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New Frontiers: Medical tourism brings potential for big business but poses big questions

From: ENT Today, January 2011

by Thomas R. Collins

More patients every year are traveling outside of the U.S. in search of lower health bills and treatments that might be unavailable to them at home.

The Deloitte Center for Health Solutions estimates that 750,000 Americans went to another country for treatment in 2007, and researchers there conclude that the industry could grow by 20 percent a year, with as many as 1.6 million U.S. residents taking these trips by 2012. Researchers caution that exact numbers are essentially unattainable, however, because estimates are largely based on self-reported figures that can’t be verified.

But with medical tourism on the rise, more and more doctors are faced with the choice of whether or not to get involved. Those who do will have to grapple with important insurance and legal questions, experts say.

Popular Procedures

Most patients are traveling to India, Singapore and Thailand, where they can get the most bang for their bucks and find the most medical facilities that are accredited by the Joint Commission International, according to Paul Keckley, PhD, executive director of the Deloitte Center. Most procedures involve savings of 50 to 70 percent, even after airfare, hotel and other travel costs are considered, Dr. Keckley said.

A survey by the Deloitte Center found that 3 percent of respondents said they’d traveled outside the U.S. to consult with a doctor or receive treatment within the last 24 months. Nine percent said they would likely go abroad for a necessary surgical procedure if they could save at least 50 percent, but 67 percent said they would not be likely to do so.

A recent survey of Americans who had considered medical travel, conducted by the Texas-based Center for Medical Tourism Research (CMTR), found that 250 of the 1,821 respondents (13 percent) had traveled abroad for health care.

The most popular treatments sought abroad are not big-ticket procedures like open-heart surgeries and hip replacements, but are instead high-volume outpatient procedures, Dr. Keckley said. How well those kinds of procedures continue to catch on will determine how big the industry will get, he said. “It will be the ability of these host institutions to package products for these short-stay outpatient procedures, whether they’re cosmetic, dental … orthopedic, ENT or others that are at least 30 percent lower in out-of-pocket costs than U.S.-based products,” he said.

Less than 10 percent of the business involves otolaryngology procedures, said Rudy Rupak, who in 2002 founded PlanetHospital, which claims to be the first medical tourism “intermediary” company created to arrange medical trips for patients. According to Rupak, the most common ENT procedures patients seek abroad are laryngectomy, septoplasty, sinus surgery and sleep apnea treatment.

“When it comes to ENT, a lot of the patients are coming to us because the doctors domestically are not giving the treatment that they want or they’re not able to solve the problem,” he said. Rupak cited the example of a patient who claimed that doctors in the U.S. were not able to mitigate pain and irritation that followed a septoplasty. The patient finally went to Singapore, where a surgeon removed bony chips around the anterior ethmoidal nerve.

Arlen Meyers, MD, MBA“This train’s going down the track whether doctors want to participate or not. It’s happening all around the world.”

—Arlen Meyers, MD, MBA

Arlen Meyers, MD, MBA, professor in the department of otolaryngology at the University of Colorado Denver Anschutz Medical Campus and co-founder of the medical tourism company MedVoy, said the company handles three or four trips a month. Dr. Meyers and others who run medical tourism companies say the care experienced by traveling patients is usually as good as, or better than, the care found by patients in the U.S.

But Dr. Keckley, who attends conferences and talks to officials with medical tourism companies about their procedures, had the impression that the degree to which the so-called intermediary companies credential foreign providers and coordinate care is “woefully modest.” He didn’t name specific companies.

“It’s not an industry that has taken seriously yet managing outcomes and managing safety,” he said. “In our next study of this, we’ll dig very deeply into clinical processes.”

Raj Joseph, co-founder and CEO of the medical tourism company MedVoy, said that is a “very general statement … At the end of the day, it depends where you are going and which provider within the country you are going [to see],” he said. “We just try to work only with Joint Commission International-accredited hospitals or American Board-certified physicians and focus heavily on continuum of care.”

Follow-Up Care

Dr. Meyers said American doctors, including otolaryngologists, are all over the map when it comes to dealing with patients who have had procedures performed abroad. “There are some doctors that have the feeling that, ‘Look, if you didn’t come to me for your initial care and you went overseas to get it, now you show up at my office, I don’t want to have anything to do with you,’” he said. “There are other doctors that say, ‘Well, if you want me to help you identify a provider overseas, O.K., I’ll have a conversation with that person, I’ll provide records, I’ll establish some sort of pre-post-op care kind of thing, and I’ll be happy to help you.”

He said it would be a mistake to ignore overseas medical care. “I think that organized medicine needs to get their arms around this,” he said. “This train’s going down the track whether doctors want to participate or not. It’s happening all around the world.”

It’s easy to see why medical travel is becoming more popular, said David Vequist, PhD, founder and director of the Center for Medical Tourism Research at the University of the Incarnate Word in San Antonio. Some facilities abroad resemble five-star resorts, he said.

A recent survey of Americans who had considered medical travel, conducted by the Texas-based Center for Medical Tourism Research (CMTR), found that 250 of the 1,821 respondents (13 percent) had traveled abroad for health care.
A recent survey of Americans who had considered medical travel, conducted by the Texas-based Center for Medical Tourism Research (CMTR), found that 250 of the 1,821 respondents (13 percent) had traveled abroad for health care.

“You could go and potentially see an ENT in a location that looks very much like a resort, has a pool, is down by the beach, things of that nature,” he said. “After you’re done with the procedure and you’re going to rest, they’d have a masseuse that would be rubbing your shoulders while you’re lying by the pool in your bathing suit and the cabana boy is bringing you margaritas. ... That’s what hospitals internationally are focusing on. Private room, private suite. And all of this for costs that are arguably 50 percent less than what you would pay in the United States.”

Some doctors are more than willing to participate, he said, referring to “cruise trips” or “vacation trips” in which a U.S. doctor goes with a patient abroad or meets a patient abroad, performs the procedure overseas, and then provides follow-up care back in the U.S.

Some doctors, particularly those in border states, are opening offices both in the U.S. and just across the border, according to Dr. Vequist.

“You actually may be unprofitable here in the United States, but in the cash-pay environment in Mexico, even receiving a lower payment, you actually may be profitable there,” he said.

Rupak of PlanetHospital said that there is an otolaryngologist in his network who provides that kind of care. “We call that program the ‘Best of Both Worlds’ program,” he said.

More and more doctors are willing to provide follow-up care to patients who have traveled abroad, he said. “These are cash-paying patients, and what’s happening to a lot of ENT practices is that they’re having to do more cases and make less money on each case,” he said. “So everybody is looking for new patients.”

They seem to be simply following patient tastes. In PlanetHospital’s first year, 2002, just two patients were sent overseas. By 2006, that number reached the hundreds. Now, the company says it has arranged about 3,600 trips overall.

“The first three or four years, there was a fear factor,” Rupak said. But now, he said, “it’s past the tipping point. Now when you tell somebody about going abroad for surgery, somebody’s either heard of it or they know a friend who’s done it.”

Liability Issues

Glenn Cohen, an assistant professor at Harvard Law School who has written papers on medical tourism, said doctors who provide follow-up care to patients treated abroad may be at a heightened risk of getting sued if something goes wrong with a procedure done on foreign soil.

“Because they’re likely going to be very unsuccessful in suing the foreign provider, the patient has a higher incentive to sue you instead,” Cohen said. “Imagine a patient has a surgery abroad and then comes back and needs a second surgery. The idea of trying to unscramble the eggs, and figure out which was which in terms of who caused the injury, is difficult. And the insurance company, which is often in control of a lot of the malpractice litigation for doctors, may have a strong incentive to settle the case.”

He advised physicians to make sure their insurance policies will protect them in such cases.

There is also the potential liability involved in referring patients to foreign physicians, Cohen said. Doctors may have the same “duty of inquiry” that they have when referring patients to other physicians in the U.S., being careful not to refer to doctors who are known to be incompetent, are substance abusers or are otherwise ill-suited to care for patients.

More insurance companies are now agreeing to reimburse for medical care received abroad, but they differ greatly when it comes to what they’ll pay for. Dr. Meyers said coverage ranges from plans that don’t cover medical tourism procedures at all to those that treat it as out-of-network care to those that cover the care completely.

Just a Fad?

Dr. Keckley said his organization will be exploring the degree to which medical travel is being encouraged by consumers themselves and how much is promoted by insurance providers and employers. To continue to grow, though, the industry must be fixated on safety, he said.

“The industry will, in the U.S., survive, grow, prosper, be a major sector of health care to the extent that it doesn’t hit any safety potholes,” he said. “The minute someone has a botched procedure somewhere and a physician back home refuses to see the patient due to liability, or the minute the media pick up on a major negative outcome as a result of fairly poor care in one of these offshore settings, then you’ve got the potential for the bubble bursting.”

Number of Medical Tourists Coming to U.S. Fairly Flat

Number of Medical Tourists Coming to U.S. Fairly Flat

Most of the attention given to medical tourism has focused on U.S. patients traveling abroad for care. But how common is the reverse situation?

The Deloitte Center for Health Solutions estimates that 400,000 non-U.S. residents sought medical care in the United States in 2008, spending almost $5 billion for health services. Most of those patients are from the Middle East, South America and Canada.

Their reasons for coming to the U.S. vary. Some come to get care that they simply can’t get in their home countries, some want to avoid long wait times, and others just want to combine business or leisure travel with some kind of specialized health care, according to the Deloitte Center.

Growth of foreign patients seeking U.S. care is expected to be sluggish, largely because travel to the U.S. has been slow since 9/11, said Paul Keckley, PhD, the Deloitte Center’s executive director.

He cautioned that it is difficult to get reliable figures.

“We can kind of get a sense of whether it’s growing, or it’s flat, or it’s declining, how they’re modifying their approach,” Dr. Keckley said. “We think inbound’s fairly flat.”

Stories circulate about large numbers of Canadian patients seeking care in the U.S., particularly those seeking diagnostic procedures such as imaging, but researchers tend to think those notions are overblown.

“Canada having such a small population and obviously having state care, it’s small,” said David Vequist, PhD, founder and director of the Center for Medical Tourism Research in San Antonio. “The thing up there is access, in terms of timing. Canadians travel obviously primarily not because of cost, but because of access.”

Dr. Keckley said there is some pent-up demand in Canada for things like cancer therapies and total-joint replacements, but the number of Canadians seeking U.S. care is fairly small.

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