Draft Trends and Drivers of Trade in Health Services* Mode 2

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Draft TrendsandDriversofTradeinHealthServices* Mode2 DavidC.Warner** *WritteninsupportoftheWHOCentreforHealthDevelopmentandtheWHODepartmentofEthics, Equity,TradeandHumanRightsinitiativeindevelopingathematicpaperon TheMovementofPatients AcrossInternationalBorders EmergingChallengesandOpportunitiesforHealthCareSystems **WilburCohenProfessorofHealthandSocialPolicy,LyndonB.JohnsonSchoolofPublicAffairs, UniversityofTexasatAustin.TheresearchassistanceofKateChambersandPaigeJenningsisgratefully acknowledged.

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner TableofContents I. EstimatesoftheExtentofMedicalTourism 3 II. GrowthinFacilitiesandServicesOutsidetheUS,Europe,andJapan 5 III. TheCategoriesofPersonsconsumingcareabroad 7 IV. AvailabilityofInsuranceCoverageforMedicalCareConsumedAbroad 11 V. Conclusion 19 VI. Appendixes 20 i. Mode2Health RelatedImportsandExportsbyCountry:2003 2006 21 ii. AccreditedHospitalsforMedicalTravelersoutsidetheUSandEurope 24 iii. IntermediariesandInformationforPatientsSeekingCareAbroad 26 VII. Bibliography 30 2

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 3 Theincreaseduseofmedicalcareinonestatebytheresidents[orcitizens]ofanotherstatehasbeen theresultofanumberofdevelopmentsrelatedtoincreasingglobalizationandinterdependence.some ofthefactorsincludetheapproximately200millionpersonsandtheirfamilieswhonowliveincountries otherthantheircountryofbirth,theincreaseintourismingeneral,theinternationalizationof accreditedwesternstylemedicalfacilitieswhichbothattractvisitorsandretainnationals,thelowcost ofobtaininginformationandmarketingalternativecare,theexistenceofgapsordelaysincoveragein sendingcountriesandsignificantcostadvantagesinreceivingcountries[exportersofcare].theagingof populationsineurope,northamericaandasiahasledtoanincreaseddemandformanyproceduresto treatchronicdiseaseconditions.atthesametime,inthefaceofincreasedevidenceofcostsavings, manywhomightbenefitfromservicesabroaddonotdosobecauseofthelackofcoverageforsuchcare eitherthroughpublicorprivateinsurance. I. EstimatesoftheExtentofMedicalTourism Thereareanumberofestimatesandroughguessesaboutthenumberofpersonsutilizingandmoney spentoncrossbordermedicalcare.acrude,butprobablyinflated,estimatemightbeonepercentof totalmedicalexpensesofmorethan$5trilliongloballywhichwouldamounttomorethan$50billiona year.butthereisawidevariationinwhatisconsideredtoqualifyforinclusioninthisfigure.thewide divergenceinrecentestimatesbydeloitteandbymckinseyconsultingofdemandbyusresidentsfor medicalservicesabroadillustratesthispoint.deloittecenterforhealthsolutionsstatedthatin 2007, anestimated750,000americanstraveledabroadformedicalcare.andthisnumberisestimatedto increasetosixmillionby2010. [Deloitte,p.3].TheprojectionsusedbyDeloitteseemtobebasedonan assumptionofalmostgeometricgrowth.mckinseystudiedmorethan20medicaltraveldestinations andconductedinterviewswithproviders,patients,andintermediariesin20countriesandconcluded that60,000to85,000inpatientsayearconstitutedthemarketinternationallyforallsourcecountries. Thisexcludedpatientswhohademergencieswhentravellingforotherreasons,patientswhotravelled foroutpatientcare,patientswhotravelledforwellnesssuchasacupunctureandmassageandalso internationalpatientsreceivingcareintheircountryofresidenceandpatientswhosoughtcareina nearbycountry.mckinseycontendsthatthecurrentnumberofusresidentsgoingabroadforinpatient careonlyamountstoabout5 10,000butthatwithinsurancecoveragetheseservicesthenumbersof travelersfromtheuscouldincreasetoasmuchas500 750,000annually[McKinsey]. Wewillexaminetheassumptionsconcerningthepotentialimpactofinsurancecoveragelaterbutthe widedivergencebetweenthetotalsispartiallyexplainedbytheverydifferentcategoriesofpatients examined.alsoneitherseemstotakeintoaccountthehighproportionofmedicaltravelerscurrently fromtheuswhoarereturningtotheirnativelandinparttoreceivemedicalcare.reedinarecent articlestates theusdepartmentofcommercein2006reportedthatinflightsurveysshowedthat therewereapproximately500,000internationaltripsfromtheunitedstatesforwhichatleastone purposewashealthtreatment. [Reed,p1433].Shepointsoutthat46%ofthesehealthseeking travelersin2004wereuscitizenswhohadbeenbornoutsidetheunitedstatesand36%werenon citizenswhileonly17%wereusbornuscitizens.thesetreatmentsincludeddentalaswellasmedical treatment[reed,p.1444].itisimportanttonotethatthisdatadoesnotincludetravelerswhodriveto MexicoorCanadaforcare.Thereareprobablyasimilarnumberoftripsfordentalorroutinemedical careinayearfromtheustomexico.

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 4 QuantitativereportsandestimatesofMode2TradeinMedicalcarearedependentonverylimitedand partialreportingbyparticipatingcountries.lautierextrapolatesfromreportedimfbalanceof PaymentsdataandtrendsinhealthexportsversustraveltrendstoestimatethatMode2tradeinhealth serviceshadreachedapproximately$11.8billionin2003upfrom$5.1billionin1997[lautier].sincehe preparedhisstudytheunservicetradedatabasehasbeendevelopedasaresultofrecommendations fromthetaskforceoninternationaltradeinservices.appendixipresentsthedatathatwereavailable asofdecember2008onexportsandimportsfrom2003to2006fromthissource.itbuildsontheimf data.aswiththeimfdatabecauseofverylimitedparticipationandlimitedmethodsofcollectionthe datashouldbegreetedwithsomeskepticism.whatisinterestingisthattherehasbeenasteady increasefrom2003to2006inmostcountriesandthatwiththeexceptionoftheusthedatathatlautier presentedfor2003isquitesimilartothedatainappendixi.aslautierpointedout,datafromthemain exportingcountriesinasiaismissingandimportdataisparticularlydifficulttodetermine.hopefullyas theunprocessbecomesmorematureanddatacollectionimprovesthisdatawillbeavaluablesource andwillreflectbilateraltradeaswellasjusttotalsforeachcountry.

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner II. GrowthinFacilitiesandServicesOutsidetheUS,Europe,andJapan AsdiscussedinboththeMcKinseyandDeloittestudiestherehasbeenrapiddevelopmentofmodern, wellfundedhospitalsinanumberofcountries inmanycaseswiththeparticipationofleadingus referralhospitalsandmedicalschools. 1 ManyofthesehospitalshavealsosoughtandobtainedJoint CommissionInternationalcertificationasameasureofqualitytoreassurethosewhonowwillstayin thecountryforcareaswellastoattractmedicaltourists.appendixiiprovidesthenamesandlinksto thewebsitesofmostofthejciaccreditedhospitals.itisnoteworthythatmostofthesehospitalswere developedtoservedomesticdemandforhighqualitymedicalservicesandtoreducethecostofpaying forcareabroad.inindiawherethereisasignificantandgrowingmiddleclassandwherethereis concernforchronicdiseaseproblemsthereisastrongdemandforthesefacilities.arecentstudy comparingindiancardiachospitalssuchasescortstoheartsurgeryintheusarguedthatthequality seemedtobecomparablealthoughtherelativecostwas$6,000inindiacomparedto$100,000inthe US.ItarguedthatinIndiathepricinghastobelowenoughtobeaffordabletothelargeIndianmarket andsoanumberofefficiencieshavebeenadopted[richmanetal].withindiainparticulartherehas longbeenalargeindianpopulationworkinginthegulf,ineastafrica,britain,andtheuswhichoften returnstoindiaformedicalcare. IntheEmirateswhereallcitizensareguaranteedaccesstohighqualitycareitisexpectedthatfarfewer tripsabroadforcarewillbeapprovednowthatthereareanumberoffirstclasshospitalslocatedthere. SimilarlyinSaudiArabiatherehasbeenaconcertedefforttodevelophighqualitytertiaryfacilitiesin manypartsofthekingdom.mostoftheinvestmentinthesefacilitiesisdomestic theuspartnersare generallymedicalschoolsorhospitalsanddonotprovidecapital.thechristushospitalsystemintheus hasenteredintoapartnershipwithagroupinmexicoandownsandmanagesachainofhospitalsin Mexico.SincetheenterpriseisnonprofittheyfinancelowincomeclinicsandservicesinMexicowith theproceedsofthepartnership.apollohospitalsinindiaandtheparkwayhospitalsysteminsingapore havealsodevelopedhospitalsinanumberofothercountriesincludingbangladesh. TraditionalChinesemedicineandAyuravedicmedicineandacupuncturearealltherapiesthatare increasinglypopularinthewest.china,india,thailand,andmalaysiaattracttourists,peoplewhowish tobetrainedinthesetherapiesanddisciplinesandpatientswhoareseekingacureoratleastimproved functioning.twomajorchinesehospitalsofferingtraditionalchinesemedicineincludebeijingtcm hospitalofchinaandguilintcmhospitalofchina.similarlythereareayuravedicspasandtreatment centersthroughoutmuchofindia.inparticularthereareanumberinkeralaandthestateofkeralahas beenworkingtoregulateandrateayurvedicresorts.chinaandindiaarenolongertheexclusivesource ofsuchtherapies.infacttherearemanypractitionersintheunitedstatesforexampleandtherearea numberofcertifiedschoolsandtrainingprogramsintraditionalchinesemedicine,acupuncture,and Ayuraveda[AppendixIIIincludessomelinkstotheseaswellaslinkstoproviders].AUSnurse rehabilitatedfromastrokeinanorthernchinesehospitalforfivemonthswhereshereceivedan intensiveregimenofdeepmassage,acupuncture,herbalmedication,steamtherapyandexercise.the totalcostwasabout$20,000 farlessthanitwouldhavebeenintheus.shewassopleasedwiththe resultsthatshehasstartedacompany[chinaconnection]connectingpeoplewithpractitioners[both standardmedicineaswellastraditionalchinesemedicine]inchina[einhorn]. 1 SincetheDeloittereportgoesintothesepartnershipsandjointventuresinquitealotofdetailitseems redundanttorepeatthespecificshere. 5

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 6 Inthelasttwoyearsorsotheinternationalavailabilityoflowercostbutgoodqualitymedicaland hospitalservices,theirquality,andrelativecosthavebecomebetterpublicizedintheunitedstatesby Time,USNews[May12,2008]andmajordailynewspapers.Forexample,afourpagesetofarticlesin thelosangelestimesonnovember12008examinednotonlythevariousoptionsabroadbutalso manyintermediaryfirmsandservicesavailabletopersonsinterestedintravellingabroadformedical services[dickerson].theintermediaryfirmsrangefromindividualwebsitesbasedinanexporting countrythatsupportandpromoteoneortwofacilitiestofirmsthatprovideawiderchoiceoffacilities, arrangetravel,arrangelodgingattheexportingcountry,orhelpcoordinateaftercareandother services.otherfirmsmayprovideresearchandothersmayjustoffertravelocityorhotels.comstyle webresourcestopotentialclients.somearepaidbythefacilities,somereceivefeesfromclients served,andsomereceivepaymentbasedonhits.also,atleasttwotradeassociationshavedeveloped torepresentprovidersandintermediariesandtopromotemedicaltourism.acompendiumofthese websitesandorganizationsandlinkstothemcanbefoundinappendixiii.arecentguidebothto facilitiesabroadandtheintermediariesavailableforeachcountryisjosephwoodman s Patients BeyondBorders.Theproliferationofinformationandeaseofdevelopingawebsitemakessortingout informationquitedifficult.

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner III. TheCategoriesofPersonsconsumingcareabroad Anearlierstudydelineatedanumberofcategoriesofconsumerswhogoabroadforhealthservicesas wellassomeothercategoriesofconsumerswhomaybeabroadforotherpurposesbutwhoconsume healthserviceswhenabroad.thesecategoriesincluded: 1. Consumerswhotravelabroadformedicalcare(whosemotivesincludeseekinghigher quality,lowercost,orfastertreatment,ortoreturntotheirnativesociety,ortoreceive servicesunavailableorillegalintheirnationofresidence); 2. Touristswhoincidentallyneedcareabroad; 3. Retireesabroad(whooftenhavecoverageinanothercountryandwhomayhaveretired abroadforthecostoramenities,andwhomaybeeithernativetothecountrytowhich theyretireorthecountryfromwhichtheyhavecoverage); 4. Temporaryormigrantworkers; 5. Crossbordercommuterswhomayhavemultinationalcoverageoptions;and 6. Residentsofmultinationalareaswithintegratedhealthsystems[Blouin,Lethbridgeetal, p.210]. Itwouldbeamistaketodismissallofthecategoriessavethefirstsinceeachcontributestoservices beingdeliveredtoeitherforeignresidentsorresidentswithforeigncoverage.andinthecaseof retireesabroadiftheyareforcedtoreturnhometoreceivecoveredcaretheirconsumptionisnot usuallyrecordedasbeingdeliveredtoaforeignresidentalthoughitis.wewilldiscussthefirstthree categoriesinsomedetail. 1. Consumers who travel abroad Consumerswhotravelabroadincludethosewhocannotaffordthecareintheircountryofresidence, thosewhocannotobtainthatcarebystayingathome,andthosewhoseekhigherqualitycarethanis available.othersmayseektotravelabroadforanonymityorculturalorlinguisticcomfort.forthose whoareuninsuredandforthosewhohaveanextendedwaitforcaretheydeemessentialandformany whoareuninsuredforaparticularprocedurecostbecomesarealconsideration.table1whichistaken fromthehealthbasewebsiteseemstobefairlyrepresentativeoftheestimatesofrelativecostsof specificproceduresforwhichoneislikelytotraveloverseas.traditionallyservicessuchasdentalcare orplasticsurgeryhavebeencandidatesfortravelersforcarebecausetheseareoftennotcoveredby healthinsurance.typicallyhoweverthetravelertravelstoafairlynearbylocationaswithusresidents ofborderstateswhogotomexicoormanyeuropeanswhogotohungryfordentalcareorplastic surgery.itisrelativelyrecentlythatpeople,otherthanthosewholiveonornearaborderwithalower incomecountry,wentabroadforrelativelymajorsurgeriesandproceduresinordertosavemoney. MostoftheprocedureslistedinTable1offerasufficientspreadincostforaprospectivepatienttobe abletoaffordairfareforthemselvesandpossiblyanotheraswellastocoverthecostofahotelroom duringrecuperation. 7

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner Table1:MedicalTourism OverseasSurgery 2 Procedure(US$) USA Singapore Thailand India TotalHip Replacemant 24,000 15,000 10,000 6,300 HipResurfacing (Birmingham) 48,000 14,000 10,000 7,000 Breast Augmentation 10,000 8,000 3,150 2,200 BreastReduction 10,000 8,000 3,919 3,000 EyelidSurgery 7,000 3,750 1,413 2,200 FaceLift 20,000 6,250 4,799 3,100 NoseSurgery 7,300 4,375 3,839 1,800 TummyTuck 8,500 6,250 4,052 3,400 Coronary Angiography 6,000 1,313 1,250 560 Coronary Angioplasty 41,000 11,250 4,150 3,500 CoronaryArtery BypassGraft 56,000 12,900 13,250 7,000 Pacemaker 7,500 5,000 3,500 Liposuction 5,000 2,133 2,500 http://www.healthbase.com:accessjanuary17,2009. Theprimaryservicesbeingdeliveredbytheexportingfacilitiesandclinicscanrangewidelyandcan include:cardiacsurgeryincludingangioplasty,valvereplacementandbypasssurgery;orthopedic surgeryincludingkneereplacement,joints,hips,shoulderandspine;plasticandcosmeticsurgery; dentalimplants,crownsandbridgework;bariatricandotherweightlosssurgery;infertilityservices;and spaswhichintegrateyogaorayuravedicmedicineandtraditionalchinesemedicineincluding acupunctureandothertherapies.someofthesearemorelikelytobeintegratedwithavacationthan others. Particularcountrieshaveserveddifferentmarketsfromabroad.AmongtheASEANnationsMalaysia, SingaporeandThailandhavemadeaconcertedefforttoattractpatientsfromabroadasincreasinglyhas thephilippines.arunanondchailandfinkpointoutthatthemajorityofpatientsintherecentpastthat visitedsingaporeandmalaysiacamefromotheraseancountriesbutthatinthailandonlyseven percentofvisitorswerefromotheraseancountrieswhilejapanwastheleadingsourcecountrybut theusandthemiddleeastprovidedanumberofpatientsaswell.mexicoprimarilyattractspatients fromtheunitedstates,bothofmexicanoriginaswellasthosebornintheus.southafricaserves muchofsouthernafricaandjordonhasinrecentyearshasbeenaleadingexporterofservicesinthe MiddleEast.TurkeyinadditiontoattractingTurkswholiveinEuropeseemswellsituatedtoattract patientsfromtheformersovietrepublicstoitseastandnorthaswellassomefromthemiddleeast. Regionalcentersofexcellencecanalsoattractpatientsfromnearbycountrieswhoareseekinghigher qualitycarethantheybelievetheycanobtainathome.chileattractsmanypatientsfrombolivia, 2 SimilarcomparisonscanbefoundintheDeloittestudyandothers. 8

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 9 TunisiaservesmanyfromLibya.AndtheUSattractsmanyfromLatinAmericaandelsewhere.Onthe otherhandalimitednumberofhospitalsinmexico[inparticularthreehospitalsinmonterrey]seemto provideahighnumberofbariatricandotherobesityrelatedsurgeriestouninsuredandunderinsured residentsoftexasandnearbystates[interviewwithhospitalofficials]. OfadvancedcountriestheUShasboththelargestnumberofuninsured 45million[USCensusBureau] andunderinsuredandalsothehighestmedicalpricesofanydevelopednation.thismeansthatif someonehasnocoverageandlimitedmeansthattheymightbeabletoscrapeupthecostofahip resurfacingorkneeoperationabroadbutitisnotwithintheirmeansintheus.similarlyeventhose withinsuranceintheusandelsewheremayfindthatoperationstheyconsidervitalsuchasplasticor cosmeticsurgery,bariatricsurgery,orsexchangeoperationsmaynotbecoveredandonlyaffordableif theygoabroad.thepotentialmarketisconstrainedbythefactthatformanywhoareuninsuredor underinsuredtheoutofpocketcostwouldstillbeseverelydifficulttomeet.theeconomicsaresimilar incountrieswheretherearelongwaitinglistsforelectiveproceduressuchaskneereplacementsor arthroscopicsurgeryandtheindividualhasthemeanstopurchasereliefbygoingabroad. Anothercategoryispatientswhogooverseastoobtainservicesforwhichtheyareeligibleintheir countryofresidencebutforwhichthelengthoftimetheyhavetowaitissignificant.anditispossible thattheserviceorproceduremightnotbeavailableintime.onesuchprocedurewouldbeanorgan transplant especiallyakidneyorlivertransplant.itishardtoknowhowmanykidneytransplantsare doneforinternationaltravelersandwhethertheyhavepaidthedonorsforthekidneys.overtimea numberofdifferentarrangementshavedevelopedindifferentcountries.shimazono,whoidentified Pakistan,Iran,India,ChinaandthePhilippinesassourcesforcommercialtransplants,estimatedthatas muchas5%oftheroughly66,000kidneytransplantsin2005worldwidewerecommercialtransplants giventopersonswhotravelledoverseas[shimazono,p.960].merionandcolleaguesidentified373 foreigntransplantsfromremovalsfromwaitinglistsintheusbetween2001and2006duetohaving receivedatransplantfromoutsidetheusregister.theybelievethatthiswasaminimumestimateand pointoutthatthenumbersofsuchremovalsincreasedbetween2001and2006.canalesandassociates identified10patientswhowereresidentinminnesotabetween2002and2006whoreceivedoverseas transplantsandreturnedtotheirkidneyprograminminneapolis.theyreportedthattheresultswere quitegood.eightweretransplantedinpakistan[allsomali],oneinchina[chinese]andoneiniran [Iranian][p.658].Therealsoseemtobeacertainnumberofnonresidentswhoreceivecadaverliversin theunitedstateswhohavemademajordonationstothepublicornonprofittransplantcenters [OrnsteinandGionna]. Alsointhecategoryoftravellingtofindserviceswhentheyarenotavailableinyourownnationisthe rangeoftherapiescategorizedundertherubricofstemcellservices.therehasbeenarapid proliferationofclinicswhichmaymakeunsubstantiatedandoverlyoptimisticclaimsontheirwebsites regardingtheconditionsforwhichstemcelltherapyisappropriateandunderstatingthepossible negativesideeffects.lauetalexamined19websitesofstemcellclinicslocatedinindia,philippines[2], Russia[2],Mexico[3],China[3],Thailand[2],Turkey,Barbados,theDominicanRepublic,andUkraine.It isunclearhowmanypeopletravelfromabroadforthesetreatments forthefoursitesthatgaveprices thecostaveraged$21,000excludingtravelandlodging.theinternationalsocietyforstemcell Researchhasissuednewguidelinesregardingcoreprinciplestoguidethe transitionofbasicstemcell researchintoappropriateclinicalapplications. [Hyunetalp.607]. Similarlytherehasbeenanincreaseinthenumbersofpersonswhogoabroadtofertilityclinics,tofind surrogatemothersatlowercost,ortohavesexchangeoperations.andacertainnumberofpeoplego

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner abroadforabortionservicesbothforprivacyandalsoinsomecasesbecausetheyarenotlegalintheir nationofresidence. 2. Tourists who incidentally need care abroad Touristsandbusinesstravelershavebeengrowinginnumbersastheworldhasbecomemore interdependentandasmoreandmorepeoplebecomeabletoaffordsuchtravel.bookmanand Bookmanciteastudybasedoninterviewswith17,000travelersfrom1996to2004thatshowedthat eightpercentoftravelerstodevelopingcountriesrequiremedicalcarewhenontheirtrip(or immediatelyafter).usuallyitisforthetreatmentofdiarrhea,althoughfortravelerstoafrica,the primaryreasonismalaria. [BookmanandBookman,p.46citingConstantine].Althoughmostofthis treatmentissimplyadoctor svisitandaprescriptionthosewhobecomemoreseriouslyinneedof medicaltreatmenteitherduetoanaccidentoranacuteeventorduetoaneedforregulartreatment forachroniccondition(suchasdialysis)theavailabilityofmodernmedicalfacilitiesmakestravelingto ordoingbusinessinanothercountryfarmoreattractive.manytravelershaveinsurancecoveragefor emergentconditionswhentheyareontripsabroad.asthepopulationinjapanandthewestagesthere willbemoreandmoreretireesgoingonextendedtripstoemergingcountriesandtheavailabilityoffirst classmedicalfacilitieswillnotonlyhelptomakemanyareasoftheworldmoretouristfriendlytheymay findmorethanhistoricallevelsofdemandfromthispopulation. 3. Retirees abroad Finally,agroupthatisoftennotincludedinthecategoryofmedicaltouristsisretireesabroad.There aretwodistinctpopulationswhoretireabroad.oneispeoplewhoareretiringtoacountrythatthey werenotborninandhavenotbeenpermanentresidentsin.thispopulationmaybeseekingbetter climate,aninterestinglivingarrangement,orlowercostsinretirement.sincetheyoftendonothave healthcoveragewhentheyretireabroadtheymayreturntotheircountryofpriorresidencewhenthey needhealthservices,buttheyarenotusuallyconsideredtobemedicaltouristswhentheyconsume servicesineithercountry.thesecondpopulationispersonswhoinretirementreturntotheircountry oforigin.althoughtheyareoftenentitledtohealthbenefitsinthecountrywheretheyworkedfor manyyearssuchbenefitsmaynotbeportableoronlypartially,sotheyalsowillreturntotheircountry ofbenefitsforservicesoratleasttoacountrywherethereisreciprocityformedicalservices.these tripsbacktothecountrywherethebenefitsarealsorarelyqualifiesasmedicaltourism. Itisverydifficulttoknowhowmanypeopleretiretoacountrydifferentfromtheonewheretheyhave benefits.forthosewhoarenotreturningtotheirnativecountryitisoftenunclearwhethertheylive parttimeintheirnewcountryorarepermanentresidents.forthosewhohavereturnedtotheirnative landtheyareoftenstillcitizensandcapturedassuchbothbythecensusandwhentheyusefacilities suchashospitals.ifitisthecasethatroughly200millionpersonsliveincountriesotherthantheir countryofbirthitisnotunreasonabletothinkthatasignificantnumberhavealsoreturnedtotheir nativelandwithentitlementtobenefitsintheirnationofemployment.similarlythereareprobably evengreaternumbersofpersonswhohaveretiredabroad.thereasonthispopulationissoimportantis thattotheextenttheyareretiringfromdevelopedcountrieswithcomprehensivebenefitstheywould costthesocialinsurancesystemagreatdealiftheyremain.iftheymovetoalowercostdeveloping nationtheycouldreceivehealthbenefitsatfirstclassfacilitiesandstillcostthecountryinwhichthey havebenefitsquitealotless.intheusforinstancewherethetotalhealthexpenditureperpersonwas $7,421in2007[Hartman]theexpendituresonandbytheover65populationaresubstantiallymoreper capita.lackofportabilityprobablymeansthatmanywhowouldotherwiseretireabroaddonot. 10

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner IV. AvailabilityofInsuranceCoverageforMedicalCareConsumedAbroad Eachgroupwhousesservicesabroadtendstohaveadifferentlikelihoodthattheywillhavethirdparty coveragefortheircareanddifferentrequirementstoqualifyforsuchcoverage.becausethisvariesalso bysendingcountryandregionitisworthreviewingthisinsomedetailfortravelers,forcrossborder plans,forpeoplewhobuysuchcoveragedirectlyandthekindsofemploymentorsocialinsurance coveragethatwouldpermitorencouragesuchuse. 1. Travelers Abroad Who Require Acute or Emergency Care Travelerswhoincidentallyhaveanacuteoremergencyneedformedicalcoverageoftenarecovered directlybytheirhomeinsurancearrangements,bysupplementalinsurancetheypurchaseorbythe socialwelfareschemeofthecountrytheyfindthemselvesin.intheeutravelerswhohavebenefitsin theirhomecountryhavetheeuhealthcardorthee111formandtheyareentitledtoacuteor emergencycareinanyothereucountry.thebenefitplansinsomeofthecountriesthatreimbursefor servicesreceivedhavedevelopednetworksofprovidersinothercountrieswheremanyoftheir beneficiariesvisit.otherwisethebeneficiaryhastogotothepublichospitalsandclinics.generallythe invoicesforcareareaggregatedatthenationallevelandthenreconciledattheeulevel[scaramagliet al].therehasbeensomeprobleminmakingthesereconciliationsbothbecauseinspain,forexample, publichospitalsmaynotaggregatethesechargesorcompileorevencollecttheminawaysothatthe nationalauthoritiescanmakethecasefortheircosts[rosenmollerandlluch].attheeulevel determininghowtomakethereconciliationsbetweencountrieshasbeenfurthercompoundedby countriesthathaveanationalhealthserviceanddonotbillatpointofserviceascomparedtothose whereallpatientsarebilledandtheirinsurerpays.sonotonlyisabillnotgenerateditisdifficultto knowwhattheappropriatepricemightbe.thisiscompoundedbythefactthatinbritainanumberof peoplehaveprivatecoverageinadditiontotheirnationalhealthcoverage.becauseofthiscomplexity thenationalhealthserviceandindividualeucountrieswithwhomthereisagreatdealoftravelhave workedoutaggregateannualpaymentstoreconciletheseaccounts. BetweentheEUandnonEUcountriesreciprocityforsuchtravelersisnegotiatedonanindividual bilateralbasis.forinstancebritainhasareciprocityagreementtocovertravelerswithaustralia,new Zealand,Malta,andsomeWestIndiancountries.Spainsimilarlyhasenteredintoagreementswith Brazil,Chile,Ecuador,PeruandParaguayaswellasAndorra.Turkeyhasfairlyextensiveagreements withseveraleucountries.othercountriessuchasfranceandgermanyhaveotherbilateral arrangements. InCanadamostprovinceshavespecificregulationsthatcoverresidentsoftheprovincewhentheyare temporarilyinanotherprovinceorwhentheyareoutsidethecountry.generallyifsomeoneisa permanentresidentofaprovincetheywillhavesomelevelofcoveragewhentravellingoutsidethe country.thelengthoftimetheycanbeoutoftheprovincewillbegenerallyfrom6monthsto12 monthsiftheyareonvacation.students,missionariesandcertaincategoriesofemployeescanbeout ofthecountryforalongerperiod.eachprovincealsogenerallyhaslimitsonwhattheywillpayfor.the totalamountspentin2006 2007forservicesoutsidethecountryforprovincesthatreportedsuch figuresrangedfrom$130,000innewfoundlandandlabradorto$25millioninontarioforoutofcountry emergencyinpatientandoutpatientinsuredhospitalandmedicalservices.inthatsameyearontario 11

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner alsospent$70.1millionforpriorapprovedtreatmentoutsidecanada. 3 Thesefiguresdonotincludeout ofpocketexpendituresorpaymentsbyprivatehealthinsurancepurchasedbycanadiansforcare outsideofcanada.unlikeinbritainwhereanumberofpersonsbuyprivatehealthinsuranceforcare insidethecountry,incanadasuchcoverageisnotavailable.butsupplementalcoverageisavailablefor careorexcesschargesforcareoutsidecanada. IntheUSMedicareandMedicaiddonotcovercareoutsidetheUnitedStatesevenforacuteand emergencycarewhiletravelingunlessitisonadirecttripbetweenthelower48andalaskaorthe facilityistheclosestappropriatefacilityforamedicalincidentthatoccursinsidetheus.afairlyhigh numberofpeoplewithmedicarecoverageeitherhavemedigapinsurancethatcoversoutofcountry acuteandemergencycareifitisduringatripoflessthan60daysdurationortheyhaveamedicare Advantageplanwhichofferscomparablecoverage.The60daylimitationwasestablishedwhen Congresslimitedprivateinsurersto12standardMedigappolicieswithclearlydefinedbenefitsso customerscouldmakepricecomparisons.forthe10standardpoliciesthatprovideforeigncoverage.thesepoliciespayfor80%ofbilledchargesforcertainmedicallynecessaryemergencycare.thecare iscoveredifitbeginsduringthefirst60daysofthetrip,andifitisn totherwisecoveredbymedicare. ForeigntravelemergencycoveragewithMedicarepolicieshasalifetimelimitof$50,000. [CMS,March 2008].OthersmayhaveanemployeeretirementbenefitthatprovidessuchcoveragebeyondMedicare. SimilarlymanyprivatepoliciesbywhichthemajorityofpeopleintheUSarecoveredwhoarenot coveredbythegovernmentplansincludecoverageforemergencycareabroadduringatripoflimited durationfromtheunitedstates.inadditionalimitednumberofuscitizensmayhaveatravelmedical Protectionplaninadditiontoallthiswhichcoversevacuationaswellasanybillsuncoveredbyprimary andsecondaryplans.theamericanexpressplancoverscareforthefirst31daysofacoveredtripupto $50,000inuncoveredexpensesincludingevacuation.Theseplansgenerallydonotcoverpreexisting conditions. 2. Cross Border Plans Crossborderplanscanincludeplansthatcovercareinaborderarea,caretoaccommodatealarge numberofmigrantworkersfromacontiguousnation,andcareinanimmigrantworkersnativeland.in EuropetherehavebeenattemptstodevelopcoverageintheborderregionbetweenBelgium,Germany andthenetherlandssothateconomiesofscalemightbedeveloped[neblingandschemkem]andalso BelgiumhospitalshaveenteredintoseveralcontractswithBritishandDutchHealthauthoritiesto providecareforpersonswithspecificneedsmotivatedinpartbywaitinglistsathome[glinosetal]. IntheUnitedStatesseveralinnovativeplanshavedevelopedinCaliforniainwhichanemployeroffersa planinwhichtheemployee,foralowerpremiumorlittleselfpay,canchoosetoonlyreceivetheircare atstipulatedprovidersinmexico.oneoftheplans,accessbaja,providesdualchoicetogroupsof50or lesssothatemployeescanpickamexicoonlyplanortheusplan.saludconhealthnetisanotherplan whichprovidesanetworkofprovidersinlosangelesandtijuanaandenrolleescanpickdifferent provideroptions.forthemexicopartofitsplan,saludconhealthnetdependsonsimnsawhichruns twoclinicsandhascontractswithhospitalsintijuana.simnsaalsoprovidesaplaninsandiegoaswell forcareexclusivelyintijuanaexceptforemergenciesandservicesnotavailableinmexico[warnerand 3 NewfoundlandandLabradordatacanbefoundathttp://www.hc sc.gc.ca/hcs sss/pubs/cha lcs/2006 cha lcs arra/nl eng.php.ontariodataontheotherhandisathttp://www.hc sc.gc.ca/hcs sss/pubs/cha lcs/2006 cha lcs arra/on eng.php 12

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner Schneider].TheWesternGrowersAssociationprovidesaplanforitsmemberswhichforamodest premiumprovidesaccesstoclinicsandhospitalsonthemexicanbordertoagriculturalworkersand theirfamilies.thisplancoversanestimated90,000workers[warnerandschneider].nearlyallthe workerswhochoosetheseplansareofmexicanoriginandmanyhavefamiliesinmexico.oneofthe greatdeficienciesoftheushealthsystemisthelargenumberofimmigrantswhoareuninsured.in 2007,while15.2%ofthewhite18 65populationoftheUSwasuninsured,59.3%oftheMexican immigrantpopulation18 65wasuninsured[NationalPopulationCouncil,p.20].Althoughtheseplans whicharelimitedtocareinmexicoarelessexpensiveitisstillhardtofindemployerswillingtooffer themandindividualsaregenerallynotwillingtopayforthemoutofpocket[bustamenteetal]. MexicointhepasthasofferedtheircitizensintheUnitedStatestheopportunitytobuythemselvesand theirfamilymembersintothemexicansocialsecurityprogram[imss];butdifficultyinprocessingthe applications,cost,andlimitedavailabilityoftheimssinruralareasallhavehelpedhistoricallytokeep enrollmentinthisprogramunder20,000.morerecentlythemexicansecretaryofhealthhassurfaceda proposaltohelpprovidecareforlegalmigrantsandtheirfamiliesinmexicoinadditiontoaccesstocare atcommunityhealthcentersintheuswhichwillbefundedinpartbymigrantsortheiremployersin theus[gonzalesbllocketal]. 3. Coverage for Medical Care Abroad Therehashistoricallybeenhealthinsuranceforexpatriatebusinesspeopleandtheirfamiliesandsome insurancethathastargetedaffluentpersonsincertainregionsoftheworld;buttheexistenceof insurancecoveragethatwillcoverelectivecareabroadisquitelimited.leadingcompaniescovering careforpersonslivingabroadincludeaetnaglobalbenefits,unitedhealthinternational,bluecross BlueShieldofAmericaandBlueWorldwideExpat,CIGNAinternational,QBEinAustralia,Goodhealthan AetnacompanylocatedintheUKandBupainternationalintheUK.AetnaGlobalBenefits isthe internationalhealthandgroupbenefitsbusinessofaetnainc.,oneoftheworld sleadingprovidersof healthandgroupbenefits.[it].currentlyprovidescoverageformorethan100,000expatriateandother internationalemployeesresidingand/ortravelinginover100countries.aetnaglobalbenefitsproducts aretailoredtomeettheuniqueneedsofglobalmembers,providingworldwidemedical,dental,life, disabilityandrelatedcoveragethathelpsmultinationalemployersattractandretainqualified employeesforoverseasassignments. Mostoftheotherfirmswoulddescribetheirmissionsimilarly andinmanycasesnotonlyhavedevelopednetworksofprovidersworldwidebutarealsogearedupto payforcarebackinthehomecountry. BritishUnitedProvidentAssociates(Bupa)acquiredbothAmedexandInternationalHealthInsurance Danmarkinrecentyears.Inadditiontoitsinternationalhealthinsurancebusinessfortravelersand expatriatesbupainternationalhascontinuedtheamedexlineofbusinesswhichcoveredmostlyaffluent residentsoflatinamericaandthecaribbeanforcareanywhereinthewesternhemisphereinmanyof theirproducts.davidmaltbysays, ManyLatinAmericansoftentraveloverseasformedicaltreatment whichiswhywehavedesignedournewproductstofitwithpeople sdifferentlifestylesandhealth requirements.thereisapolicytomeetyourneedsandthoseofyourfamily. SimilarllytheAzulor premiumversionsofpolicieswrittenbygruponacionalprovincialinmexicohavecoveredcareintheus aswellasinmexico.inbothcasesthemoreexpensivepoliciesprovidesubscriberscoverageforcarein othernations.thedevelopmentoflowerpremiumpoliciesforpeoplewhoarewillingtogoforcare abroadarenotgenerallyavailableexceptinthecaliforniapoliciesdiscussedabove. 13

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 14 TheEUhasrecentlyclarifiedtherightsofcitizensofitsmembercountriestochoosetoseek nonemergencycareinothercountriesintheeu.thiswastheconsequenceofseveraldecisionsbythe EuropeanCourtofJusticeandtheresultofextensivedeliberationsamongstthecountriesoftheEU. Theproposeddirective,whichwillbeconsideredbytheEuropeanParliamentandtheCouncilof Ministersinthecomingmonths,establishesthatpatientsmayseekambulatorycareabroadforany servicestheyareentitledtointheirowncountryandtobereimbursedfortheircostsuptothelevelof reimbursementintheirowncountry.thedirectivealsoestablishesarighttohospitalcareand treatmentabroaduptothelevelthepatientisentitledtointheirowncountrybutitdoessaythat undercertaincircumstancesamemberstatemaydecidetointroduceasysteminwhichpatients requireanadministrativepriorauthorizationbeforeseekingcareabroad. [Europa].Anumberof safeguards,includingequaltreatmentofthosewhoseekcareabroad,availabilityofpatientrecords, recognitionofpharmaceuticalsneededincontinuityoftreatment,andlegalrecourseformedicalerrors, arealsobuiltintothedirective.thereisnothinginthedirectivethatimpliesitcouldbeextendedto othercountriesaswell.atthesametimeonemightthinkthatnativesofturkey,algeria,orindiaor Pakistanwhoareentitledtothesebenefitsmightnothaveatleastamoralcasethattheyshouldbeable toreturn home forcareandbereimbursedonthesamebasis. IntheUnitedStatesthelargenumberofuninsuredpersonsaswellasmanywithlimitedcoverageor withlargedeductiblesorsomewithmedicalsavingsaccountshasledtoestimatesthatthereislikelyto beasubstantialmarketforinternationalcoverageinthefuture[deloitte,ehrbecketal].althoughin principleitwouldbepossibletoincentivizesuchcarebycoveringtravelcostsandpreferentialcost sharingforthosewhotraveltopreferredprovidersinpracticeithasbeendifficult.healthinsurancein theunitedstatesisgenerallyregulatedbythestateinwhichthepersonlives.but,iftheemployer self insures bearingsomeoftherisk,thentheyescaperegulationbythestatesandcandevelopmore innovativebenefitplans.ingeneralthereseemstobereluctancebyinsurerstodevelopplansthat wouldforcebeneficiariesintogoingtoforeignproviderssincetheycouldbeconsideredliableifthere arebadresultsandtheymightbeconsideredtheonedeeppocket.anadministratorwhohasbeen associatedwithseveraljciaccreditedhospitalsinthegulftoldmethatafirmthatservesasan intermediarybetweenbenefitplansandproviderssaidthattheycouldprovidecontractsifthehospital wouldprovidea50%savingsonwhatitcostintheus,ifallthephysicianswereeithercertifiedintheus oratthecomparablebritishstandard,ifthehospitalwerejcicertified,hadacceptableinfectionand complicationrates,andprovidedaguaranteedevacuationtoacountrythatismoreadvancedmedically [probablysingaporeoreuropedependingonthelocationofthehospital].hesaidthatincombination theserequirementsweretoodifficultorcostly. Individualswhoareuninsuredornotinsuredforsomethinglikeplasticsurgeryorbariatricsurgeryhave beenthemostlikelytochoosetotravellongdistances.thisisfortworeasons;ontheonehandifthey areuninsuredtheyoftenhavetopaytheretailratewhichisoftenmorethantwiceasmuchastherate commercialinsurersareabletonegotiateorgovernmentprogramslikemedicareofmedicaidpay.the secondreasonisthattheyoftenhaveaveryspecificneedsuchaschronichippain,oradesireforplastic orbariatricsurgeryandtheyareabletocomeupwiththespecificfundsneededtopayforthetrip abroadandthecare.giventheirlimitedresourcestheonlychoiceiswhethertheywanttodothe procedureabroadornotatall.infactthereisacanadianfirm[northamericansurgery]which specializesinfindingusproviderswhowilltakelessformanyoftheseproceduresandthatseemsto skimoffsomeofthosefromtheusorcanadawhowouldconsidergoingabroad.withincreased unemploymenttherewillcertainlybemoreintheuswhoareuninsured;butatthesametimewith economicuncertaintypeoplemaybelesslikelytospendfundsondiscretionarymedicalprocedures.

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner AndpartoftheObamastimulationpackagethathaspassedthehousebutnottheSenateisatemporary subsidyforpersonswhohavelosttheirjobstobeabletocontinuetheirhealthinsurancecoverage.in 2008, 3percentofthepopulationwasenrolledinaconsumer drivenhealthplan[dchp],upfrom2per centin2007and1percentin2006.enrollmentinhdhpsremainedat11percent.overall,9.8million adultsages21 64withprivateinsurance(representing6.6percentofthatmarket)wereeitherinaCDHP oranhdhpthatwaseligibleforanhas[healthsavingsaccount],buthadnotopenedtheaccount. [Frontsin,p.1].Althoughhighdeductibleplansdoencouragesavingsandcosteffectivemedicalusethe costofsurgeryoverseaswouldtendtoexceedthedeductibleinanycasesothatthenetsavingstothe individualislikelytobenegligible. Thereareanumberofpilotprogramsthathavebeeninauguratedforcoverageoverseasbutthereis limitedevidencesincetheirlaunch.aetnainitiatedaprogramforhannafordsupermarketswhere AetnaofferedtocovercertainproceduresoutsidetheUnitedStates. WorkersgotoSingaporeforhip replacementsurgerywithoutincurringanyout of pocketmedicalcosts.inadditionthepatientanda companiongetfreeairfareandhotelaccommodations. Aetnareportsthat aplanmemberwouldsave about$3,000bygoingtosingapore. AsofJune2008, notoneofhannaford s27,000workershas selectedtheforeigncareoption,nothaveanyotherlarge employeegroupsaskedaetnatoincludeitas anoption,accordingtoaspokesmanfortheinsurer. [Scott].BlueCrossBlueShieldofSouthCarolina hasspunoffcompanionglobalhealthcareasanindependentsubsidiary.thesubsidiaryhasoffereda medicaltourismoptiontodoctorscarewhooperatehealthclinics.todatenoneofthe1000 employeesanddependentscoveredbydoctorscarehavechosentogoabroadsincetheoptionhas beenavailable[smerd].wellpoint[whichistheagglomerationofformerbluecrossblueshieldplans thatareforprofit]isstartingasimilarprogrambeginninginjanuary2009throughitsaffiliateanthemof Wisconsin.TheyareprovidingaccesstoanetworkofprovidersinIndiaatareducedoutofpocketcosts toemployeesofserigraph awisconsinbasedproviderofprinteddecoratingsolutions[anthemblue CrossBlueShieldofWisconsin]. AsomewhatdifferentapproachisthattakenbySekureHealthPlanswhichhasdevelopedanetworkof providersintheusandthroughoutmexicowhohavenegotiatedpricesforservices.servicesinclude dietcounseling,massagetherapy,chiropracticandacupunctureinadditiontostandardmedicaland dentalservices.agrouporindividualcanpurchasemembershipwhichentitlesthemtothesepricesif theyuseanetworkprovider.portionsofthenetworkcanbeusedinconjunctionwithalimitedbenefit medicalinsuranceplan.asimilarmodelmightbedevelopedwithawiderpackageofinternational providersinthenetwork.swissrehasdevelopedtheoptionofmedicalcareabroadforselffunded employersintheuswhopurchasetheirstoplosscoverage[worldmedassist].inprincipalthereshould notbeadifficultyincludingselectedhospitalsandclinicsabroadinapposolongastheplanisself insured. ThereisnodoubtthatawarenessoftheoptionofgoingabroadformedicalcareintheUShasgrown exponentially.continuedrapidgrowthinthismarkettotheextentprojectedbybothdeloitteand McKinseyisunlikely. 4. Portability of coverage in retirement Therearetwodistinctpopulationswhowishtoretireabroadand,forboth,portabilityofthehealth benefitstheyareentitledtosothattheircarewillbecoveredinthecountrytheychoosetoretiretocan makeamajordifferenceinwhetherornottheychoosetoretireabroadandtheburdentheymay imposeonthecountrytheyretireto.thefirstpopulationincludespersonswhochoosetoretireabroad fromtheirnativecountrybecauseofcost,amenities,culturalinterest,oradesiretobeofservice.the 15

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 16 secondpopulationincludesthosewhowishtoreturntotheirnativecountryinretirement.thereare somedifferencesbetweenthesetwogroupsandalsosomedifferencesinentitlementsandportability soiwilldiscussthemseparately. Itisalsoimportanttonotethatthepopulationenteringtheirretirementyearswillgrowveryrapidly overthenextdecadesinmanycountries.intheusin2006therewere31.6millionpersons55 64,18.9 million65 74,13.2million75 84and5million85andover.InEuropein2007inFrance,Germany,Italy andgreatbritainalonethereweremorethan45millionpersons65andover.injapanthereweremore than26.8millionover65in2007.andinchinawhiletherewere102millionpersons65andoverin 2007therewillbeanestimated322millionby2050. 4 Allofthesecountriesnotonlywillhaveagrowing portionoftheirpopulationenteringtheseagestheyallfaceseriousfiscalchallengestofindawayto supportthispopulationandprovidehealthcareaswell. Manycurrentlydochoosetoretireabroad.LargenumbersofnorthernEuropeansretiretoSpain, Portugal,GreeceandItaly.RetireesfromtheUSandCanadaareincreasinglyretiringtoMexico,Costa Rica,Panama,andevenEcuador.Retirementcommunitiesarespringingupandexpandinginseveral locationsinbajacalifornia,alongthemexicanpacificcoast,thegulfofcortezandinyucatanfor example.japanalsohasinthepastconsideredthedevelopmentofsilvertownswhereretireescould moreeconomicallyretire.theattractionistheclimate,muchlowerexpenses,verylowpropertytaxes andtheabilitytohirehouseholdhelpataffordablerates.butformanythelackofmedicalcoverage whenabroadcanmakeitdifficulttoremainabroadinretirementordetersthemfromconsideringthe optioninthefirstplace. IntheEUasdiscussedaboveretireescanmovetheirentitlementfromonecountrytoanothercountry intheeu.iftheyaremovingfromtheuktospainforinstanceitmeansthattheythenusethespanish publicsystemandneedtomovetheircoveragebacktotheukiftheydecidetoreturn.manyretirees insteadusetheireuhealthcardasiftheyaretemporarilyabroadwhentheyhaveanacuteincidentor anemergencyandthenpayoutofpocketforroutinecareandreturnhomeformoreseriousneeds. AlternativelysomeofthehealthinsuranceschemesinGermanyandelsewherehavedeveloped networksofproviderswheretouristsandretireesarelikelytobesoitisnotnecessarytotransferones coverage[rosenmollerandlluch].atthesametimemanywhoaredependentonthestateforfinancial assistancearenotabletocontinuetoreceivethatiftheyleavetheirhomecountry.coverageoutside theeuonlyisavailablethroughbilateralagreements. IntheUSsomeretireesabroadhavecoveragethroughtheircorporateretirementcoveragealthough thatoftenwillnotcovercareforextendedcareabroad.since2000,tricare,whichisthehealth coverageformilitaryretireesandtheirdependents,coverscareforbeneficiarieslivingabroad.the VeteransAdministrationwillcovercareforserviceconnecteddisabilities.Thevastmajority,however, donothavecoverageaftertheageof65exceptthroughmedicareandmedigappolicieswhichwillnot covercareforthoseresidingabroad.weinterviewedanumberofretireesinmexicoandconductedan onlinesurveytodiscovertheirmedicalcoverageandwhethertheywouldusemexicanphysiciansand hospitalsifmedicarecoveredtheminmexico.wefoundthatmanyreturnedtothestateswhenthey neededmedicalcareandthatsomeenrolledinthemexicansocialsecuritysystem[imss]forroutine carebutalsotohavecoveredcareincaseofamedicalemergency[warner].forthosewholive permanentlyinmexicoitisnecessarytopayapremiumofatleast$96.40amonthtomaintain 4 TheUSdataisfromtheUSCensus.DataforothercountriesisfromthePopulationReferenceBureau. http://www.prb.org/data.finder.aspx

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 17 MedicarePartB[physicianandoutpatientdiagnostic]coverageand$30ormoreamonthforMedicare prescriptioncoverageeventhoughneitherwillpayforcareordrugsobtainedinmexico.ifabeneficiary doesnotcontinuethiscoverage[thepremiumsaresubtractedfromsocialsecuritychecks]thenthey havetowaittobereinstatedandforeveryyeartheyarenotcoveredtheirfuturepartbpremiums increaseby10percentayearandtheirdrugpremiumsbyonepercentamonth[centersformedicare andmedicaidservices]. ItwouldappearclearthatifMedicarecoveragewereavailabletoretireestoMexicothatmorewould retirethere,thatthecoststomedicaremightbesignificantlyless,andthatfuturesocialserviceand Medicaidcostsinnursinghomesmightbeavertedtotheextentthatpeoplewouldbeabletostayin theirhomesandtopayforassistanceinmexico[warnerandjahnke].themexicangovernment requestedintheannualmeetingofnaftafinanceministersinaugustof2007thatsuchcoveragebe provided.boththephilippinesandpanamahavemadeasimilarrequest.inallcasesitwassuggested thatthecenterformedicareandmedicaidservices[cms]beauthorizedtoconductapilotstudyof makingsuchcoverageportableorpossiblygrantawaiversoretireestothesecountrieswouldbe covered.inthe2008electionthedemocratsabroadadvocatedthatmedicarecoverageforretirees abroadshouldbeimplemented.sofarcmshasstatedthatitrequirescongresstoauthorizeany internationaldemonstrationprogram.itwouldseemtobeprudentforcmstoatleastdosometest experimentstoseewhatthecost,accessandqualityofcareissuesmightbeinservingapopulationthat isonlylikelytogetmuchlarger. Forthosewhowishtoreturntotheirnativelandaftermanyyearsabroadtheabilitytobringthe capacitytopayforfirstclasshealthserviceswouldnotonlymakethetransitionmoreattractiveforthe individual,itwouldalsomaketheindividualamoresignificantfinancialassettotheoriginalsending country.inallcasesthismightnotbenecessary.greeceandaustraliaconcludedasocialsecuritytreaty inwhichworkerswereentitledtocombineyearsworkedinbothsystemsforthedeterminationoftheir socialsecuritybenefitsandforthosewhoreturnedtogreecewhohadhadatleastoneyearworkingin thegreeksocialinsurancesystemthepensionerandhisfamilyareentitledtohealthcarecoverage underthegreeksystem[embassyofgreece].therearelargenumbersofimmigrantworkersineurope, NorthAmerica,theGulf,andJapan,HongKong,andAustralia.Europehasconcludedsomeagreements oncoordinationofpensionswithalgeria,morocco,andtunisiaandturkeyhasextensiveagreementsas well.portabilityofhealthbenefitsinretirementseemstobeanissuewhichneedstobenegotiatedona bilateralbasisbetweenthetwonations.turkeyseemstohavenegotiatedanagreementwherebya retireebacktoturkeywhohasworkedsubstantiallytheirworkingcareeringermanyoraustriaorthe NetherlandsorindeedothernationsintheEUhasportablebenefitsbackinTurkeyfromthecountry wheretheyworked[holzmanetalp.18].moroccohasnegotiatedasimilararrangementwith Germany.Morocco sarrangementwithaustriahoweverjuststipulatesthataustriawillpaynomorein MoroccothanitwouldpayasachargeinAustria;butAustria shospitalsareheavilysubsidizedandthe chargesareconsequentlywellbelowcost.austriawillpayaturkishretireeuptofullaustriancostsince thatiswhatisstipulatedintheiragreement.ontheotherhandamoroccanwhoreceivesafrench pensionandreturnstomoroccohasamonthlycontributiontothefrenchpublichealthsystemtaken outoftheirpensionbuthasnotaccesstocareinmorocco[holzman]. MostofthestatesintheGulfdonotpermitmigrantstobecomecitizensbuttheydoencouragethemto buyintoretirementschemesintheirhomecountries.andgenerallyitseemstheyareexpectedtofend forthemselvesbackintheirhomecountriesattheendoftheirterm[s]inthegulf.inasiathe Philippinesisamajorexportingcountry mostwhogotojapanorsaudiarabiareturntothephilippines inretirement.idonotknowhowarrangementsworkbetweenjapanandthephilippines.

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner IntheUSMexicanimmigrantswhoworktheequivalentof10yearsareeligibletoretireat62under SocialSecurityandtoreceiveMedicareat65.Iftheyareundocumentedthantheymayfinditvery difficulttoclaimtheseearnedbenefits.howevermedicarewillnotcoverservicesforthemwhenthey returnhomeinanycase.therearealsoanumberofmexicanimmigrantstotheuswhoarepermanent residentsbutwhoneverbecamecitizensprimarilybecauseoflimitedenglishproficiency.suchpersons arenotallowedtoleavetheusformorethansixmonthsatatime.thuseveniftheyhadportable MedicarecoverageandcouldinprincipleretiretoMexicotheywouldhavetomakesurethattheynever stayedlongerthansixmonthsatatime.otherwisetheycouldlosetheirpermanentresidentstatusand alsotheirrightstomedicare. Itishardtoknowhowmanymigrantstothewealthierstatesarelikelytoreturntotheirnative country estimatesbasedonexperiencesinthe19 th andfirsthalfofthe20 th Centuriesseemtoimply quiteawiderange.inanycaseitwouldnotbeunusualtothinkthatfairlysoontherewouldbeatleast 25 30millionwhohavereturnedifnotallofretirementage.Thatcombinedwith3 5millionretirees fromeurope,northamerica,japan,andelsewhere,whohavedecidedtoretiretonationssuchas Mexico,CostaRica,thePhilippines,Malaysia,Panama,India,northAfrica,Fiji,Tahiti,Brazil,Turkey,and Argentinacouldmeanamajorpossibleinfusionoffundsintothesecountriesbothformedicalcareand tosupporttheeconomy.onemillionpersonsspending$10,000percapitaonlivingand$5,000on averageonmedicalcarecanbring$15billionannuallyinforeignexchangeintoaneconomy.thereis alsosomedevelopinginterestinthedoharoundtotakethepositionthatsuchimmigrantsasmode4 workersareentitledtothesamebenefitsinretirementasthosenativeworkerstheyworkedalongside [Holzmanetal]. 18

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 19 V. Conclusion Increasedglobalizationwillcertainlyleadtoincreasedcrossborderutilizationofservices.Becauseofan ingrainedpreferenceforreceivingcareinonescountryofresidenceitisunlikelythatevenwith coverageformedicaltourismthatallofthe economicadvantage willbeachievedbycoveringsuch care inpartbecausethepersoncoveredisunlikelytoreapmanyofthebenefits.itdoesappearthat substantialbenefitswouldariseforallconcernedifhealthcoverageinretirementcouldfollowretirees tothecountrieswheretheyretire.countriescancontinuetoaddresssomeoftheseissuesona bilateralbasisbutabroaderperspectivemightbewarranted.althoughjointcommissioncertificationis agoodfirststeptowardsdeterminingqualityitmightbeagoodideatodevelopmandatoryreportingof medicalerrorsandinfectionratesnotonlyat exportinghospitalsandclinics butalsoathospitalsand clinicsintheus,japanandeurope.similarlysomemethodofcertifyingwebsitesandtheirclaimsboth forthosemaintainedbyprovidersandindependentonesshouldbeundertaken.perhapsmore objectiveauditsneedtobedevelopedsothatquality,cost,andpossibleproblemscanbebetter identifiedandmadepublic. AtthispointtheredoesnotseemtobemuchmovementbynationsundertheGATStoopenupthe privateorpublichealthinsurancemarketsinthesenseofrequiringthatinsurerscovercareabroadasif ittookplaceintheirhomecountry.thegatsisnotanimpedimenttoacountrydecidingtotaxtheir firstclasshospitalswhichareservingmedicaltourists.thisisanexportindustryandanationcantaxits exportsfreely.evenwithanagreementbyinsurersnottodiscriminatebetweenforeignanddomestic providersitishardtoseewhytravelcostswouldneedtobecovered. InsomewaystheEUisdevelopingprotocolswithintheEUwherebycitizenscanreceivecareacross nationalboundaries.perhapsastheeubetterdevelopsprotocolsandarrangementswithcountries outsidetheeu,japanandtheuswillbegintodosoaswell.furtherstudyisrequiredtoevaluateand developinsuranceinitiativesbothintheprivatesectorandthepublicsectoraswell.

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 20 VI. Appendixes

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner AppendixI Mode2Health RelatedImportsbyCountry:2003 2006 21

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner Mode2Health RelatedExportsbyCountry:2003 2006 22

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner UnitedNationsServiceTradeDatabasesTableMethodology TheMode2Health relatedimportandexporttableswerecreatedusingdataextractedondecember 12 th,2008,fromtheunitednations(un)servicetradedatabase. 5 Allhealth relatedtravelimportand exportdatawasextractedusinganexpressselectiondataquerycommand,andanalyzedinstata.the datarepresentedinthesetablesaredirectvaluesastheyexistintheunservicetradedatabase. TheUNServiceTradeDatabasewaslaunchedonJune1 st,2007,andcollectsservicetradedataknownas ExtendedBalanceofPaymentsServices(EBOPS)directlyfromparticipatingcountries.Country specific datacollectionmethodologyisnotcurrentlyavailable. TheUNServiceTradeDatabaseisaproductoftheManualonStatisticsofInternationalTradeinServices (MSITS)developedbytheTaskForceonInternationalTradeinServices.TheTaskForcerepresentsThe StatisticalOfficeoftheEuropeanCommission(Eurostat),theInternationalMonetaryFund(IMF),the OrganizationforEconomicCo OperationandDevelopment(OECD),theUnitedNations(UN),theUnited NationsConferenceonTradeandDevelopment(UNCTAD),andtheWorldTradeOrganization(WTO). AlthoughhistoricallytheIMF,Eurostat,WTO,andOECDhavedataonservicetrade,itisdifficulttoparse outtherelatedexpensesbymodeorsector.toaddressthisissue,thetaskforceoninternationaltrade inservicesdevelopedadisaggregatedcategoricalsystemthatwouldencouragecountriestocollect moredetailedservicetradedataandallowresearcherstobetterunderstandtheservicetradeflows. KnownasEBOPS(ExtendedBalanceofPaymentsServices),fromthesecategoriesyouareableto distinguishservicetrademodesandsector,andmorespecifically,mode2health relatedtrade. Duetoseveralcircumstancesuniquetocollectingdataacrossmanycountrieswithvaryingdegreesof capability,thedatabasehassomelimitations: Dataisnotyetavailableontradingpartners;thatis,dataonexportandimportsisbyservice, butnotbytradingcountry(i.e.youcanseeallhealth relatedexports,butnotwheretheycome fromorwherethepatientscomefrom). NotallcountriesareusingtheEBOPSclassificationsystemyet,asthereisa phasedrollout on usingthesecategories. TherearemajorgapsforinstancetheUShasexportdatabutnotimportdataandseveral prominentasiancountriesdonotprovideexportdata. Differences between Mode 2 health related Import and Export tables and Lautier s Table 1: Main Exporting Countries, health services Althoughamajorityofthemode2health relatedexportspresentedinthispaperfor2003andthose presentedintable1ofmarclautier spaperexportofhealthservicesfromdevelopingcountries:the caseoftunisiaarewithinafive percentpointrangeofeachother,thereislargediscrepancybetween theexportvaluesfortheunitedstates($1.57billionand$2.14billionrespectively). Onepossibleexplanationforthisdiscrepancycanbeattributedtodifferentdatasourcesandthe progressmadeinservicetradedatacollectionsincethepublicationoflautier spaper.lautier svalues arederivedfromtheimf sbalanceofpaymentsstatisticsdatabase,whicharecountry specificdatathat havebeencollectedonanannualbasis,anddatebackto1948.submittingmode2health relatedtravel dataiscurrentlyvoluntaryforcountries.datafortheunservicetradedatabasebetweentheyears 2000 2005wascollectedretrospectivelyfromcountriesin2006.Datafrom2006forwardiscollected annually.whilealsovoluntaryforcountriestosubmitdatatotheunservicetradedatabase,the emphasisplacedoncollectingandrecordingdataontradeinservicesbythetaskforceoninternational TradeinServicessinceits inceptionin2002couldhaveledtoanincreaseinaccuracy,anddefinitelyan increaseincountriesreportingservicetradedata. 5 http://unstats.un.org/unsd/servicetrade/default.aspx 23

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner AppendixII AccreditedHospitalsforMedicalTravelersoutsidetheUSandEurope Western Hemisphere BarbadosFertilityClinicChristChurchBarbadoswww.barbadosivf.org ClinicaslasCondesSantiagoChilewww.clincscondes.cl/ ClinicaBiblicaHospitalSanJoseCostaRicawww.clinicabiblica.com CIMAHospitalSanJoseCostaRicawww.cimahospital.com/start.html 6 ChristusMuguerzaAltaEspecialidadHospitalMonterreyMexicowww.christusmuguerza.com.mx ABCHospitalsMexicoCitywww.abchospital.com HospitalSanJoseTecdeMonterreyMexicowww.hsj.com.mx/ Brazilhas9hospitalsaccreditedbyJCAHIplusambulatorycareprogramsandotherservices HospitaldoCoracaoSaoPaulowww.hcor.com.br/index.asp HospitalIsraelitaAlbertEinsteinSaoPaulowww.einstein.br/ingles HospitalSamaritanoSaoPaulowww.samaritano.com.br Europe NaHomoiceHospitalPraguewww.homolka.cz/en/index.php Middle East TherearefouraccreditedhospitalsinJordanincluding: JordanHospitalAmmanwww.jordan hospital.com KingHusseinCancerCenterAmmanwww.khcc.jo Thereare25accreditedhospitalsinTurkeyincluding: AcibademHealthcareGroupIstanbulwww.acibademinternational.com AnadoluMedicalCenterKocaeliTurkeywww.anadolusaglik.org IstanbulMemorialHospitalwww.memorial.com.tr/eng KentHospitalIzmirwww.kenthospital.com/kenthastanesi/eng/default.asp GayrettepeFlorenceNightingaleHospitalIstanbulwww.florence.com.tr/en Thereare14accreditedhospitalsintheUnitedArabEmiratesincluding: AlNoorHospitalanditsbrancheswww.alnoorhospital.com/# AmericanHospitalDubaiwww.ahdubai.com DubaiHospitalweb.dohms.gov.ae/dh/ InternationalModernHospitalDubaiwww.imh.ae TawamHospitalAlAinwww.tawam hosp.gov.ae ZulekhaHospitalSharjahwww.zulekhahospitals.com/zhdubai/index Qatarhas5accreditedhospitalswhicharerunbythegovernmentownedHamadMedicalCorporation www.hmc.org.qa/hmcnewsite/. Thereare18hospitalsinSaudiArabiawhichareaccredited. 6 SourceJointCommissionInternationalwww.jointcommissioninternational.org/JCI Accredited Organizations/. AccessedJanuary5,2009 24

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 25 Israelhas3accreditedhospitals. DarAlFouadHospitalGizaEgyptwww.daralfouad.org/ Asia Indiahas10JCIaccreditedhospitalsalongwithanaccreditedeyeambulatoryprogram. AsianHeartInstituteMumbaiwww.ahirc.com ApolloHospitalsHyderabad,Chennaietc.www.appollohospitals.com WokhardtHospitalsBangaloreandMumbaiwww.wockhardthospitals.net NethradhamaSuperSpecialtyEyehospitalBangalorewww.nethradhama.org ThePhilippineshastwoaccreditedhospitals: St.Luke smedicalcenterquezoncityphilippineswww.stluke.com.ph/ TheMedicalCityPasigCityPhilippineswww.themedicalcity.com/Site/MedicalCity/Home.aspx?SS=822 Singaporehas12accreditedhospitalsincluding: AlexandraHospitalSingaporewww.alexhosp.com.sg ChangiGeneralHospitalSingaporewww.cgh.com.sg GleneaglesHospitalandMedicalCenterSingaporewww.gleneagles.com.sg JohnsHopkinsSingaporeInternationalMedicalCentrewww.imc.jhmi.edu KKWomen sandchildren shospitalwww.kkh.com.sg MountElizabethHospital[alsoParkwayHospitalGroup]www.mountelizabeth.com.sg NationalCancerCentreSingaporewww.nccs.com.sg NationalUniversityHospitalwww.nuh.com.sg SingaporeGeneralHospitalwww.sgh.com.sg TanTockSengHospitalwww.ttsh.com.sg SeveranceHospitalSeoulwww.yuhs.or.kr/en Chinahassixaccreditedhospitals. UnitedFamilyHospitalandClinicsinShanghaiandBeijing www.unitedfamilyhospitals.com/shen_index.asp CliffordHospitalGuangzhouwww.clifford hospital.org/en/jci.html SirRunRunShawHospitalwww.srrsh.com/ HongKongAdventistHospital,HongKongwww.hkah.hk.org/ Taiwanhasfouraccreditedhospitalsincluding: Min ShengGeneralHospitalTaoyuanCityTaiwanwww.e ms.com.tw TaipeiMedicalUniversitywww.wanfang.gov.tw/english/index.html Thailandhasfouraccreditedhospitals: BangkokHospitalMedicalCenterwww.bangkokhospital.com BumrungradInternationalHospitalBangkokwww.bumrungrad.com Samitivej.SukhumvitHospitalBangkokwww.samitivej.co.th SiloamHospitalLippoKarawaciIndonesiawww.siloamhospitals.com/hospitals/lippokarawaci.aspx

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner AppendixIII IntermediariesandInformationforPatientsSeekingCareAbroad General Information and Trade Groups USNewsarticle[May2008]lists42hospitalsabroadwhich havepassedathree partevaluationby HealthyTravelMedia,aChapelHillNCfirmthatsurveysforeignhospitalsandpublishesPatientsBeyond Borders [p.46]. InternationalMedicalTravelAssociationwasestablishedin2006forprovidersandmembersofthe tourismindustry.www.intlmta.org/web/imta/hometheyhavea42itempatientbillofrightsand sponsorconferences MedicalTourismAssociationIncisanInternationalNon ProfitinPalmBeachJohnathanS.Edelheit Presidentwww.MedicalTravelAuthority.comsponsoranannualconference IntermediariesintheUS AllMedicalTourism.comisasearchenginewhichpermitsapatienttoputincountryoforiginand desiredprocedure.thenafterregistrationwill,likeexpedia,travelocityorasimilarsearchsite,provide pricesandastarratingofthefacilityforthatprocedure.youcanpickthefivesitesyouwouldliketo hearfromandbecontactedbyprofessionalsfromthatsite.www.allmedicaltourism.com BridgeHealthInternational:www.bridgehealthinternational.comcompanyhasanextensivenetwork thatitwillreferpatientstoaswellasprovidingtheminformationaboutalternatives. CosmeticSurgeryTravelanditssistercompanyIntermedGlobalspecializeinprovidingexclusivemedical vacationsinbangkokandsingaporewww.cosmeticsurgerytravel.comandwww.intermedglobal.com CompanionGlobalHealthwww.companionglobalhealth.comBlueCrossBlueShieldofSouthCarolina developedarelationshipinitiallywithahospitalinthailandandthensubsequentlyestablished CompanionGlobalHealthcareanetworkofinternationallyaccreditedhealthfacilities.Companion Globalhealthalsoworkswithselfinsuredplanstoofferanoverseasoption. HealthTravelGuides:providescompleteservice,hasrelationshipswithanumberofhospitalsand providesatechnologywhichwasdevelopedtoprovidemedicalservicestomorethanamilliontravelers worldwide.thecompanyfocusesitsmedicaltourismservicesprimarilyonmexico,thecaribbeanand SouthAmerica.Thecompanyalsoprovidesaplatformforprovidergroupsabroadwhowishtolicense theirtechnologytoprovideservicesundertheirownname.theyprovidetheservicetobusinesses underthenamehealthtraveltechnologies.www.healthtravelguides.com MedJourneysmarketsservicesatJCIaccreditedfacilitiesinThailand.India,Singapore,Malaysia, Turkey,Poland,CostaRica,Mexico,andBrazilwww.medjourneys.com.Theyhavecasemanagersthat talktotheprospectivepatientsbeforeandafterthetripandcontractwithindividualsinthedestination countries. MedRetreatUSownedandoperatedprovidesmanyservicestomedicaltravelers.Itwasestablishedin 2003andoperatesasamedicaltravelagencytodestinationsinSouthandCentralAmerica,theMiddle EastandAsiawww.medretreat.com. 26

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner MedicalTourismCorporationlocatedinPlanoTexaswww.medicaltourismco.com TheMedicalTouristCompanyislocatedinBritain.ItreferspatientstophysiciansandhospitalsinIndia, Cyprus,Poland,SingaporeandSpain.Thereareextensivetestimonialsonitswebsite.Theyalsorefer forayuravedictreatmentsaswell.www.themedicaltouristcompany.com Healthbaseonlinewww.healthbase.comlocatedinNewtonMasschargesaflatfeeforitsservicewhich istohelpaprospectivemedicaltravelerfindtheappropriatefacilityorphysician.theyhave informationonmanyaccreditedhospitalsandphysicianswhichifyoujoinisavailabletoyou.theyclaim to takecareofallone smedicaltourismdetailsfromarrangingthesurgeryandfinancingoptionsto visas,travel,lodging,andtourism. PatientsWithoutBorderslocatedinBostonMassachusetts.Thewebsitesaystheyprovideafullrange ofreferral,precare,aftercare,coordinatetravelarrangements,provideconciergeservices.according tothewebsitetheyhavearrangementswithhospitalsinchileandargentinabutareplanningtoexpand theirnetwork.theyhaveinformationforbusinessesandinsurersontheirwebsitealthoughitisunclear iftheyhavesuchcontracts.www.patientswithoutborders.us PlanetHospitalwww.planethospital.comfoundedin2002inCaliforniaisoneofthelargermedical referralsites.ithasrelationshipswithhospitalsin12countries.itwillworkwithinsurersaswellas individuals. PlacidWaywww.placidway.com/index.phpisasitewhichidentifiesanumberofprovidersand therapiesaroundtheworldaswellasnewsaboutmedicaltourismandalternativetherapies.itis primarilyaresourcewhichdoesselladsithinkbutdoesnotarrangeforthetripsitself.itisquite comprehensive. WorldMedAssistwww.worldmedassist.com.Providesanetworkofprovidersbothonitswebsiteand alsoservesasthethirdpartymedicallogisticsproviderforswissreinprovidingaforeignmedicaloption aspartoftheselffundedstoplossinsuranceprovidedinall50states.notethiswouldbeanoptionto includethesenetworksaspartofthestoplossprotectionforselffundedemployers.swissresaysitis thefirstintheusonanationalbasistoprovidemedicaltravelasanoption.worldmedassistsaysit referstoonlyjciornearjcitertiaryhospitals/ Provider Groups and Destination Country Specific Entities India HealingTouristforexampleseemstobeconnectedwithahospitalorgroupofhospitalsinIndia.Their mailingaddressisinorissa.onefindsitswebsiteingoogleads.www.healingtourist.com IndiaAmericaglobalsolutionswww.iagsolutions.comlocatedinColoradooffersspecialtycareatseveral facilitiesinindia.thefounderhadheartsurgeryinthe90sindelhiandsubsequentlytotalknee replacementsurgery.thewebsiteincludesseveralvideosabouttheescortheartinstituteindelhi. IndUSHealthwww.indushealth.comlocatedinNorthCarolinaandpartnerswithApollohospitals, EscortsHeartInstituteinNewDelhiandWockhardtHospitalsaswellasMaxiHealth.Offersnormal medicaltraveloptionsaswellastheirnetworktoselfinsuredemployers. 27

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 28 www.bestmedjourneys.comlocatedinbrooklynnewyork.specializesinsendingpatientstovetted hospitalsinindiaandarrangingforstaysandotherrequirements.itisasubsidiaryofacompanythat originallywenttoindiatorecruitnursestocometotheunitedstates. www.meditours.orglocatedinbritishcolumbiaprovidesmedicaltravelservicestocanadiansandus residentswhowishtousejasolikhospitalinmumbaiorseveralinstitutionsinkerala. TajMedicalGroupwww.tajmedical.comwithheadquartersinLondonhasorganizedtripstoIndian providersforpatientsprimarilyfromgreatbritain,canada,andeurope.theyhaveopenedausofficeto attractmoreuspatients. Israel IMSGlobalwww.medicaltourismforyou.comarrangesmedicaltravelto18medicalcentersinIsrael. Theyhavedividedtheirservicesintothreecategories:fertility/infertility,children smedicalservices,and adultmedicalcare. Malaysia www.cureontour.comprovidespersonalservicestotravelersseekingcareinmajorkualalumpur hospitalsofferspricebreaksforagencyclients www.malaysiahealthcare.comformedpartnershipwithmalaysia slargesthospitalnetworks.theweb sitepermitstheclienttoscheduleholidaysaswellasmedicalprocedures.theceorecentlystatedthat 360,000medicaltouristsvisitedMalaysiain2007,anincreaseof20%from2005.Hesaidthevisitors wereprimarilyfrombangladesh,indonesia,japan,singapore,themiddleeastandeurope. Philippines HealthandLeisureisaPhilippinesbasedfacilitator.www.healthandleisure.net Singapore MedicalSingapore:www.medicalsingapore.com/.LocatedinSingaporeandcoordinatesservicesand providesinformationonhospitals,hotels,andphysiciansinsingapore. Thailand BumrungradHospitalwww.bumrungrad.com/index inter.aspxoneofthepioneersinmedicaltourism.a majorinternationalhospital. SerokoloHealthTourismislocatedinJohannesburg,SouthAfricaandseemstoarrangeservices includingspas,plasticandcosmeticsurgeryandorthopedicandelectivesurgeryinhospitalsandclinics inseverallocationsinthecountryhttp://www.serokolo.co.za. Insurance Plans SekureHealthwww.mysekure.com/english/index.phpprovidesaccesstoanumberofnetworksof providersintheusandmexicoitcanbeusedasitselforaspartofalimitedbenefitplan.itmaybeused aspartofthesymetralifeinsuranceselectbenefitsplan. AccessBajaHealthPlanwww.blueshieldca.com/producer/smallgroups/products/health/baja/Access BajaisahealthplandevelopedbyBlueShieldofCalifornia.Whenitisasmallgroup[lessthan50 employees]itmustbeofferedinconjunctionwithanotherplanwhichtheemployeecanchoose.it

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner locksthosewhochooseitintoobtainingtheircareinmexico.generallytheemployermustbewithin50 milesoftheborder. SaludconHealthNethttp://askoleg.com/healthnet_salud.htmhasanumberofhealthinsurance productsitsellsinsoutherncaliforniathatcoverscareinmexicoforenrolleesandtheirfamilies. Simnsawww.simnsa.comoperatesaPPOinMexicowhichitmarketsdirectlytoSanDiegoCounty employersaswellasprovidingthemexicancomponentofsaludconhealthnetsnetwork. BUPAInternationalLatinAmerica http://www.bupa.co.uk/about/html/pr/250208_bupa_international_latin_america_caribbean.html InsurancecompanythatsellshealthinsurancepoliciesinCentralandLatinAmericathatcoverscarein theusaswellaselsewhere. Traditional Chinese Medicine, Acupuncture and Ayurvedic AnoverviewoftraditionalChinesemedicineandmedicaltourscanbefoundat http://www.meddicaltourismchina.org/mtcweb/tcmpackage.htm OrganizationcertifyingTraditionalChineseMedicineandAcupunctureschoolsintheUSwww.ccaom.org NationalAyurvedicAssociationwww.ayurveda nama.org. 29

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 30 Bibliography AnthemBlueCrossBlueShieldofWisconsin,AnthemBlueCrossandBlueShieldIntroduces InternationalMedicalTourismPilotProgram,PressRelease,November12,2008. http://biz.yahoo.com/prnews/081112/clw089.html?.v=90 Arunanondchai,JutamasandCarsonFink, TradeinHealthServicesintheASEANregion, Health PromotionInternational,Vol.21pp.59 66,2006 Barsoum,RS, TrendsinUnrelated donorkidneytransplantationinthedevelopingworld, Pediatric Nephrology,Vol23,Issue11,pp.1925 1929,November2008. Bhagwati,JagdishandSandipMadan, WeNeedFreeTradeinHealthCare, OpEd,WallStreetJournal, May27,2008. Blouin,Chantal,JaneLethbridge,DidarSingh,RichardSmith,andDavidWarner, TradeinHealth ServicesUndertheFourModesofSupply:ReviewofCurrentTrendsandPolicyIssues, inchantal Blouin,NickDragerandRichardSmith,eds.,InternationalTradeinHealthServicesandtheGATS: CurrentIssuesandDebates,WorldBank,WashingtonDC,2006 Bookman,MilicaZ.andKarlaR.Bookman,MedicalTourisminDevelopingCountries,Palgrave Macmillan,NY,2007 BUPAPressRelease,BupaInternationallaunchesnewhealthcoverforcustomersinLatinAmericaand thecaribbean,february21,2008 http://www.bupa.co.uk/about/html/pr/250208_bupa_international_latin_america_caribbean.html accessedjanuary25,2009 Bustamante,O,Ojeda,G,Castenda,X,ThewillingnesstopayforcrossborderhealthInsurancebetween theunitedstatesandmexico,healthaffairs,volume27,issue1,pp.169 178,January February2008 Canales,MT,BLKasiske,MERosenberg, TransplantTourism:OutomesofUnitedStatesResidentsWho UndergoTransplantationOverseas, Transplantation,Vol82,No.12,1858 1862,December27,2007 CentersforMedicareandMedicaidServices,MedicareandYou2009,CMSPublicationNo.10050 19, September2008 CentersforMedicareandMedicaidServices,MedicareCoverageOutsidetheUnitedStates,CMS PublicationNo11037,RevisedMarch2008http://www.medicare.gov/Publications/Pubs/pdf/11037.pdf Chanda,Rupa,TradeinHealthServicesI(CommissiononMacroeconomicsandHealth,WorldHealth Organization,WorkingPaperSeries,PaperNo.WG4:5,2001) Comarow,Avery, UndertheKnifeinBangalore, U.S.NewsandWorldReport,May12,2008,pp 42 50 Constantine,David, TravelersIllness:TheSouvenirsNobodyWants, NewYorkTimes,January17,2006

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 31 Cortez,Nathan, PatientsWithoutBorders:TheEmergingGlobalMarketforPatientsandtheEvolution ofmodernhealthcare, IndianaLawJournal,Volume83:pp.71 132,Winter2008 DeloitteCenterforHealthSolutions, MedicalTourism:ConsumersinSearchofValue,2008 Diaz Briquets,Sergio, Medicare:APotentialIncome GeneratingActivityforCubaintheFuture, Cuba intransition,asce2001 Dickerson,Maria, AguideforAmericansseekingaffordablemedicaltreatmentabroad, LosAngeles Times,November1,2008 Ehrbeck,Tilan,CeaniGuevara,andPaulD.Mango, Mappingthemarketformedicaltravel, the McKinseyQuarterly,May2008,pp.1 11 Einhorn,Bruce, ATraditionalChineseAlternativetoUSHospitals, BusinessWeek.comNovember 9,2008 http://www.businessweek.com/globalbiz/content/nov2008/gb2008119_464684.htm?campaign_id=rss_ daily EmbassyofGreece, GreeceandAustraliasignbilateralSocialSecurityagreement, May23,2007press release. EUROPA,QuestionsandAnswersonthedraftDirectiveontheapplicationofpatients rightsincrossborderhealthcare,memo08/473,july2,2008 FinancialTimesarticleDecember4,2008 Scientistswarnon Rogue Stemcellpractitioners Frontsin,Paul,Findingsfromthe2008EBRIConsumerEngagementinHealthCareSurvey, Employee BenefitsResearchInstitute,No.323,November2008 Gentleman,Amelia, IndiaNurturesBusinessofSurrogateMotherhood,NewYorkTimes,March10, 2008p.15 Glinos,IreneA.,RitaBaetenandNicoleBofin, Cross bordercontractedcareinbelgianhospitals, in Rosenmoller,Magdalene,MartinMcKeeandRitaBaeten,PatientMobilityintheEuropeanUnion: LearningfromExperience,EuropeanObservatoryonHealthSystemsandPolicies,WorldHealth Organization,2007 GonzalesBlock,MiguelAngel,SilviaBecker Dreps,LuzAngelicadelaSierradelaVega,etal,Salud Migrante:AProposalforBi nationalhealthinsurance,perspectivesinpublichealthcollection,health SystemsSeries,NationalInstituteofPublicHealth,Cuernevaca,Mexico,2008 Hamill,SeanD., UniversityofPittsburghMedicalCenter,WorkingWithaG.E.Unit,PlansBigExpansion Abroad, NYTimes,November13,2008 Hartman,Micah,AnneMartin,PatriciaMcDonall,AaronCaitlanandtheNationalHealthSpending AccountsTeam, NationalHealthSpendingin2007:SlowerDrugSpendingLeadstotheLowestRateof Growthsince1998, HealthAffairs,28,no1JanuaryFebruary2009,pp.246 261

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 32 Holzmann,Robert,JohannesKoettl,andTarasChernetsky, PortabilityRegimesofPensionandHealth CareBenefitsforInternationalMigrants:AnAnalysisofIssuesandGoodPractices,SocialProtection DiscussionPaperSeriesNo.0519,SocialProtectionUnit,HumanDevelopmentNetwork,WorldBank May2005 Hyun,Insoo,OllieLindvall,LaraAhrlund Richter,ElenaCattaneoetal,NewISSCRGuidelinesUnderscore MajorPrinciplesforResponsibleTranslationalStemCellProcedures,CellStemCell,Volume3,December 4,2008,pp.607 609 Insure.com, Thedoctorisin 9,000milesaway:InsuranceforMedicalTourism updatednovember 19,2008http://www.insure.com/articles/healthinsurance/medical tourism.htm Ker,Unmesh, OutsourcingYourHeart,Time,May21,2006,availableat http://www.time.com/time/magazine/article/0,9171,1196429 1,00.html Koettl,Johannes[undertheguidanceofandwithinputfromRobertHolzmannandStefanoScarpetta], TheRelativeMeritsofSkilledandUnskilledMigration,TemporaryandPermanentLaborMigration,and PortabilityofSocialSecurityBenefits,SPDiscussionPaperNo.0614,WorldBank,November2006 Lau,Darren,UbakuOgbogu,BenjaminTaylor,TaniaStafinski,DevidasMenonandTimothyCaulfield, StemCellClinicsOnline:TheDirecttoConsumerPortrayalofStemCellMedicine, CellStemCell, Volume3December4,2008pp.591 594 Lautier,Marc, ExportofHealthServicesfromDevelopingCountries:TheCaseofTunisia, SocialScience andmedicine,67,2008,101 110 Matoo,AadityaandRandeepRathindran, HowHealthcareInsuranceInhibitsTradeinHealthCare, HealthAffairs,vol.25,no.2(March/April2006) Merion,RM,ADBarnes,MLinetal, Transplantsinforeigncountriesamongpatientsremovedfromthe UStransplantwaitinglist, AmericanJournalofTransplantation,Vol8,Issue4,pp,988 996,Part2,2008 Milstein,ArnoldandMarkSmith, WilltheSurgicalWorldBecomeFlat?:Americans SeekingCheaper SurgicalProceduresAbroadWillProvideOnlyModestRelieffromOurSpreadingAffordabilityProblem, 26HealthAffairs,137(2007) NationalPopulationCounciloftheGovernmentofMexico,UniversityofCaliforniaatBerkeleySchoolof PublicHealth,andUniversityofCaliforniaatLosAngelesSchoolofPublicHealth,MigrationandHealth: LatinosintheUnitedStates,MexicoCity,Mexico,October2008. Nebling,ThomasandHans WilliSchemken, Cross bordercontracting:thegermanexperience, in Rosenmoller,Magdalene,MartinMcKeeandRitaBaeten,PatientMobilityintheEuropeanUnion: LearningfromExperience,EuropeanObservatoryonHealthSystemsandPolicies,WorldHealth Organization,2007 Ornstein,CharlesandJohnGionna, Afterlivers,cashtoUCLA, LosAngelesTimes,May31,2008

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner 33 Rai,Saritha, UnionDisruptsPlantoSendAilingWorkerstoIndiaforCheaperMedicalCare,NYTimes, Oct11,2006,atC6 Reed,CM, MedicalTourism, MedicalClinicsofNorthAmerica,Vol92,No6,pp.1433,November 2008. Richman,BarakD.,KrishnaUdayakumar,WillMitchell,andKevinA.Schulman, LessonsfromIndiain OrganizationalInnovation:ATaleofTwoHeartHospitals, HealthAffairs,Volume27,No.5,pp.1260 1271 Rosenmoller,MagdaleneandMariaLluch, MeetingtheneedsoflongtermresidentsinSpain, in MagdaleneRosenmoller,MartinMcKeeandRitaBaeten,PatientMobilityintheEuropeanUnion: LearningfromExperience,EuropeanObservatoryonHealthSystemsandPolicies,WorldHealth Organization,2007pp.59 78 Rosenmoller,Magdalene,MartinMcKeeandRitaBaeten,PatientMobilityintheEuropeanUnion: LearningfromExperience,EuropeanObservatoryonHealthSystemsandPolicies,WorldHealth Organization,2007 Sang Hun,Choe, Seoulwoosmedicaltouristsfornips n hips, NewYorkTimes,November16,2008 Scaramagli,Simonetta,DarioZanon,FrancescoRonfini,LuigiBertinato,andFrancoToniolo, Healthcare fortouristsinthevenetoregion, inrosenmoller,magdalene,martinmckeeandritabaeten,patient MobilityintheEuropeanUnion:LearningfromExperience,EuropeanObservatoryonHealthSystems andpolicies,worldhealthorganization,2007pp.79 98 Scott,Gale,AetnaOffersNewYorksavingsonsurgery, Crain snewyorkbusiness,june16,2008vol24, Issue24,pp27 http://ezproxy.lib.utexas.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=f5han =33203352&site=ehost live] ShimazonoY, Thestateoftheinternationalorgantrade:aprovisionalpicturebasedonintegrationof availableinformation, BulletinoftheWorldHealthOrganization,Vol85,pp.955 962,December2007 SmerdJeremy,LargeCompanieshoppingaboardmedicaltourism,WorkforceManagementJune23, 2008,Vol87.Issue11,p.8 10 Spar,Debora, ReproductiveTourismandtheRegulatoryMap, 352NewEnglandJournalofMedicine, 531,532(2005) Terry,NicholasP., Under RegulatedHealthcarePhenomenainaFlatWorld:MedicalTourismand Outsourcing, 29W.NewEng.LawReview,421(2007)(HealthLawSymposiumIssue) USCensusBureau,CurrentPopulationSurvey,March2008. USCongress,TheGlobalizationofHealthCare:CanMedicalTourismReduceHealthCareCosts?Hearing BeforetheSenateSpecialCommitteeonaging,109 th Congress(2006)

Draft TrendsandDriversofTradeinHealthServices DavidC.Warner Warner,DavidC.,[projectdirector],MedicareinMexico:InnovatingforFairnessandCostSavings, LyndonB.JohnsonSchoolofPublicAffairs,theUniversityofTexas,PolicyResearchProjectReportNo. 156,Austin,Texas,2007 Warner,DavidC.andLaurenJahnke, TowardBetterAccesstoHealthInsuranceCoverageforU.S. RetireesinMexico, SaludPublicadeMexico43(1):pp.59 66,January February2001 Warner,DavidC.andPabloSchneider[ProjectDirectors],CrossBorderHealthInsurance:Optionsfor Texas,U.S.MexicanPolicyReportNo.12,LBJSchoolofPublicAffairs,UniversityofTexasatAustin, AustinTexas,2004 Woodman,Josef,PatientsBeyondBorders:AffordableWorldClassMedicalTravel,HealthyTravel Media,ChapelHill,NorthCarolina,2008 WorldMedAssist, SwissRe scommercialinsurancelaunchesmedicaltravelinsuranceoffering, OverlandParkKansas,July22,2008. http://www.worldmedassist.com/medical_tourism_insurance_swiss_re.htmaccessedjanuary29,2009. 34

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