Medical Tourism: Global Competition in Health Care
|
|
- Jane Stone
- 2 years ago
- Views:
Transcription
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.
How to Cut Health Care Costs
How to Cut Heath Care Costs INSIDE: TEN TIPS FOR MEDICARE BENEFICIARIES What is one of the biggest financia surprises in retirement? Heath care costs. It s a growing concern among many Medicare beneficiaries,
Early access to FAS payments for members in poor health
Financia Assistance Scheme Eary access to FAS payments for members in poor heath Pension Protection Fund Protecting Peope s Futures The Financia Assistance Scheme is administered by the Pension Protection
Introduction the pressure for efficiency the Estates opportunity
Heathy Savings? A study of the proportion of NHS Trusts with an in-house Buidings Repair and Maintenance workforce, and a discussion of eary experiences of Suppies efficiency initiatives Management Summary
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow some of which may not appy your account Some of these may
Uncovered Report: Cash Plan and Private Health Insurance Explained
Uncovered Report: Cash Pan and Private Heath Insurance Expained Contents 3 Introduction 4 Cash pan products 6 Private heath insurance products 9 How the two pans match up? 10 Concusion 33256_ONEGI_GEN3480_BRO.indd
ELECTRONIC FUND TRANSFERS. l l l. l l. l l l. l l l
Program Organization = Number "1060" = Type "123342" = "ETM2LAZCD" For = "502859" "TCCUS" "" Name "WK Number = Name "First "1001" = "1" Eectronic = "1001" = Financia "Jane Funds Doe" Northwest Xfer PG1
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES
About ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow, some of which may not appy your account. Some of
A Description of the California Partnership for Long-Term Care Prepared by the California Department of Health Care Services
2012 Before You Buy A Description of the Caifornia Partnership for Long-Term Care Prepared by the Caifornia Department of Heath Care Services Page 1 of 13 Ony ong-term care insurance poicies bearing any
CUSTOM. Putting Your Benefits to Work. COMMUNICATIONS. Employee Communications Benefits Administration Benefits Outsourcing
CUSTOM COMMUNICATIONS Putting Your Benefits to Work. Empoyee Communications Benefits Administration Benefits Outsourcing Recruiting and retaining top taent is a major chaenge facing HR departments today.
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow some of which may not appy your account Some of these may
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l l. l l
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow, some of which may not appy your account Some of these
l l ll l l Exploding the Myths about DETC Accreditation A Primer for Students
Expoding the Myths about DETC Accreditation A Primer for Students Distance Education and Training Counci Expoding the Myths about DETC Accreditation: A Primer for Students Prospective distance education
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l. l l. l l. l l
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow some of which may not appy your account Some of these may
A short guide to making a medical negligence claim
A short guide to making a medica negigence caim Introduction Suffering from an incident of medica negigence is traumatic and can have a serious ong-term impact on both the physica and menta heath of affected
Protection Against Income Loss During the First 4 Months of Illness or Injury *
Protection Against Income Loss During the First 4 Months of Iness or Injury * This note examines and describes the kinds of income protection that are avaiabe to workers during the first 6 months of iness
CONTRIBUTION OF INTERNAL AUDITING IN THE VALUE OF A NURSING UNIT WITHIN THREE YEARS
Dehi Business Review X Vo. 4, No. 2, Juy - December 2003 CONTRIBUTION OF INTERNAL AUDITING IN THE VALUE OF A NURSING UNIT WITHIN THREE YEARS John N.. Var arvatsouakis atsouakis DURING the present time,
Message. The Trade and Industry Bureau is committed to providing maximum support for Hong Kong s manufacturing and services industries.
Message The Trade and Industry Bureau is committed to providing maximum support for Hong Kong s manufacturing and services industries. With the weight of our economy shifting towards knowedge-based and
Infrastructure for Business
Infrastructure for Business The IoD Member Broadband Survey Infrastructure for Business 2013 #5 The IoD Member Broadband Survey The IoD Member Broadband Survey Written by: Corin Tayor, Senior Economic
Annual Notice of Changes for 2016
Easy Choice Best Pan (HMO) offered by Easy Choice Heath Pan, Inc. Annua Notice of Changes for 2016 You are currenty enroed as a member of Easy Choice Best Pan (HMO). Next year, there wi be some changes
Program Management Seminar
Program Management Seminar Program Management Seminar The word s best management schoos are noted for their superior program execution, high eves of customer satisfaction, and continuous program improvements.
CERTIFICATE COURSE ON CLIMATE CHANGE AND SUSTAINABILITY. Course Offered By: Indian Environmental Society
CERTIFICATE COURSE ON CLIMATE CHANGE AND SUSTAINABILITY Course Offered By: Indian Environmenta Society INTRODUCTION The Indian Environmenta Society (IES) a dynamic and fexibe organization with a goba vision
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l. l l
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow some of which may not appy your account Some of these may
Business Banking. A guide for franchises
Business Banking A guide for franchises Hep with your franchise business, right on your doorstep A true understanding of the needs of your business: that s what makes RBS the right choice for financia
Niagara Catholic. District School Board. High Performance. Support Program. Academic
Niagara Cathoic District Schoo Board High Performance Academic Support Program The Niagara Cathoic District Schoo Board, through the charisms of faith, socia justice, support and eadership, nurtures an
Construction Plant and Health & Safety Training
Construction Pant and Heath & Safety Training The Driving Force Behind Your Training Monks Training Services based in Leyand has for severa years been providing construction pant and heath & safety training.
Pay-on-delivery investing
Pay-on-deivery investing EVOLVE INVESTment range 1 EVOLVE INVESTMENT RANGE EVOLVE INVESTMENT RANGE 2 Picture a word where you ony pay a company once they have deivered Imagine striking oi first, before
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l. l l. l l
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow, some of which may not appy your account Some of these
Health Savings Account 2013 2014 reference guide
Heath Savings Account 2013 2014 reference guide Information at your fingertips This ist of chapters and page numbers wi hep you find the information you need quicky. A detaied ist of sections and topics
ICAP CREDIT RISK SERVICES. Your Business Partner
ICAP CREDIT RISK SERVICES Your Business Partner ABOUT ICAP GROUP ICAP Group with 56 miion revenues for 2008 and 1,000 empoyees- is the argest Business Services Group in Greece. In addition to its Greek
endorsed programmes With our expertise and unique flexible approach NOCN will work with you to develop a product that achieves results.
endorsed programmes With our expertise and unique fexibe approach NOCN wi work with you to deveop a product that achieves resuts. NOCN is a eading reguated UK awarding organisation that has been creating
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow, some of which may not appy your account Some of these
Distribution of Income Sources of Recent Retirees: Findings From the New Beneficiary Survey
Distribution of Income Sources of Recent Retirees: Findings From the New Beneficiary Survey by Linda Drazga Maxfied and Virginia P. Rena* Using data from the New Beneficiary Survey, this artice examines
Older people s assets: using housing equity to pay for health and aged care
Key words: aged care; retirement savings; reverse mortgage; financia innovation; financia panning Oder peope s assets: using housing equity to pay for heath and aged care The research agenda on the ageing
Human Capital & Human Resources Certificate Programs
MANAGEMENT CONCEPTS Human Capita & Human Resources Certificate Programs Programs to deveop functiona and strategic skis in: Human Capita // Human Resources ENROLL TODAY! Contract Hoder Contract GS-02F-0010J
DOING BUSINESS WITH THE REGION OF PEEL A GUIDE FOR NEW AND CURRENT VENDORS
DOING BUSINESS WITH THE REGION OF PEEL A GUIDE FOR NEW AND CURRENT VENDORS TABLE OF CONTENTS INTRODUCTION... 1 GOVERNANCE... 1 COMMONLY PURCHASED GOODS AND SERVICES... 1 HOW TO REGISTER YOUR COMPANY...
A practical guide to personal financial advice Finding the right financial adviser and advice that works for you. Getting advice
A practica guide to persona financia advice Finding the right financia adviser and advice that works for you Getting advice About ASIC The Austraian Securities and Investments Commission (ASIC) reguates
Order-to-Cash Processes
TMI170 ING info pat 2:Info pat.qxt 01/12/2008 09:25 Page 1 Section Two: Order-to-Cash Processes Gregory Cronie, Head Saes, Payments and Cash Management, ING O rder-to-cash and purchase-topay processes
Filling the Revenue Gap
Fiing the Revenue Gap How Brokers Can Leverage Vountary Benefits to Buid Business Benefits at Work Series A Coonia Life White Paper May 2011 Tabe of Contents Executive Summary 1 Vountary Benefits Create
AA Fixed Rate ISA Savings
AA Fixed Rate ISA Savings For the road ahead The Financia Services Authority is the independent financia services reguator. It requires us to give you this important information to hep you to decide whether
Australian Bureau of Statistics Management of Business Providers
Purpose Austraian Bureau of Statistics Management of Business Providers 1 The principa objective of the Austraian Bureau of Statistics (ABS) in respect of business providers is to impose the owest oad
The definition of insanity is doing the same thing over and over again and expecting different results
insurance services Sma Business Insurance a market opportunity being missed Einstein may not have known much about insurance, but if you appy his definition to the way existing brands are deveoping their
Health Savings Account 2014-2015 reference guide
Heath Savings Account 2014-2015 reference guide www.seectaccount.com Information at your fingertips This ist of chapters and page numbers wi hep you find the information you need quicky. A detaied ist
Advance PLM Software Solutions for Complex Business Processes
Advance PLM Software Soutions for Compex Business Processes Abstract As customers word-wide camour for more technoogicay rich products, be it a car, or a smartphone, manufacturers are having to contend
IMPLEMENTING THE RATE STRUCTURE: TIERING IN THE FEE-FOR-SERVICE SYSTEM
The New Jersey Department of Human Services Division of Deveopmenta Disabiities 1 IMPLEMENTING THE RATE STRUCTURE: TIERING IN THE FEE-FOR-SERVICE SYSTEM Eizabeth M. Shea Assistant Commissioner Thomas S.
Income Protection Options
Income Protection Options Poicy Conditions Introduction These poicy conditions are written confirmation of your contract with Aviva Life & Pensions UK Limited. It is important that you read them carefuy
Immunisation of healthcare and laboratory staff
12 of heathcare and aboratory staff Heath and safety at work Under the Heath and Safety at Work Act (HSWA) 1974, empoyers, empoyees and the sef-empoyed have specific duties to protect, so far as reasonaby
Industry guidance document Checkout workstations in retail - safe design and work practices
Industry guidance document Checkout workstations in retai - safe design and work practices Industry guidance document Checkout workstations in retai - safe design and work practices WorkSafe Contents Foreword...
PREFACE. Comptroller General of the United States. Page i
- I PREFACE T he (+nera Accounting Office (GAO) has ong beieved that the federa government urgenty needs to improve the financia information on which it bases many important decisions. To run our compex
(David H T Lan) Secretary for Home Affairs
Message We sha make every effort to strengthen the community buiding programme which serves to foster among the peope of Hong Kong a sense of beonging and mutua care. We wi continue to impement the District
How to deal with personal financial problems
How to dea with persona financia probems D I S P U T E R E S O L U T I O N Introduction Heping you face the future with confidence In 2014, the eve of consumer debt in the UK grew to reach a seven-year
professional indemnity insurance proposal form
professiona indemnity insurance proposa form Important Facts Reating To This Proposa Form You shoud read the foowing advice before proceeding to compete this proposa form. Duty of Discosure Before you
Professional Kingston
Professiona Kingston Organisationa and workforce deveopment soutions n Facuty of Business and Law Aways improving 0/1 Contents Wecome 2 Why Kingston? 4 Course portfoio 6 Course detais 8 Work-based earning
Subject: Corns of En gineers and Bureau of Reclamation: Information on Potential Budgetarv Reductions for Fiscal Year 1998
GAO United States Genera Accounting Office Washington, D.C. 20548 Resources, Community, and Economic Deveopment Division B-276660 Apri 25, 1997 The Honorabe Pete V. Domenici Chairman The Honorabe Harry
MARKETING INFORMATION SYSTEM (MIS)
LESSON 4 MARKETING INFORMATION SYSTEM (MIS) CONTENTS 4.0 Aims and Objectives 4.1 Introduction 4.2 MIS 4.2.1 Database 4.2.2 Interna Records 4.2.3 Externa Sources 4.3 Computer Networks and Internet 4.4 Data
We are XMA and Viglen.
alearn with Microsoft 16pp 21.07_Layout 1 22/12/2014 10:49 Page 1 FRONT COVER alearn with Microsoft We are XMA and Vigen. Ca us now on 0115 846 4900 Visit www.xma.co.uk/aearn Emai alearn@xma.co.uk Foow
3.3 SOFTWARE RISK MANAGEMENT (SRM)
93 3.3 SOFTWARE RISK MANAGEMENT (SRM) Fig. 3.2 SRM is a process buit in five steps. The steps are: Identify Anayse Pan Track Resove The process is continuous in nature and handed dynamicay throughout ifecyce
ELEVATING YOUR GAME FROM TRADE SPEND TO TRADE INVESTMENT
Initiatives Strategic Mapping Success in The Food System: Discover. Anayze. Strategize. Impement. Measure. ELEVATING YOUR GAME FROM TRADE SPEND TO TRADE INVESTMENT Foodservice manufacturers aocate, in
D VISION. OCtech. orangeburg-calhoun technical college. email askme@octech.edu. call 803.535.1234 or 1.800.813.6519
HeathScienceOutside_Layout 1 8/20/2015 10:04 AM Page 1 D VISION orangeburg-cahoun technica coege focus nursing+heath science emai askme@octech.edu ike us foow us ca 803.535.1234 or 1.800.813.6519 office
Qualifications, professional development and probation
UCU Continuing Professiona Deveopment Quaifications, professiona deveopment and probation Initia training and further education teaching quaifications Since September 2007 a newy appointed FE ecturers,
Business schools are the academic setting where. The current crisis has highlighted the need to redefine the role of senior managers in organizations.
c r o s os r oi a d s REDISCOVERING THE ROLE OF BUSINESS SCHOOLS The current crisis has highighted the need to redefine the roe of senior managers in organizations. JORDI CANALS Professor and Dean, IESE
The guaranteed selection. For certainty in uncertain times
The guaranteed seection For certainty in uncertain times Making the right investment choice If you can t afford to take a ot of risk with your money it can be hard to find the right investment, especiay
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l l
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow, some of which may not appy your account Some of these
Ricoh Legal. ediscovery and Document Solutions. Powerful document services provide your best defense.
Ricoh Lega ediscovery and Document Soutions Powerfu document services provide your best defense. Our peope have aways been at the heart of our vaue proposition: our experience in your industry, commitment
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES
ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow, some of which may not appy your account Some of these
Chapter 3: Investing: Your Options, Your Risks, Your Rewards
Chapter 3: Investing: Your Options, Your Risks, Your Rewards Page 1 of 10 Chapter 3: Investing: Your Options, Your Risks, Your Rewards In This Chapter What is inside a mutua fund? What is a stock? What
Fixed income managers: evolution or revolution
Fixed income managers: evoution or revoution Traditiona approaches to managing fixed interest funds rey on benchmarks that may not represent optima risk and return outcomes. New techniques based on separate
AUSTRALIA S GAMBLING INDUSTRIES - INQUIRY
Mr Gary Banks Chairman Productivity Commission PO Box 80 BELCONNEN ACT 2616 Dear Mr Banks AUSTRALIA S GAMBLING INDUSTRIES - INQUIRY I refer to the Issues Paper issued September 1998 seeking submissions
Strengthening Human Resources Information Systems: Experiences from Bihar and Jharkhand, India
Strengthening Human Resources Information Systems: Experiences from Bihar and Jharkhand, India Technica Brief October 2012 Context India faces critica human resources (HR) chaenges in the heath sector,
Benefits That Count. Colonial Life is the proud sponsor of SHRM s Annual Employee Benefits Survey. coloniallife.com
Benefits That Count Coonia Life is the proud sponsor of SHRM s Annua Empoyee Benefits Survey cooniaife.com 1 Dear Empoyer: Randa C. Horn President & CEO Coonia Life & Accident Insurance Company 1200 Coonia
Advanced ColdFusion 4.0 Application Development - 3 - Server Clustering Using Bright Tiger
Advanced CodFusion 4.0 Appication Deveopment - CH 3 - Server Custering Using Bri.. Page 1 of 7 [Figures are not incuded in this sampe chapter] Advanced CodFusion 4.0 Appication Deveopment - 3 - Server
Teamwork. Abstract. 2.1 Overview
2 Teamwork Abstract This chapter presents one of the basic eements of software projects teamwork. It addresses how to buid teams in a way that promotes team members accountabiity and responsibiity, and
INDUSTRIAL AND COMMERCIAL
Finance TM NEW YORK CITY DEPARTMENT OF FINANCE TAX & PARKING PROGRAM OPERATIONS DIVISION INDUSTRIAL AND COMMERCIAL ABATEMENT PROGRAM PRELIMINARY APPLICATION AND INSTRUCTIONS Mai to: NYC Department of Finance,
Capability Development Grant. Build business capabilities to sharpen your competitive edge
Capabiity Deveopment Grant Buid business capabiities to sharpen your competitive edge 1 Buid up your business with the Capabiity Deveopment Grant The Capabiity Deveopment Grant (CDG) is a financia assistance
Quality Monitor HEALTH QUALITY ONTARIO 2012 REPORT ON ONTARIO S HEALTH SYSTEM
Quaity Monitor HEALTH QUALITY ONTARIO 2012 REPORT ON ONTARIO S HEALTH SYSTEM This report is a too for driving a cuture of quaity, vaue, transparency and accountabiity throughout the heath system in Ontario.
WHITE PAPER BEsT PRAcTIcEs: PusHIng ExcEl BEyond ITs limits WITH InfoRmATIon optimization
Best Practices: Pushing Exce Beyond Its Limits with Information Optimization WHITE Best Practices: Pushing Exce Beyond Its Limits with Information Optimization Executive Overview Microsoft Exce is the
Bite-Size Steps to ITIL Success
7 Bite-Size Steps to ITIL Success Pus making a Business Case for ITIL! Do you want to impement ITIL but don t know where to start? 7 Bite-Size Steps to ITIL Success can hep you to decide whether ITIL can
Learning from evaluations Processes and instruments used by GIZ as a learning organisation and their contribution to interorganisational learning
Monitoring and Evauation Unit Learning from evauations Processes and instruments used by GIZ as a earning organisation and their contribution to interorganisationa earning Contents 1.3Learning from evauations
Leadership & Management Certificate Programs
MANAGEMENT CONCEPTS Leadership & Management Certificate Programs Programs to deveop expertise in: Anaytics // Leadership // Professiona Skis // Supervision ENROLL TODAY! Contract oder Contract GS-02F-0010J
READING A CREDIT REPORT
Name Date CHAPTER 6 STUDENT ACTIVITY SHEET READING A CREDIT REPORT Review the sampe credit report. Then search for a sampe credit report onine, print it off, and answer the questions beow. This activity
Key Features of Life Insurance
Key Features of Life Insurance Life Insurance Key Features The Financia Conduct Authority is a financia services reguator. It requires us, Aviva, to give you this important information to hep you to decide
HEALTH PROFESSIONS PATHWAYS
T heoffic eofcommuni t yco egeres ea r c ha ndl ea der s hi p Co egeofe duc a t i ona ti i noi s The Heath Professions Pathways (H2P) Consortium is a nationa consortium comprised of nine coeges in five states
TERM INSURANCE CALCULATION ILLUSTRATED. This is the U.S. Social Security Life Table, based on year 2007.
This is the U.S. Socia Security Life Tabe, based on year 2007. This is avaiabe at http://www.ssa.gov/oact/stats/tabe4c6.htm. The ife eperiences of maes and femaes are different, and we usuay do separate
STRATEGIC PLAN 2012-2016
STRATEGIC PLAN 2012-2016 CIT Bishopstown CIT Cork Schoo of Music CIT Crawford Coege of Art & Design Nationa Maritime Coege of Ireand Our Institute STRATEGIC PLAN 2012-2016 Cork Institute of Technoogy (CIT)
Sage Accounts Production Range
Sage Accounts Production Range The abiity to dri-down from the face of the accounts makes reviewing accounts so easy. Sage Accounts Production Software As individua as you and your cients Jim O Leary,
Green power. options
Green power options How a our universities can hep stop cimate change by switching to green eectricity In January 2001 Peope & Panet caed on every UK university to switch to green eectricity, generated
The Productive Therapist and The Productive Clinic Peter R. Kovacek, MSA, PT
The Productive Therapist and The Productive Cinic Peter R. Kovacek, MSA, PT Format Interactive Discussions among equa peers Constructive argument Reaity Oriented Mutua Accountabiity Expectation Panning
Managing Business Risks from Major Chemical
Managing Business Risks from Major Chemica Process Accidents Mariana Bardy 1, Dr Luiz Fernando Oiveira 2, and Dr Nic Cavanagh 3 1 Head of Section, Risk Management Soutions Savador, DNV Energy Soutions
Life Insurance. Customer Information Brochure
Customer Information Brochure Life Insurance Asteron Life Limited ABN 64 001 698 228 465 Victoria Avenue Chatswood New South Waes 2067 Issued 1 Juy 2003 Expires 10 March 2004 Issue No 1 You shoud read
SPOTLIGHT. A year of transformation
WINTER ISSUE 2014 2015 SPOTLIGHT Wecome to the winter issue of Oasis Spotight. These newsetters are designed to keep you upto-date with news about the Oasis community. This quartery issue features an artice
Network/Communicational Vulnerability
Automated teer machines (ATMs) are a part of most of our ives. The major appea of these machines is convenience The ATM environment is changing and that change has serious ramifications for the security
Budgeting Loans from the Social Fund
Budgeting Loans from the Socia Fund tes sheet Pease read these notes carefuy. They expain the circumstances when a budgeting oan can be paid. Budgeting Loans You may be abe to get a Budgeting Loan if:
INDUSTRIAL PROCESSING SITES COMPLIANCE WITH THE NEW REGULATORY REFORM (FIRE SAFETY) ORDER 2005
INDUSTRIAL PROCESSING SITES COMPLIANCE WITH THE NEW REGULATORY REFORM (FIRE SAFETY) ORDER 2005 Steven J Manchester BRE Fire and Security E-mai: manchesters@bre.co.uk The aim of this paper is to inform
Undergraduate Studies in. Education and International Development
Undergraduate Studies in Education and Internationa Deveopment Wecome Wecome to the Schoo of Education and Lifeong Learning at Aberystwyth University. Over 100 years ago, Aberystwyth was the first university
Accreditation: Supporting the Delivery of Health and Social Care
Accreditation: Supporting the Deivery of Heath and Socia Care PHARMACY E F P T O L P E D P E C M F D T G L E F R Accreditation: Supporting the Deivery of Heath and Socia Care June 9, 2015 marks Word Accreditation
MICROSOFT DYNAMICS CRM
biztech TM MICROSOFT DYNAMICS CRM Experienced professionas, proven toos and methodoogies, tempates, acceerators and vertica specific soutions maximizing the vaue of your Customer Reationships Competency
Ricoh Healthcare. Process Optimized. Healthcare Simplified.
Ricoh Heathcare Process Optimized. Heathcare Simpified. Rather than a destination that concudes with the eimination of a paper, the Paperess Maturity Roadmap is a continuous journey to strategicay remove
Back to the Basics: Building a Financial Safety Net Begins with Life and Disability Insurance. Benefits at Work Series. A Colonial Life White Paper
Back to the Basics: Buiding a Financia Safety Net Begins with Life and Disabiity Insurance Benefits at Work Series A Coonia Life White Paper November 2011 Tabe of Contents Executive Summary 1 The Far-Reaching
Recognition of Prior Learning
Recognition of Prior Learning Information Guideines for Students EXTENDED CAMPUS This subject materia is issued by Cork Institute of Technoogy on the understanding that: Cork Institute of Technoogy expressy
Welcome to Colonial Voluntary Benefits. Thank you for your interest in our Universal Life with the Accelerated Death Benefit for Long Term Care Rider.
Heo, Wecome to Coonia Vountary Benefits. Thank you for your interest in our Universa Life with the Acceerated Death Benefit for Long Term Care Rider. For detai pease ca 877-685-2656. Pease eave your name,
ASSET MANAGEMENT OUR APPROACH
ASSET MANAGEMENT OUR APPROACH CONTENTS FOREWORD 3 INTRODUCTION 4 ASSET MANAGEMENT? 6 THE NEED FOR CHANGE 6 KEY PRINCIPLES 7 APPENDIX 1 19 GLOSSARY 20 2 FOREWORD Few things affect our customers ives as