United States a country with neary 300 miion more residents. 26 Panama has high quaity heath care, concentrated primariy in the metropoitan areas. Medica standards at Panama s top hospitas are comparabe to those in the United States. Indeed, many Panamanian physicians were trained in the United States. Hospita Punta Pacifica in Panama City, Panama, is an affiiate of U.S.-based Johns Hopkins Internationa. 27 Medica care in Panama is 40 percent to 70 percent ess expensive than in the United States. 28 Medica Tourism within the United States. Domestic medica trave invoving patients seeking more advanced treatment faciities in other cities or states is reativey common. Speciaty hospitas buit to provide orthopedic and cardiac treatment attract patients from many communities. These faciities generay provide better quaity care and higher patient satisfaction than genera hospitas. 29 Many patients trave great distances to receive care at the word-renowned Ceveand Cinic and the Mayo Cinic, two high quaity heath care providers. Medica intermediaries hep patients seect physicians and hospitas. How Patients Obtain Treatment Abroad Patients who aren t famiiar with specific medica faciities abroad can coordinate their treatment through medica trave intermediaries. Many intermediaries use the Internet to recruit patients. 30 These services work ike speciaized trave agents. 31 Cients of MedRetreat, for exampe, can choose from a menu of 183 medica procedures from seven different countries: India, Thaiand, Maaysia, Brazi, Argentina, Turkey and South Africa. 32 Intermediaries investigate heath care providers and screen customers to assess those who are physicay we enough to trave. Some intermediaries are affiiated with specific medica providers and send patients excusivey to those providers. But most intermediaries seek to create a broad network of providers and destinations to meet the diverse needs of patients. For instance, some patients might prefer to pay a higher fee in exchange for ess trave time, whie others might be wiing to trave greater distances to save money. In addition, intermediaries often have doctors and nurses on staff to assess the medica efficacy of procedures and hep patients seect physicians and hospitas. For exampe, Medica Tours Internationa, which sent more than 1,300 patients abroad in 2005, empoys medica personne to assist patients in trip panning and treatment decisions. 33 One of the best-known firms in the medica tourism industry is Caifornia-based PanetHospita. [See the sidebar, PanetHospita. ]

10 Medica Tourism: Goba Competition in Heath Care PanetHospita PanetHospita is a medica tourism intermediary that screens providers to ensure quaity of care and assists in connecting patients to internationa heath care providers. The company ony refers patients to providers with recognized credentias that meet American standards. Once PanetHospita has identified quaity heath care providers, it works cosey with them to ensure they maintain quaity and provide superior patient services. If the providers fai to do so, they are dropped from the referra network. Initia patient screening consists of these steps: When a cient contacts PanetHospita, the medica staff reviews PanetHospita charges a fat fee for medica intermediary services. the patient s medica history to determine whether or not he or she is we enough to trave. Staff members then hep the cient choose an appropriate physician and destination. The cient s medica records are digitized and paced onine to aow physicians in the destination country to review his or her medica history. PanetHospita then arranges a conference ca between the potentia patient and physician to discuss the procedure. Once the patient chooses a physician, PanetHospita assigns a case manager from the destination country to make arrangements for the procedure, incuding additiona detais such as ce phone service, transportation and airport transfers. Case managers attend to a needs that arise whie the patient is in the destination country. Whie some intermediaries charge a percentage of the fees patients pay for medica care, PanetHospita charges a $295 concierge fee for arranging medica trips.

11 The Nationa Center for Poicy Anaysis FIGURE II Cost of Rhinopasty (thousands of U.S. doars) $4,500 $3,500 Pricing is highy competitive for procedures that aren t covered by insurance. $1,500 $850 India Croatia, Egypt, Turkey United Kingdom United States Source: Sarah Dawson with Keith Poard, Guide to Medica Tourism, TreatmentAbroad.net, 2007; and Cosmetic Pastic Surgery Costs, avaiabe at Why Treatment Abroad Costs Less Fees for treatments abroad range from one-haf to as itte as one-fifth of the price in the United States. In some cases prices are 80 percent ower abroad. Savings vary depending upon the destination country and type of procedure performed. For exampe: Apoo Hospita in New Dehi, India, charges $4,000 for cardiac surgery, compared to about $30,000 in the United States. Hospitas in Argentina, Singapore or Thaiand charge $8,000 to $12,000 for a partia hip repacement one-haf the price charged in Europe or the United States. Hospitas in Singapore charge $18,000 and hospitas in India charge ony $12,000 for a knee repacement that runs $30,000 in the United States. A rhinopasty (nose reconstruction) procedure that costs ony $850 in India woud cost $4,500 in the United States. 34 [See Figure II.]

12 Medica Tourism: Goba Competition in Heath Care Patients can aso find ower-priced nonsurgica procedures and tests abroad: An MRI in Brazi, Costa Rica, India, Mexico, Singapore or Thaiand costs from $200 to $300, compared to more than $1,000 in the United States. 35 A six-hour comprehensive fitness exam incuding an echocardiogram, stress test, ung-function test and utrasound of interna organs costs ony $125 at India s Rajan Dha Hospita; a simiar battery of tests in the United States coud easiy top $4, Why Are Foreign Hospitas Abe to Offer Lower Prices? Prices for treatment are ower in foreign hospitas for a number of reasons. Labor costs. In the United States, abor costs equa more than haf of hospita operating revenue, on the average. 37 Wage rates and other abor costs are ower overseas; specifics were not avaiabe, but as one exampe, at Fortis hospitas in India: 38 FIGURE III Private Out-of-Pocket Spending on Heath Care 78% 51% Prices are ower where patients pay out of pocket for heath care. 26% 13% United States Thaiand Mexico India Source: Sarah Dawson with Keith Poard, Guide to Medica Tourism, TreatmentAbroad.net, 2007; and Cosmetic Pastic Surgery Costs, avaiabe at

13 10 The Nationa Center for Poicy Anaysis Package prices for services are common. Doctors earn about 40 percent ess than comparabe physicians in the United States. Median nurses saaries are one-fifth to one-twentieth of those in the United States. The wages of unskied and semiskied abor, such as janitors and orderies, are aso much ess. These ower abor costs make it much ess expensive to buid and operate hospitas in other countries. 39 Less (or No) Third-Party Payment. Markets tend to be bureaucratic and stifing when insurers or governments pay most medica bis. 40 In the United States, third parties (insurers, empoyers and government) pay for about 87 percent of heath care. 41 So patients spend ony 13 cents out of pocket for every doar they spend on heath care. As a resut, they do not shop ike consumers do when they are spending their own money, and the providers who serve them rarey compete for their business based on price. A much higher percentage of private heath spending is out of pocket in countries with growing, entrepreneuria medica markets. For instance, patients pay 26 percent of heath care spending out of pocket in Thaiand, 51 percent in Mexico and 78 percent in India. 42 [See Figure III.] When patients contro more of their own heath care spending, providers are more ikey to compete for patients based on price. Consequenty, these countries have more competitive private heath care markets. In the United States, the markets for those medica services for which patients usuay pay out of pocket, such as eective cosmetic surgery or vision correction (Lasik), are much more entrepreneuria and competitive. Patients contro the doars that pay for these procedures, so physicians compete with one another on price. For exampe, the cost of standard Lasik has faen about 20 percent over six years. Price Transparency and Package Pricing. One criticism of American hospitas and cinics is that prices are difficut to obtain and often meaningess when they are discosed. 43 Patients who ask potentia providers to quote a price are ikey to be disappointed. 44 In fact, many peope have itte idea of the cost of medica treatments. A recent Harris Po found: 45 Consumers can guess the price of a new Honda Accord within $1,000, but when asked to estimate the cost of a four-day hospita stay, those same consumers were off by $12,000! Furthermore, 68 percent of those who had received recent medica care did not know the cost unti the bi arrived, and 11 percent said they never earned the cost at a. In the internationa heath care marketpace, the situation is quite different. Package prices are common, and medica trave intermediaries hep

14 Medica Tourism: Goba Competition in Heath Care 11 TABLE I The Cost of Medica Procedures in Seected Countries (in U.S. doars) Cash-paying patients pay higher prices than insurers in most U.S. hospitas. U.S. U.S. Procedure Retai Price * Insurers Cost * India ** Thaiand ** Singapore ** Angiopasty $98,618 $44,268 $11,000 $13,000 $13,000 Heart bypass $210,842 $94,277 $10,000 $12,000 $20,000 Heart-vave repacement $274,395 $122,969 $9,500 $10,500 $13,000 (singe) Hip repacement $75,399 $31,485 $9,000 $12,000 $12,000 Knee repacement $69,991 $30,358 $8,500 $10,000 $13,000 Gastric bypass $82,646 $47,735 $11,000 $15,000 $15,000 Spina fusion $108,127 $43,576 $5,500 $7,000 $9,000 Mastectomy $40,832 $16,833 $7,500 $9,000 $12,400 * Retai price and insurers costs represent the mid-point between ow and high ranges. ** U.S. rates incude at east one day of hospitaization; internationa rates incude airfare, hospita and hote. Sources: Subimo (U.S. rates); PanetHospita (internationa rates), cited in Unmesh Kher, Outsourcing Your Heart, Time, May 21, patients compare prices. [For exampes, see Tabe I.] Even providers who do not offer fixed pricing wi provide reasonaby accurate price quotes. As a resut, medica centers and cinics that treat arge numbers of medica tourists routiney quote prices in advance and ook for ways to reduce patients costs. 46 Few Cross-Subsidies. In American fu-service nonprofit genera hospitas, revenues from treatments for some patients are used to cover the costs of providing treatments to other patients. This cross-subsidization is possibe because some medica procedures produce more revenue than it costs to provide them. For exampe, the revenue from routine heart catheterization procedures or diagnostic imaging systems in a community hospita might be used to subsidize indigent heath care or the cost of operating the emergency room. This means that a hospita s charges for the heart procedure more than cover its costs, but its charges for emergency room care do not cover those costs. If there is no competition for the business of heart patients in the hospita s service area, it can cross-subsidize without osing revenue. However, a provider who does not cross-subsidize coud offer the cardiac treatment for a ower price or coud make a profit charging the same

15 12 The Nationa Center for Poicy Anaysis Foreign hospitas have fewer cost-increasing reguations and cross-subsidies. price. In the United States, such providers have emerged in the form of highy efficient speciaty hospitas. Nonprofit community hospitas compain that speciaty hospitas skim off ucrative surgeries but do not provide the services that community hospitas do, such as emergency departments and charity care for the uninsured. This has ed to a moratorium on new speciaty hospitas in the Medicare program. 47 Streamined Services. Some foreign medica providers operate highy efficient focused factories. These are speciaty cinics and hospitas where tasks and procedures have been streamined for the highest efficiency simiar to the way a Toyota automotive pant operates. 48 For exampe, Fortis Heathcare s Rajan Dha Hospita in New Dehi uses a business mode that combines the personaized service of the hote industry with the industria processes of an automaker both industries in which its senior executives have experience. 49 Jasbir Grewa, Rajan Dha s vice president for operations, spent years working for the Hiton hote chain. He describes their hospita as a hote providing cinica medica exceence. Fortis chairman Harpa Singh, who came from the automotive industry, emphasizes the need to streamine processes in such a way that procedures can be performed quicky and efficienty. 50 Limited Mapractice Liabiity. Mapractice itigation costs are aso ower in other countries than in the United States. Whie American physicians in some speciaties pay more than $100,000 annuay for a iabiity insurance poicy, a physician in Thaiand spends about $5,000 per year. Thaiand does not compensate victims of negigence for noneconomic damages, and mapractice awards are far ower than in the United States. 51 Fewer Reguations. Excessive heath care reguations in the United States prevent American hospitas from making the sort of coaborative arrangements many internationa hospitas use. For instance, faciities abroad can structure physicians compensation to create financia incentives for the doctors to provide efficient care, whereas American hospitas usuay cannot. The reason: Physician compensation arrangements in American hospitas cannot vioate the Stark (anti-kickback) aws. Foreign hospitas can aso empoy physicians directy a practice prohibited by many states. 52 For instance, physicians in India contract with hospitas to provide a certain number of hours per month in return for a guaranteed fixed fee. Patients seect the hospita based on reputation and then choose an appropriate doctor who works with the hospita. In this regard, physicians depend on hospitas for business rather than the other way around. Ensuring Quaity for Medica Tourists Some American medica trade groups caution patients about the quaity of treatment abroad. 53 Speaking of foreign medica providers, Bruce Cun-

16 Medica Tourism: Goba Competition in Heath Care 13 FIGURE IV Cardiac Surgery Mortaity 13.8% Caifornia Hospitas 6.2% 2.1% 2.9% Hospitas that Treat Internationa Patients <1% <1% <1% 0% University of Caifornia Davis Medica Center 1 Fountain Vaey Regiona Medica Center 1 Caifornia Hospita Average 1 Desert Regiona Medica Center 1 Bevery Hospita 1 Ceveand Cinic 2 Apoo Hospita Group 3 Wockhardt Hospitas 3 1 Zhongmin Li et a., Coronary Artery Bypass Graft Surgery in Caifornia: 2003 Hospita Data, Caifornia CABG Outcomes Reporting Program, Office of Statewide Heath Panning and Deveopment, February Avaiabe at Access verified June 22, The mortaity rate for primary isoated CABG is 0.6 percent. See Wecome to the Department of Cardiovascuar Surgery, Ceveand Cinic Foundation Web site. Avaiabe at https://www.ccf.org/heartcenter/pub/about/speciaties/ cvsurgery.asp. Access verified June 22, Arnod Mistein and Mark Smith, Wi the Surgica Word Become Fat? Heath Affairs, Vo. 26, No. 1, January/ February 2007, pages

17 14 The Nationa Center for Poicy Anaysis The quaity of American hospitas varies widey. ningham, president of the American Society of Pastic Surgeons, tod the U.S. Senate Seect Committee on Aging, Without a compete understanding of the medica standards for the heath institution or faciity, medica providers, surgica training, credentias, and postoperative care associated with surgery, a patient can be i-informed and worse, at significant risk. 54 In fact, Cunningham s warning coud easiy appy to U.S. hospitas as we. Information on quaity is not readiy avaiabe to patients, and what is avaiabe is often difficut to interpret or irreevant. Measuring Quaity. Despite caims of high U.S. standards, resuts vary widey by hospita. Consider one of the most commony performed procedures in the United States today coronary artery bypass graft (CABG) surgery: Hospitas in Caifornia that perform CABG surgery have an average mortaity rate of neary 3 percent (2.91). 55 The Caifornia average is neary four times higher than the Ceveand Cinic, considered the best hospita in the nation by U.S. News & Word Report. 56 A number of foreign hospitas are accredited in the United States. Coser inspection of Caifornia hospitas shows wide variations in quaity: 57 [See Figure IV.] The University of Caifornia Davis Medica Center experienced no deaths among the 136 patients receiving CABG surgery in Fountain Vaey s mortaity rate of 2.14 percent was beow the state average of 2.91 percent. But Desert Regiona Medica Center, which performed a simiar voume of surgeries, had a mortaity rate of more than 6 percent twice the Caifornia average and 10 times Ceveand Cinic s average. Bevery Hospita performs few CABG procedures, which may expain its high mortaity rate of percent. How does the quaity of faciities overseas compare to those in the United States? Some of the more prestigious providers, such as Apoo Hospita Group and Wockhardt Hospitas (which is affiiated with Harvard Medica Schoo) in India, and Bumrungrad Internationa Hospita in Thaiand, offer a better eve of care than the average community hospita in the United States. 58 [See the sidebar on Bumrungrad.] As in the United States, many hospitas abroad do not discose recognized quaity indicators. But most hospitas that compete on the internationa eve generay do. Dartmouth Hitchcock Medica Center in New Hampshire and Ohio s Ceveand Cinic have quaity indicators on their Web sites. 59

18 Medica Tourism: Goba Competition in Heath Care 15 Bumrungrad Bumrungrad Internationa Hospita in Bangkok, Thaiand, is a modern mutispeciaty hospita with 554 beds, accredited by the Joint Commission Internationa. 1 Its main 12-story buiding was constructed in 1997 to compy with U.S. hospita buiding and safety standards. The medica staff of more than 900 incudes about 200 U.S. board-certified physicians. Many others hod icenses in Austraia, Europe and Japan. A team of 800 nurses assists with patient care. A number of foreign hospitas are accredited in the United States. Bumrungrad tracks more than 500 measures of quaity and patient safety. It treats about 430,000 medica tourists a year from 190 different countries. This number incuded neary 60,000 American patients in Bumrungrad is equipped with a the atest diagnostic equipment. It has 150 cinica exam suites, two cardiac catheterization abs and 19 operating theaters, two of which are specificay designed for cardiac surgeries. The hospita uses Goba Care Soutions Hospita 2000, a sophisticated heath information technoogy system. This software is designed to recognize and prevent dangerous drug interactions, store patient records eectronicay and fuy integrate a areas of patient management and hospita operations. 3 The hospita staff assists patients with trave arrangements, airport pickup, interpreters and odging if needed. Seventy-five percent of Bumrungrad s patients pay cash for services. 4 1 Bumrungrad Web site 2 Louisa Kamps, The Medica Vacation, Trave + Leisure, Juy 3, Goba Care Soutions Web site 4 Mark Roth, $12 for a Haf Day of Massage for Back Pain, Pittsburgh Post-Gazette, September 10, 2006.

19 16 The Nationa Center for Poicy Anaysis Some American hospitas have foreign affiiates. Nationa University Hospita Singapore aso discoses information demonstrating that its quaity compares very favoraby internationay. 60 India s Apoo Hospita Group has devised a cinica exceence mode to ensure its quaity meets internationa heath care standards across a its hospitas. 61 Other Indian hospitas are working to create standards for reporting performance measures. Eectronic Medica Records. Because potentia medica tourists must first be evauated remotey, most arge heath care providers and medica intermediaries for patients use eectronic medica records (EMRs) to store and access patient fies. Patients can then discuss the procedures with potentia physicians via conference ca. 62 Modern hospitas abroad aso use information technoogy to identify potentia drug interactions, manage patient caseoads and store radioogy and aboratory test resuts. 63 By contrast, ony about one out of four U.S. hospitas store medica records eectronicay. 64 Third parties pay 87 percent of medica bis in the U.S. heath care system, and most of the third parties do not reimburse physicians or hospitas for the use of EMRs. Since others pay the bis, patients usuay do not choose hospitas or physicians based on their use of EMRs. 65 Hospita Accreditation. More than 120 hospitas abroad are accredited by the Joint Commission Internationa (JCI), an arm of the Joint Commission for the Accreditation of Hospitas that accredits American hospitas participating in Medicare. 66 The Internationa Standards Organization (ISO) aso accredits hospitas that meet internationay agreed-upon standards. Neary 150 foreign hospitas are accredited by ISO and JCI. 67 In addition, some countries are adopting their own accreditation standards. For instance, the Indian Heathcare Federation is deveoping accreditation standards for its members in an attempt to reassure potentia patients about India s high quaity heath care. 68 Hospita Affiiation. Some foreign hospitas are owned, managed or affiiated with prestigious American universities or heath care systems: The Ceveand Cinic owns faciities in Canada and Vienna, Austria; and in Abu Dhabi, the cinic aready manages an existing faciity and is buiding a new hospita. 69 Wockhardt (India) is affiiated with Harvard Medica Schoo. 70 Hospita Punta Pacifica in Panama City, Panama, is an affiiate of U.S.-based Johns Hopkins Internationa. 71 JCI-accredited Internationa Medica Centre in Singapore is aso affiiated with Johns Hopkins Internationa. 72

20 Medica Tourism: Goba Competition in Heath Care 17 Some foreign hospitas have U.S. trained or U.S. certified physicians. Daas-based Internationa Hospita Corp. is buiding and operating hospitas in Mexico that meet American standards. 73 Bumrungrad Internationa Hospita in Thaiand has an American management team to provide American-stye care. 74 Physician Credentias. Foreign heath care providers and medica trave intermediaries aso compete on quaity by touting the credentias of the medica staff. These physicians are often U.S. board-certified, whie others have internationay respected credentias. Many of the physicians working with medica tourists were trained in the United States, Austraia, Canada or Europe. Neary two-thirds of the physicians who work with PanetHospita have either feowships with medica societies in the United States or the United Kingdom, or are certified for a particuar speciaty by a medica board. 75 Onine Communities. Potentia patients can get some idea of the safety and quaity of medica providers by searching onine for testimonies of patients who have had surgery abroad. These Internet communities faciitate the exchange of information about providers, incuding faciity ceaniness, convenience, price, satisfaction with medica services and the avaiabiity of odging whie recuperating. PasticSurgeryJourneys.com has buit such a community. Members, incuding both former and prospective patients, can exchange information in onine discussion forums on such topics as destinations, specific physicians and types of surgery. Members answer questions about side effects, compications and occasionay even discuss patients who have died from surgery. A few members who had cosmetic surgery have even posted before-and-after photos. If a faciity performed ow-quaity work on a member, others in the community know to avoid the provider. 76 For exampe, patients who were disfigured by Mexican cosmetic surgeons created a Web site (http://www.cirujanospasticos.info) to warn away other patients. HeathMedicaTourism.org is another Web site with a forum where members can interact. 77 Authors of books on medica tourism aso interact with readers onine. Jeff Schut, author of Beauty From Afar, has inks to artices, reviews and a bog where readers can comment on topics of interest. 78 When Things Go Wrong. Even with the most skied physicians, patients may have adverse outcomes. When a medica tourist experiences injury or even death, it is natura to wonder whether a poory trained physician or substandard hospita payed a part. Of course, sometimes adverse events are due to the patient s pre-existing heath conditions or other factors not the faut of the physician; but, as with any service providers, doctors aren t perfect. Litte evidence exists to indicate that botched operations are a widespread probem in the medica tourism industry. Anecdota evidence tends to invove cosmetic surgery patients who went to faciities that were not screened by a respected intermediary or whose physicians credentias were not checked.

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